Sharing Best Practice across Clinical and Geographical Boundaries: The Introduction of an Integrated Care Pathway (ICP) for people dying with Chronic Kidney Disease (CKD)

R Lewis, K Tarhuni, A Webb

Hull Royal Infirmary

Problem Most people with CKD die in hospital. For some this is circumstantial due to the logistics of organising community or hospice care at short notice. But for many, the individual and family concerned choose to spend this difficult time in an environment in which they are familiar. Following a retrospective audit of people dying with CKD in Hull, it was found that no systematic management approach existed and the plan and implementation of care was often poorly documented. This resulted in varying standards of symptom control and an uncoordinated and often incidental provision of care.

Purpose The purpose of the study was to review the impact of establishing a ‘best practice’ model of end of life care within our acute specialist unit.

Design An Integrated Care Pathway for people dying with CKD was introduced. The pathway is based on the Liverpool model, the Gold standard with NHS beacon status, and adjusted for local circumstances. It offers a holistic program of care for the patients’ and their families in the last 48 hours of life. The specific aims are to optimise symptom control, abolish unnecessary interventions and simplification of the unified patient record. Six months later we undertook a case note review of all the patients who died in the nephrology wards during this period.

Findings Within this period 36 patients died, just under a third (31%) were admitted onto the pathway. In comparison to those not entered onto the pathway, these patients were significantly more likely to have non-essential medications stopped and unnecessary interventions discontinued (58%:15%) and were more likely to have symptom management medication prescribed in advance of them requiring it (83%:21%). In addition, the families’ of those patients on the pathway were more likely to have had a discussion with the medical staff caring for their relative (83%:42%) The pathway supported a high quality, best practice, systematic programme of care that was clearly documented by the multidisciplinary team.

Conclusion Those patients who were entered onto the pathway were significantly more likely to receive systematic end of life care that reflected best practice principals and values. Incidentally, the proportion of patients not entered onto the pathway was unexpectedly high. Preliminary enquiries suggest that ‘the diagnosis’ of dying has been an issue with these patients and plans are underway to explore this problem further.

Relevance Sharing best practice across clinical boundaries is essential if we are to provide a quality assured service. In addition to the explicit support of the whole multidisciplinary team, a collaborative approach with the Marie Curie centre and our Trust’s palliation team has allowed us to provide our patients with a programme of end of life care that compares with the best.