QJM Advance Access originally published online on June 24, 2008
QJM 2008 101(8):643-648; doi:10.1093/qjmed/hcn071
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Patient flow from critical care to renal services: a year-long survey in a critical care network*
From the 1Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, 2North East and Cumbria Critical Care Network, North Tyneside General Hospital, North Shields, Tyne and Wear, and 3Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, UK
Address correspondence to Stephen E. Wright, MRCP (UK), FRCA, Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP. email: s.e.wright{at}dsl.pipex.com
Received 2 December 2007 and in revised form 26 May 2008
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Summary |
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Background: The NSF for Renal Services stresses the importance of collaboration between renal services and critical care networks in managing patients with acute renal failure in the most clinically appropriate setting. Anecdotal evidence in our region suggested that some patients were remaining on critical care inappropriately because of a lack of capacity for step-down care in local renal units.
Aim: To determine the number of extra days patients spend on critical care receiving single-organ renal support before transfer to a renal unit.
Design: Prospective, multi-centre, service evaluation.
Methods: Prospective data were collected over a one-year period by either daily telephone calls or bedside review. Follow-up data were retrieved from electronic and patient records.
Results: Five hundred and forty-two patients received renal replacement therapy (RRT) in critical care. With 68 (12.5%) patients already receiving RRT for end-stage renal failure, this gave an incidence of new RRT on critical care of 234 per million population per year. The median duration of RRT on critical care was 4 days (range 1–30). One hundred and twenty-seven patients (23%) were discharged from critical care still requiring RRT. A period of single-organ renal support (median 2 days, range 1–8) was provided to 74 of these patients (58%) using 113 critical care bed days.
Discussion: Over half of patients receiving RRT on discharge from critical care in our network received a short period of single-organ renal support before step-down. This may represent either delayed discharge from critical care or a potential opportunity for care in an alternative high-dependency facility.
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Introduction |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix 1AcknowledgementsReferences |
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Patients requiring renal replacement therapy (RRT) on critical care make significant demands on both critical care and renal services. Many of these patients have multi-organ failure, require prolonged hospital admissions and do not survive their critical illness. For those who do survive to discharge from critical care a period of on-going RRT may be required. Delays in the step-down of these patients from critical care to renal wards may lead to inappropriate use of expensive critical care beds, cancelled operations and unplanned transfers. Patient outcomes may also be affected if the use of continuous RRT rather than intermittent therapies limits mobility and physiotherapy.
The National Service Framework (NSF) for Renal Services stresses the importance of managing patients with acute renal failure (ARF) in the most clinically appropriate setting.1 Patients who no longer require critical care but still require RRT should ideally be transferred to a renal unit in a timely fashion. However over 40% of critical care units in the United Kingdom do not have access to on-site renal beds, potentially slowing this transfer.2 The NSF for Renal Services also stresses the need for collaboration between renal services and critical care networks in delivering care to acutely ill renal patients.1 The proposed introduction of a national tariff for both renal and critical care services under ‘Payment by Results (PbR)’ may change the way the care of these patients is funded.3 Prospective data are few and will be useful for planning, commissioning and delivering services to these patients.
In our region, anecdotal experience had suggested that some patients were requiring a longer period of renal support in critical care because of a lack of capacity for step-down care in local renal units. To investigate the scale of the problem we undertook a 12-month, collaborative, prospective study of all adult patients receiving RRT within the North East and Cumbria Critical Care Network. The aim of this study was to determine the number of extra days patients spent on critical care requiring single-organ renal support before transfer to a renal unit or to a nonspecialist ward with on-site renal support.
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Methods |
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The North East and Cumbria Critical Care Network is one of 25 critical care Networks in the United Kingdom. The Network serves an adult population of approximately 2 million and comprises 145 critical care beds (82 level 3 and 63 level 2) in 12 critical care units. The 11 hospitals involved provide the full range of acute and elective hospital services including cardiothoracic services and some supra-regional services such as heart and lung transplantation (Appendix 1). Three of the hospitals in the network have renal units providing inpatient dialysis on-site. In the year April 2005/2006 there were over 6000 admissions to critical care units in the network.
Our study met all the criteria for Service Evaluation as defined by the National Patient Safety Agency.4 Written permission was received for the collection, storage and use of patient identifiable data from the Caldicott guardian of each NHS Trust in the North East and Cumbria Critical Care Network. Between 1 March 2005 and 28 February 2006 two members of the research team (JM and LB) collected data on all patients receiving RRT in the network. Data were collected from the nurse caring for each patient by daily telephone calls (Monday to Friday) and any patients requiring RRT at that time or at any time since the previous phone call were identified. An exception was at the Freeman Hospital where data was collected seven days a week by the renal Specialist Registrars of the critical care nephrology service. Data collection continued until patients were discharged to a ward, transferred to another critical care unit or no longer required RRT on critical care. Patients already receiving RRT for end-stage renal failure were included if they received RRT on critical care. Readmissions to critical care or transfers from another critical care unit were included if they required RRT on critical care. The number of organ systems supported was determined daily using a simplified version of the NHS Critical Care Minimum Data Set (Table 1).5 Patients were defined as having a period of single-organ renal support if they had more than one day of single-organ renal support at the end of their critical care stay. Follow-up data were collected from electronic and patient records.
