TOOLKIT: IMPROVING CKD MANAGEMENT IN GENERAL PRACTICE A guide to the improvement of CKD management in your MidCentral General Practice .

To be used in conjunction with the Collaborative Clinical Pathways

February 2015

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Chronic Kidney Disease (CKD) is estimated to affect approximately 10% of the population. The disease is

usually asymptomatic, but it is detectable. There is evidence that early treatment can prevent or delay the

progression of CKD, reduce or prevent the development of complications and reduce the risk of cardiovascular

disease and other vascular events such as stroke. Early detection, effective management and appropriate

referral to specialist services can also reduce the need for dialysis, transplantation, and the associated costs.

However, because of a lack of specific symptoms people with CKD are often not diagnosed, or diagnosed late

when CKD is at an advanced stage. The purpose of this toolkit is to assist General Practice with early

recognition and management of CKD, and also appropriate referral (see appendix 1 for referral information).

The importance of early diagnosis and treatment of CKD at the earliest possible stage cannot be

underestimated1. Therefore, strategies aimed at earlier identification of CKD and, where possible, prevention

of progression to established renal failure are clearly needed. Early detection and treatment in General

Practice is considered to be cost effective, in both financial and human terms2.

This toolkit is to be used by General Practice Teams to assess and improve back-room processes for

management of CKD. Specifically this toolkit provides a guide to:

1) Identify, code and recall patients with CKD (please contact your practices Clinical Quality Facilitator

(CQF) to request assistance with this process).

2) Check training and education requirements of your staff

3) Access relevant tools and services relevant to CKD.

This Guide does not provide patient facing CKD management advice. Guidance on best practice patient facing

functions of CKD management can be found in the relevant Collaborative Clinical Pathways. These include:

Management of Increased Creatinine

Chronic Kidney Disease Management

These two pathways are accessed via the Map of Medicine. To request a password for access to Map

of Medicine or for enquiries e-mail clinicalpathways@midcentraldhb.govt.nz

[1] NHS Kidney Care (2010) Kidney disease: Key facts and figures

[2] Department of Health (2007) The National Service Framework for renal services: Second progress report

Purpose of this Toolkit

CKD Management

Quality Improvement Activities

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CKD Management Practice Snapshot

A General Practice Self-Assessment Tool

The purpose of completing the Practice Snapshot is to establish a baseline of what is currently happening in your practice to manage people with CKD. Once you have completed this snapshot you will have a good idea of improvements your practice team will need to develop and implement to benefit your patients and practice.

Practice: Name of assessor:

Date: New or follow-up assessment:

Measurement Comments

Chronic Kidney

Disease (CKD) 1. Do you have concerns about

how CKD is managed in the

practice

Yes No

2. Do you believe that the

practice database identifies

all enrolled patients with

eGFR at stages 3, 4 and 5

according to CKD

Management in General

Practice Guidelines? (see

appendix 3)

Never

Rarely

Sometimes

Mostly

Always

3. What are the suspected

numbers of patients in this

practice with CKD? Answer

this question by doing a

query build within the PMS

for all those classified by

READ codes K06, or K05.

Note: it is preferable that

going forward you use code

K06 –see appendix 5. Note

2: ask your Clinical Quality

Facilitator for assistance.

Date:

Prior to project commencement Follow-up

Stage 3

Stage 4

Stage 5 Total

2

4. The practice undertakes

opportunistic screening for

CKD? How is this done?

(See appendix 2).

Yes No

Method:

5. The practice accurately

codes patients with CKD

under the appropriate PMS

READ codes K05, K06?

Yes No

6. There are processes in place

for recall following abnormal

results received for CKD?

Yes No

7. There are processes in place

for recall following abnormal

results received for those

people ‘at risk’ of developing

CKD (eg with diabetes,

hypertension, cardiovascular

disease and smoking).

Yes No

8. Now contact the CPHO

Practice Liaison Team or

your practice Clinical Quality

Facilitator (CQF) and ask

them to complete an App

based query build for your

practice for eGFR less than

or equal to 60 (Note, this

query build requires an App

and can currently only be

completed by Practice

Liaison or a CQF).

Date: Number of practice patients with eGFR ≤60:

9. Now compare the results

from question 8 above with

the results from question 3.

Question 3 total: Question 8 total: Difference:

3

Measurement Comments

Family History Family history is routinely (at least

annually) reviewed for CKDii, CVD,

and diabetesiii

Never

Rarely

Sometimes

Mostly

Always

Collaborative

Clinical Pathways The practice uses the Map of

Medicine for the management of

CKD and Diabetes?

Yes No

The practice has been offered

training and support in the use of

Map of Medicine and has taken

training to ensure appropriate skill

levels?

Yes No

The practice is using the Collaborative

Clinical Pathways referral form

Never

Rarely

Sometimes

Mostly (90%)

Always

(100%)

Training and

Education All staff offered training to enable

team members to use screening and

recall systems effectively?

