Appendices: Clinical Director plans and good practice tabulation

1 Berkshire Kidney Unit

What are your plans for increasing home dialysis?

1. We have increased our HD staffing levels recently in order to increase the number of patients. This will allow for more than one patient to be trained at a time and also provide additional resources for ongoing management of the existing home programme.

2. We are moving to a fixed HHD model, to reach wider patient cohort / different financial economy whilst still using NxStage. Machines have been purchased and these will be based in each unit allowing staff to train patients in a familiar environment and closer to their homes. Staff training is currently in progress as we are about to roll out this model. The plan will be to use Quanta traditionally in patients’ homes three times weekly or to mimic NxStage therapy dialysing four to two times weekly sessions but for shorter hours. With the purchase of four Quanta machines from capital funds during Covid we now have the ability to place a machine in all of our chronic dialysis units. We already have them in place and the chronic dialysis nurses have learnt how to use the machines and are using them as part of daily fleet. Pathway for new patients for home HD will start on this machine until they start their focused training with the home HD team. We have now budgeted extra resource to cover workforce to allow us to increase the programme.

3. Additional operator for the insertion of radiological PD catheters - a new renal consultant appointed, and a period of training and supervision has been completed / signed off. We now have two renal consultants that can insert radiological catheters we identified as potential single point of failure for our service. This has addressed this and increased service flexibility/availability which in time should increase PD numbers.

4. Revisit all patients that joined our programme acutely - to revisit education / modality choice to ensure no one on HD that would want / prefer PD.

5. To re-explore and promote shared care with our HD units - it is hoped this will reduce patient dependency, promote confidence, and encourage patients to transition to HHD. An option in time for those that want HHD but can’t because of lack of space in their home / fear they can undertake HD independently but in a supported environment.

6. Start an acute PD programme - we have this already but lack of internal space in x ray prevent our pd inserters from providing the service in real time. But it remains high on the agenda.

Do you have any examples of good practice that can be shared?

We offer patients a trial on the machine first. We have recognised over time that by having training machines in a unit, you see an increase in patient interest. We regularly have promotional events and invite patients to these that are from PD, low clearance and transplant to explore future options.

2 University Hospitals Birmingham

What are your plans for increasing home dialysis?

We are actively participating in the KQUIP DAY life programme and continue to take a pro-active approach to offering home therapies at the pre-dialysis stage. In addition to this we routinely re-visit the option of HHD with all In-centre Haemodialysis (ICHD) patients and are working on a pathway to enable more PD patients to move to HHD when needed.

Do you have any examples of good practice that can be shared?

1. ACE Acceptance, Choice and Empowerment (ACE) project at pre-dialysis stage for patients.

2. ICHD questionnaire to promote home dialysis.

3 Bradford Teaching Hospitals NHS Foundation Trust

What are your plans for increasing home dialysis?

Below are some of the main achievements to date.

1. We have introduced monthly combined Home Therapies, Advanced Kidney Care Clinic (AKCC) and Transplant Multidisciplinary Team (MDT) meetings for all patients in Bradford and Airedale. The principal aim of this meeting is to ensure quality and safety of patient care during the transition to dialysis, by coordinating timely access placement and improving access to pre-emptive renal transplantation.

2. We have introduced new opportunities to facilitate home therapies as part of our Renal Strategy, including haemodialysis shared care unit at St Luke’s (new starters experiencing shared care from the outset) and new haemodialysis facilities at Bradford Royal Infirmary.

3. We have restarted our practice of a monthly HD checklist to reinforce regular review of patient interest in home therapies.

4. As part of the new development at St Luke’s, we are able to set up our own carousel of patient information materials on the large TV screen in the new dialysis unit waiting area, including information about HD shared care, we share resources such as ‘There’s no place like home’ to support home therapies discussions with our patients as appropriate.

5. The current staffing levels of 1 Full Time Equivalent (FTE) of Band seven with 0.8 FTE of Band six (longterm sickness) and 1.6 FTE of Band five support the combined peritoneal dialysis (PD) and home haemodialysis service. The turnaround rate for Band five staff in the last three years has ranged from 50% to 80%. Therefore, retaining and recruiting staff with the right expertise into home dialysis is a major challenge. We are committed to produce and implement a Quality Improvement (QI) strategy that links to the KQuIP Home Therapies work stream, the Renal Services Transformation Programme (RSTP), our Trust GIRFT initiatives and the NKF project. We have initiated collection and reporting of a range of process and outcome longitudinal metrics to demonstrate trends in activity that we are using to support business cases to increase our current staffing levels.