Apexa Kuverji,1 Jo Reed,3 Harpreet Sawhney,3 June James,2 Rob Gregory,2 James Burton,1 Andrew Frankel3 on BEHALF OF Diabetes Care in Haemodialysis Working Group
1 John Walls Renal Unit, Leicester General Hospital, Leicester, UK.
2 Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK.
3 Imperial College Healthcare NHS Trust UK
Address for correspondence: Dr Apexa Kuverji
John Walls Renal Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
E-mail: apexa.patel1989@gmail.com
https://doi.org/10.15277/bjd.2022.343
The Diabetes Care in Haemodialysis (DiH) working group aims to improve the care of people with diabetes mellitus on the haemodialysis unit by supporting the implementation of the 2016 JBDS guidelines. In order to support the implementation of the guideline recommendations the DiH working group have established a set of standards, developed an audit tool to demonstrate adherence to standards, and have developed educational support for haemodialysis staff both online and delivered face-to-face.
We publish audit findings from five distinct haemodialysis units, highlighting the impact of the educational programme on the achievement of guideline standards. We also report the impact of the COVID-19 pandemic on diabetes care and quality improvement.
Br J Diabetes 2022;22:36-41
Key words: audit, haemodialysis, standards, Diabetes Care in Haemodialysis, end stage kidney disease
People with End Stage Kidney Disease (ESKD) caused by diabetes mellitus (DM) account for 27.8% of people on maintenance haemodialysis (MHDx). When taking into account those with ESKD and DM where DM is not the cause of renal disease, this figure rises up to 40% in some units.1 This population are at a particularly high risk of complications such as non-traumatic lower extremity amputation,2 cardiovascular events,3 and death, with overall survival on MHDx in people with diabetes being approximately half that of their non-diabetic peers (3.7 vs. 7 years).4
Due to the scheduling of haemodialysis and the burden of disease, people with diabetes who are on MHDx often find difficulty in accessing the care required for their diabetes, and this cohort may receive suboptimal care. Since they may be under the care of multiple disciplinary teams, this population is also at risk of receiving fragmented care. It is therefore important to integrate joint working to ensure that care is not overlooked or duplicated. In 2016, guidelines aimed at defining good quality care for a person with diabetes on MHDx were published by the Joint British Diabetes Societies (JBDS) in conjunction with the Renal Association.5 These guidelines have been widely supported and have been endorsed by Diabetes UK, Kidney Care UK and the Association of British Clinical Diabetologists. However, despite this widespread support and dissemination, it is unclear whether they are being used widely to improve the care of this population.
The Diabetes care in Haemodialysis (DiH) group defines core standards of care, and provides an audit tool to identify areas of substandard practice. It also provides educational tools to engage haemodialysis staff and people with DM. We describe how utilising the educational programme and other outputs of the DiH can be used to improve diabetes care.
The DiH strategy is built around a defined set of standards to define care of people with DM on MHDx that align broadly to the recommendations made within the JBDS guideline document. These standards were agreed upon by relevant key stakeholders and represent the core standards for DM care:
a) All people with DM undergoing MHDx should have a documented annual review of their diabetes which includes review of glycaemic control, dietary review and foot and eye screening
b) All people with DM on MHDx should have a clearly defined and personalised method of assessing glycaemic control, agreed with and understood by the individual (this should include access to continuous glucose monitoring where appropriate)
c) All people with DM and on MHDx with a HbA1c <58mmol/mol who are on a hypoglycaemic treatment (insulin or a sulphonylurea) should have had an intervention to minimise the risk of hypoglycaemia
d) All people with DM and on MHDx with a HbA1c >80mmol/mol should have had access to advice from the diabetes specialist team in order to facilitate improvement in glycaemic control
e) All units should ensure that there is a clearly defined and easy to access rapid escalation pathway for individuals with active foot complications.
Subsequently an audit tool was created to support the implementation of guidelines and to allow for measure of adherence to standards by haemodialysis staff. The tool included eleven audit standards and measures, exclusion criteria and an audit question corresponding to each standard. The audit standards of care, with the corresponding JBDS recommendations, are highlighted in Table 1.
An important aspect of this strategy has been to engage the multiprofessional haemodialysis staff and people with DM. A face-to-face educational programme for haemodialysis staff was piloted in February 2019 in two renal networks (Imperial College London and Leicester) to ensure that the programme was fit for purpose and meeting the learning needs. An e-Learning module is currently under development to ensure learning is consolidated and resources for learning are provided to haemodialysis units.
Any programme aimed at improving care for people with long-term conditions must also include elements that facilitate patient activation and self-care. In order to support this, a patient charter was created in conjunction with Kidney Care UK and published in Kidney Matters Magazine and on the Kidney Care UK website in February 2020.6 This document is designed to raise awareness and to empower people with DM to be involved in their diabetes care and to understand what to expect in relation to this care once upon a haemodialysis unit.
Education session feedback
Two pilot study days were carried out sequentially for haemodialysis unit staff, first in Leicester and then at Imperial College London, in February 2019. The topics covered are listed below:
The feedback evaluation from both groups (with 14 haemodialysis staff from each group) was extremely positive, as shown in Figure 1 and Figure 2. Feedback from the first session (Figure 1) was carefully evaluated and the second session was adjusted in response to this, resulting in an improvement in feedback (Figure 2).