None Some Most All (100%)

Update sessions are provided to staff

on using screening and recall systems

effectively?

Never

Rarely

Sometimes

Mostly

Always

4

All nurses have completed the

Kidney Disease Knowledge and

Skills programme?

None Some Most All (100%)

All nurses have

completed the e-

learning tools for…

Diabetes

None Some Most All

CVD risk

assessment

None Some Most All (100%)

Measurement Comments

Other Services

Patients are referred to

Community Clinical Nurses Long

Term Conditions (CCN LTC) CPHO

where relevant

Never

Rarely

Sometimes

Mostly

Always

Patients are referred to other

members of the primary Chronic

Care Team E.g.:

-Smoking cessation

-Physical activities educator

-Dietitian

-Clinical Pharmacist

- Psychology long term conditions

Never

Rarely

Sometimes

Mostly

Always

5

The data gathered in this Practice Snapshot will assist your practice to assess how well

your systems and processes support CKD patient care. It also provides a baseline for

quality improvement. Use the Improvement Tool provided for development,

implementation, and monitoring of quality improvements.

Thank you for taking a rigorous approach to providing quality CKD patient care. Contact

Lois Nikolajenko RN. MN CNS LTC PHC HCD for any further information

i This tool combines the MDHB Long Term Conditions Wellness Model in conjunction with the Wagner Chronic Care Model, (2004) and

Royal New Zealand College of General Practitioners. (2009). Aiming for Excellence – RNZCGP Standard for New Zealand General Practice. Wellington. (Approved for use July, 2009). ii

Kidney Health New Zealand. Modified from original from Med-E-Serv Pty, Chronic kidney disease update. Accessed 27 April 2009 from www.kidney.primed.com.au

iii New Zealand Guidelines Group, (2009). New Zealand cardiovascular guidelines handbook. Wellington.

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CKD Management Gap Analysis Tool

The purpose of completing this Gap Analysis is to identify where the practices approach to CKD management needs to change. Once you have completed the Gap Analysis you will be better positioned to plan changes using the PDSA tool.

To complete the Gap Analysis fill in the template below following these three steps:

1) Future CKD Management in our Practice: identify the objectives for CKD management in your practice that you would like your practice team to achieve. This identity’s the place the practice will be when the team has improved process around CKD.

2) Current CKD Management in our practice: this information can be taken from the

practice snapshot you completed earlier.

3) Proposed actions: identify how the practice team will bridge the gap between current and future CKD management practices

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CKD MANAGEMENT GAP ANALYSIS TOOL FUTURE CKD

MANAGEMENT IN OUR

PRACTICE LOOKS LIKE

……..

CURRENT CKD

MANAGEMENT IN OUR

PRACTICE LOOKS

LIKE….

PROPOSED ACTIONS

Screening

Identification

Coding

8

Recall

Family history

Collaborative Clinical Pathways

Training and education

CKD Management Improvement Tool

The purpose of completing this CKD Management Improvement Tool is to enable your practice team to successfully plan and implement improvements in CKD management that will benefit your patients and your practice.

Based on the results from the ‘Practice

Snapshot-Renal’ and ‘Renal Gap Analysis’ it is

likely that your practice team will have

identified that they need to implement a

number of changes.

It is recommended that your practice team

work on a limited number of improvements at

any one time. It is also recommended that

your practice team ensures momentum by

delegating one member of the team to be in

charge of driving the improvement process

forward.

Use the ‘Model for Improvement’ and Plan Do

Study Act (PDSA) to guide your improvement

process. This will ensure you are able to

determine whether your change is an

improvement. A Model for Improvement and

PDSA template are included below. For

assistance with this process contact your

Clinical Quality Facilitator (CQF).

Model For Improvement

1. What are we trying to accomplish? What is the aim of the improvement?

•Set the aim which should be time specific and measurable.

•Define the specific population that will be affected

Aim:

2. How will we know that a change is an improvement? Establish a quantitative measure to

determine if a specific change actually leads to an improvement.

Measures:

3. What changes can we make that will result in improvement? Your team will have already identified changes when you completed the Renal Gap Analysis. List all possible changes here. Choose to work on the changes that will produce the greatest impact. Use a new PDSA template for each change you choose to implement.

Possible changes:

Plan Do Study Act (PDSA)

Which change are we going to test with this PDSA Cycle?

Plan: List the tasks needed to set up this test of

change

Person responsible

Date to be completed

Predict what will happen when the test is carried out

Measures to determine if prediction succeeds

Do: Carry out the change or test, collect data and begin analysis

Study: Complete analysis of data. Compare data to predictions and summarize what was

learned.

Act: Are we ready to make a change? Plan for the next cycle.