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Data were transferred from a pro-forma to a Microsoft Access database and then to an Excel spreadsheet for analysis (Microsoft, Redmond, WA). Continuous variables are presented as mean and standard deviation if normally distributed or median and inter-quartile range if nonparametric. Categorical variables are presented as a number and percentage of sample size. Continuous variables were compared by a Mann–Whitney U-test if nonparametric. Discrete variables were compared by Chi-square. All statistical analysis was performed using Minitab 14 Statistical Software (Minitab Inc, PA).
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Results |
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During the 12-month study period, 542 patients received RRT on critical care in the network. Because of readmissions and transfers between critical care units in the network, RRT was provided during 574 critical care admissions. Sixty-eight (12.5%) patients were already receiving RRT for end-stage renal failure, giving an incidence of 234 per million population per year of new RRT on critical care.
Patients requiring RRT on critical care tended to be male (64%) with a median age of 66 years (range 17–96). Referring specialities included surgical specialties (59%), nephrology (7%) and other medical specialities (34%). The median duration of RRT on critical care was 4 days (range 1–30). In total 2376 patient days of continuous RRT and 885 sessions of intermittent haemodialysis (IHD) were delivered. Fifteen patients were transferred out of the network and lost to follow up, six of these were transferred from critical care and nine from other ward beds. Of the remaining 527 patients who required RRT on critical care, 219 (42%) survived to hospital discharge. The length of stay on critical care and other wards following discharge from critical care is shown in Table 2. Patients surviving to discharge from intensive care tended to have a longer ICU stay in hospitals without an on-site renal unit (median 11 days, range 1–103) compared to those with (median 9, range 1–102) (P = 0.06).
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One hundred and twenty-seven patients stepping down from critical care to a renal ward, or to a nonspecialist ward with on-site renal support, spent a median of 14 days on the ward and required a mean of four sessions of IHD (range 1–28 sessions). A period of single-organ renal support (median 2 days, range 1–8) was provided to 74 (58%) of the 129 patients still requiring RRT on critical care discharge. These patients required 113 critical care patient bed days. This period of single-organ renal support was significantly longer in the eight hospitals without a renal unit on-site (median 3.5 days, range 1–7) compared to the hospitals with an in-patient dialysis unit (median 2 days, range 1–5) (P = 0.02). Of the 68 patients already receiving RRT for end-stage renal failure a similar proportion received a period of single organ support (19%) to those who did not have end-stage renal failure (16%) (P = 0.46).
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Discussion |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix 1AcknowledgementsReferences |
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We found over half of patients who required RRT on discharge from critical care had a period of single-organ renal support before step-down to a renal unit. This period of support was significantly longer in those hospitals without a renal unit on-site. Overall the period of renal support tended to be short and the number of critical care bed days used relatively small. In general our findings would suggest good cooperation between critical care and renal services and would not support the anecdotal impression that there are frequent delays in the step-down of patients to renal units in our region. Nevertheless we did identify a small group that may represent either delayed discharge from critical care or a potential opportunity for care in an alternative high-dependency facility.
We could identify very little published data regarding patient flow between critical care and renal services. A study by Hegarty et al.6 prospectively identified patients with severe single-organ ARF in the Greater Manchester area over a 6-week period. They found 13 (46%) of 28 patients had an unacceptable delay in transfer—either initially to a critical care unit, or latterly in transfer from critical care to renal services.
Our study design has several strengths and some limitations. We collected data prospectively, over a 12-month period, from patients in a defined geographical area—our local critical care network. We used recognized criteria for organ failure5 and chose clear end points (duration of single-organ support on critical care) rather than try to classify what are often complex clinical and administrative decisions.
The data we collected do not allow us to determine the reasons behind the period of single-organ renal support or whether discharge was felt to be delayed at the time. We considered a retrospective review of the clinical notes and after completion of this study we examined the notes from a cohort of patients with delayed discharge. Unfortunately we found that the factors influencing the timing of discharge or transfer were poorly documented. More detailed questioning at the time may have provided further information but we were conscious of the amount of data one could reasonably expect to collect by telephone. We were also aware of a potential Hawthorne effect, where our daily telephone calls and questions may actually influence the timing of discharge.7
We did not collect data on the indications for initiating RRT in critical care and accept that in this setting, RRT may be used for indications other than renal failure. The incidence figures (234 per million population per year) we report are therefore for the new requirement for RRT on critical care rather than the true incidence of ARF in the population. Our results are in keeping with the findings of a prospective 11-week study in the Grampian, Highland and Tayside regions of Scotland which found an incidence of either acute or acute-on-chronic renal failure requiring RRT (on either critical care or a renal unit) of 203 per million per year.8 The true incidence of ARF requiring RRT should be readily available once the National Renal Dataset is established. The NSF for Renal Services defined ‘information requirements’ including gathering data on patients admitted with ARF.9 In response, the National Renal Dataset is being developed by the NHS Information Centre in collaboration with the UK Renal Registry and UK Transplant.10
The economic implications of our findings should be considered. We found 113 critical care patient bed days were used to provide single-organ renal support before step-down. Earlier transfer of these patients may allow potential cost-savings. In addition, extra capacity in critical care may avoid the costs resulting from unplanned inter-hospital transfers or cancelled elective surgery. Prompt transfer may also allow savings for the purchasers of health care, the Primary Care Trusts (PCT), if the charges for caring for these patients are less on the renal ward than on critical care.
