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Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease Owen JE; Walker RJ; Edgell L; Collie J; Douglas L; Hewitson TD; Becker GJInt J Qual Health Care 2006[Apr]; 18 (2): 145-51OBJECTIVE: The objective of this study was to design and implement an efficient pathway to ensure a smooth transition of patients with advanced chronic kidney disease to dialysis. SETTING: In our dialysis service, as elsewhere, we recognized that there was an unacceptably high rate of inadequately prepared patients commencing dialysis. Knowledge of clinical practice and research-based guidelines has not in itself changed clinical practice and patient management. MAIN MEASURE: : To address these problems, multidisciplinary process redesign teams reviewed pre-existing arrangements by assessing current practice. The review identified critical points where problems could occur: failure to notify patients to dialysis service, late referral for vascular surgery, and inadequate pre-dialysis education. As a result of this process, we have formulated a modified and coordinated pre-dialysis programme. RESULTS: In association with process redesign, the proportion of patients registered 'late' decreased from 29% in July-September 2000 (pre-implementation) to 6% in January-March 2004 (P < 0.01) with the corresponding median time from registration to commencement of dialysis increasing from <1 month to 14 months (P < 0.01). Patients not registered with the service decreased from 57 to 0% (P < 0.001). Eighty-three per cent of patients commenced dialysis with a permanent vascular access in January-March 2004, compared with 24% in July-September 2000 (P < 0.001). CONCLUSIONS: Through process redesign, more of our patients are known to us before commencement of dialysis, a greater proportion of which are provided with pre-dialysis education and permanent vascular access. Our results highlight that implementation remains the final and most difficult challenge of the guideline process.|*Critical Pathways[MESH]|*Process Assessment, Health Care[MESH]|*Renal Dialysis[MESH]|Ambulatory Care Facilities/*standards[MESH]|Benchmarking[MESH]|Catchment Area, Health[MESH]|Catheterization, Central Venous[MESH]|Creatinine/blood[MESH]|Delivery of Health Care, Integrated[MESH]|Evidence-Based Medicine[MESH]|Female[MESH]|Geography[MESH]|Humans[MESH]|Kidney Failure, Chronic/diagnosis/*therapy[MESH]|Male[MESH]|Patient Care Management/*standards[MESH]|Patient Education as Topic[MESH]|Referral and Consultation[MESH]|Victoria[MESH] |