APPENDIX 1: Guideline for referral to MidCentral Health Renal Service

GUIDELINE FOR REFERRAL TO MCH RENAL SERVICE

General enquiries for advice can be made by emailing: renalenquiries@midcentraldhb.govt.nz (enquiries sent to this address must not be patient specific). All other clinical referrals should include the following:

Demographics: NHI Referrer Enrolled/Regular GP DOB Family Name GP Phone First Given Name Enrolled/Regular Practice Practice Fax Date of Referral Address Daytime phone Ethnicity Gender Residency status

Lab Results: (Please have these results available. Hard copy need not be sent if result is available on Éclair) Urinalysis and Microscopy Urea and Creatinine CBC

Calcium, Phosphate and Albumine Urine Protein: creatinine ratio Previous laboratory results

Presenting Problem: Acute Kidney Injury Acute on Chronic Kidney Injury

Request for Iron Infusion

Chronic Kidney Disease 2 years PDC (Prediction of dialysis commencement – see Map of Medicine) Request Special Authority for EPO – Erythropoietin (include relevant results) Other

Special Authority Request: Drug requiring Special Authority Expiry date (for renewals)

History of the Presenting Problem (chronological events that resulted in the presenting problem):

Potential Cause: Your thoughts about the cause of renal failure

Clinical Measures: Height Weight

BP Any Physical examination of relevance

Past Medical History: Attach relevant specialist notes/investigations done outside MCH, include CVD risk factors

Current Medications: Include any adverse drug reactions – with side effects

Renal Referral Guideline, 2014

APPENDIX 2: Opportunistic Screening for CKD

Screening everyone with a single demographic risk factor for CKD as an independent clinical activity is not feasible in primary

care. However, testing those identified according to their risk of CKD as part of a CVD risk assessment or diabetes check is a

realistic practice activity. The individual’s risk factors for CKD should be considered when deciding whether to arrange

screening for CKD with a serum creatinine (and eGFR) and urine ACR.

Risk factors for CKD:

Hypertension

Diabetes

BMI > 35

Cardiovascular disease

Family history of kidney disease

Prostatic syndrome/urologic disease

Nephrotoxic drugs

Māori, Pasifika or Indo- Asian ethnicity

Age over 60.

(From Ministry of Health MANAGING CHRONIC KIDNEY DISEASES IN PRIMARY CARE: A NATIONAL CONSENSUS STATEMENT,

June 2014)

APPENDIX 3: The Classification of CKD

CKD is a general term for chronic disorders that affect kidney structure and function. Complications from CKD may

in time affect all organ systems. However most people with mild or moderate CKD have no symptoms.

CKD is classified using the KDIGO criteria (see below). This is independent of the underlying cause of the kidney

disease. Each stage is characterized by a GFR range. This is an estimate of kidney function based on serum

creatinine as measured by the laboratory.

Patients in stage 1 and 2 CKD have documented kidney disease (e.g. diabetic nephropathy or polycystic kidney

disease etc) and are sub-classified by GFR. Patients in stages 3-5 have reduced GFR on which the classification is

based. Since GFR declines in the overall population by 1ml/minute/year many elderly patients have reduced GFR

and so fulfill the criterion for CKD stage 3. Most of these do not have any evidence of active or structural kidney

disease. A kidney biopsy in these elderly patients is likely to reveal sclerotic changes affecting renal vessels ,

glomeruli and interstitium (arteriolonephroscerosis) which might be described as aging-related. .

Fig 1.CKD classification and prognostic risk from the CKD Consensus Consortium (1)

APPENDIX 4: CKD Management in General Practice Summary Guide

APPENDIX 5: How to set up a Common Read Code Information included in these instructions:

How to set up a common read code

How to add keywords to a common read code To setup a common read code 1. Go to setup – clinical – read 2. This will bring up the Read Codes screen. Click on the magnifying glass to search for the read code that you wish to make common. This will bring up the Find Read screen. In this screen search for the disease code that you want. 3. Highlight the code you wish to make Common, and then click OK.

Ensure that the ‘Look In’ box is set to All Chapters

Remove the tick from the ‘Common Only’ box before searching

Type in the disease code that you wish to search for

This screen will now appear. This read code has now been made common. To add keywords to a common read code 4. In order to add keywords to a common read code, go to setup – clinical – read. Double click on the read code you wish to modify or select the ‘Open an Existing Read Code’ icon. This will bring up the View Read screen 5. The View Read Screen will be opened. Select the Add Key button. Then type the keyword into the empty space and click OK e.g. type 1 This has added these key words to that selected read code.

The Open an Existing Read Code icon

Make sure the ‘common’ box is ticked

6. To use the keywords, bring up the ‘Find Read’ screen. Ensure ‘common only’ box is ticked, and search for the key words. For example This will bring up the read code you have associated that term with

Ensure that in the ‘Look In’ box, all chapters is selected

Ensure that the ‘Common Only’ box is ticked