The introduction of ‘Payment by Results (PbR)’, a new tariff-based system of health care funding, will change the way that ARF is funded both for critical care and renal services.3,11,12 Currently all renal dialysis falls outside the scope of PbR and individual NHS Trusts negotiate with the PCTs for this using guidance figures from the Department of Health. These indicative payments are relatively small at £163 for a session of in-patient haemodialysis by the 2007/08 tariffs.13 Any other funding for patients still requiring RRT after discharge from critical care often comes under the original diagnostic code, for example a major surgical procedure, and is not explicitly marked for renal services. This situation has been recognized as unsatisfactory and will be addressed by the new PbR tariffs, Healthcare Resource Group (HRG) 4.0, which are due to be introduced from April 2009.14 To ensure that all specialized activity is recognized, all diagnostic codes will be taken into account and a separate and additional tariff will be allocated for treatment of ARF. The proposed tariff for nonelective ARF is £2207–2748 for a hospital spell up to 22–31 days, whilst the tariff for nonelective RRT on the renal unit is £1485–3940 for a spell of up to 16–35 days.15
The national PbR tariff for critical care is being piloted by six critical care networks and is not expected before April 2009.3 Currently the NHS Trusts recover the costs for critical care by a variety of arrangements with the PCTs.16 Although the tariffs are under development the proposed method for determining the HRG for adult critical care patients is available.17 Using this method the HRG is determined by the highest number of organs supported during the patient's stay on critical care. This determines the daily tariff, which is then multiplied by the length of stay on critical care. Although this method is apparently straightforward there are potential problems that the pilot sites are examining.18 Most relevant to our study is that the days of single-organ support towards then end of a critical care admission will attract the same tariff as the early days of multi-organ failure. This could generate a perverse incentive, for the NHS Trusts at least, to use critical care to its maximum capacity, delaying discharges to the renal ward and slowing patient flow.
Clearly patients who no longer need critical care should be transferred at an appropriate time to a ward with staff and facilities appropriate to their needs. We have identified a number of patients recovering from critical illness who still require renal support on discharge from critical care. If we are to transfer these patients to a renal unit more promptly we must consider what configuration such units would have. It is likely there are a range of solutions to this depending on local needs, existing services and individual enthusiasm and expertise. Guidelines from the Renal Association recommend that renal units should be equipped to provide level 2 care for patients with severe acute kidney injury or do so in conjunction with critical care services.19 For some renal units this would require significant service development to be able to provide level 2 care as described in ‘Comprehensive Critical Care’ and meet the standards sufficient to charge the critical care tariff under PbR.20,21
Finally there are also issues with regard to training. A recent report from the Royal College of Physicians (RCP) noted that renal trainees have less exposure to ARF in intensive care units than previously, with resulting lack of experience in the evaluation of critically ill patients.22 This RCP working party recommended that renal medicine trainees should spend a 3-month period of training in critical care.22 Good collaboration between critical care and renal services will continue to be essential for the effective development of services to care for these complex patients.
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Appendix 1 |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix 1AcknowledgementsReferences |
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Participating hospitals: Freeman Hospital, Royal Victoria Infirmary and Newcastle General Hospital, Newcastle upon Tyne; University Hospital of North Durham, Durham; Sunderland Royal Hospital, Sunderland; Queen Elizabeth Hospital, Gateshead; South Tyneside General Hospital, South Shields; North Tyneside General Hospital, North Shields; Wansbeck General Hospital, Ashington; Cumberland Infirmary, Carlisle; West Cumberland Infirmary, Whitehaven.
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Notes |
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*This study was presented as a poster at The Renal Association Annual Conference, 21 May 2007, Brighton, UK.
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Acknowledgements |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix 1AcknowledgementsReferences |
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We would like to thank the following for their help with data collection: the nursing staff of the North East and Cumbria Critical Care Network, the renal specialist registrars and Marie Connolly of the Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne. Details on the National Renal Dataset were kindly provided by Alison Roe, Project Manager at the NHS Information Centre for health and social care, 1 Trevelyan Square, Leeds. Information on PbR was kindly provided by Jonathan Storey, North East Strategic Health Authority, Newcastle upon Tyne.
Conflict of interest: None declared
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References |
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1. Department of Health UK. The National Service Framework for Renal Services. Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life Care. (2005) London: Department of Health.
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18. Department of Health UK. Payment by Results: Technical Papers. Critical Care Funding and Payment by Results (2003) London: Department of Health. [http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=8416&Rendition=Web].
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22. Royal College of Physicians. The Changing Face of Renal Medicine in the UK: the Future of the Speciality. Report of a Working Party. (2007) London: RCP.
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