Qualitative feedback from both groups included quotes such as:
Baseline results from haemodialysis units
The audit tool was initially piloted at three haemodialysis units:
The pilot was then extended to include three further units:
A total of 249 people with DM were included in the audit. The pilot questionnaire was distributed for the individuals and dialysis nurses to fill out. The results for each standard at each haemodialysis unit are shown in Table 2.
Changes were made to the data collection tool after gathering the initial data and user feedback from all haemodialysis units. The final data collection tool was approved taking the feedback into consideration.
Improvement in a region
Three haemodialysis units were re-audited after implementation of DiH-sponsored interventions. The results are highlighted in Table 3.
The interventions included:
Audit tool
There was a difference in the manner in which the audit tool was completed across all the dialysis units. Unit 1 questionnaires were filled in by a DSN and renal doctor; Unit 2 asked the dialysis nurses to fill in the questionnaire; Unit 3 asked the individuals with DM to fill in the questionnaire; and at Unit 4, 5 and 6 the dialysis nurses and a renal doctor completed the questionnaire in conjunction with the individuals.
One of the problems encountered when collecting the data was the lack of documentation by the user; many of the boxes were left blank on the questionnaires that were given to dialysis nurses or individuals with DM to fill in (at Unit 1, 2 and 3). The data from these units may have been influenced by patient recall or limited access of the user to medical records. There were missing data from Unit 3: 30 questionnaires in total were handed out to people with DM on MHDx and only 12 were returned with responses. This suggests that input or oversight from a healthcare professional may lead to better completion of the audit questionnaire. This was confirmed by improved completion of the audit from Units 4, 5 and 6, where the data collected from individuals with DM were cross-checked by a healthcare professional with documented data collected from various IT systems and medical records.
By piloting the audit questionnaire with different users, valuable feedback was gained that enabled adaptation of the questionnaire to make it more practical and fit for use. The questionnaire was adapted in the following ways:
To address the variations in audit user, an audit tool pack, with instructions for use, was developed and distributed to dialysis units to ensure that data were collected and recorded as fully and accurately as possible. The pack was also uploaded to the DiH website for other renal networks to access.7
The improvement of care
Simple interventions improved compliance with most of the care standards measured. Referral to secondary care services for diabetes review resulted in Standard 1a (named diabetes healthcare professional) improving from 68% to 93.8% and Standard 1b (annual diabetes specialist review) improving from 34% to 54.7%. Dietary advice (Standard 1c) improved from 32.7% to 58.8% after presenting the initial findings to the renal dietitians and engaging them into the project. Virtual diabetes-dialysis MDT meetings were conducted to identify those at risk of hypoglycaemia. These improved the compliance to Standard 3b (hypoglycaemia risk) from 44.4% to 51.9%. The educational sessions and foot care pathway empowered the nurses to identify foot problems early and improved compliance to Standard 5a (weekly foot inspections) from 50% to 68.6%.
There was significant variation in degree of improvement between the three units, particularly for standards relating to nursing care. Two of the units showed significant improvement within the first few months, however there was a delayed improvement shown from one of the units. This was attributed to a number of factors, including a change in service provider, inadequate training, and low level of staff confidence in recognising foot complications.
The impact of COVID-19 on diabetes care
The COVID-19 pandemic has affected many usual care processes in the NHS. It has also had an impact on service improvement. Provision of opportunistic diabetic eye screening at the dialysis unit was put on hold due to infection control measures during the COVID-19 pandemic. The compliance to Standard 1d (annual eye screening) therefore remained relatively stable throughout the year.
Regional outpatient care was initially cancelled to support inpatient services, and subsequently restarted in virtual format to reduce the risk of infection transmission. Compliance to Standard 4 (review in preceding 3 months if HbA1c >80 mmol/mol) dropped from 100% to 66.7% during this period of the COVID-19 pandemic. An explanation for this may be the temporary suspension of outpatient care. Further re-audits may show that the compliance to the standard resumes once usual care processes resume.
Future DiH work
Current care has been evaluated based on the standards above, but the 2021 updated guidance from JBDS may prompt adaptation of the standards. In particular, Standard 3b may be modified to state that, “All people on insulin or a sulphonylurea should have assessment by blood glucose monitoring/continuous glucose monitoring to determine if they require a reduction in dose.” This will take into consideration cases where HbA1c may be falsely low due to altered red cell turnover and reduce the risk of treatment being automatically reduced inappropriately.
The DiH audit tool has been developed to collect information about the standards of diabetes care on haemodialysis units. The tool is easy to use but pilot studies revealed that in order to improve completion of the audit questionnaire, encouragement and input from healthcare professionals is critical. The educational programme has received positive feedback and has resulted in improvement in compliance to standards on re-assessment. The compliance to some standards has been affected by competing demands driven by the COVID-19 pandemic, and further re-audits are necessary to assess the long-term effects of this. Future work from DiH includes releasing e-learning materials for haemodialysis staff, adapting standards based on the future JBDS guideline updates and sharing areas of good practice.
Conflict of interest AK, HS, RG: none. JR: paid by NAPP for non-promotional meetings. AF: receipt of research grants, preparation of educational materials and attendance at drug advisory boards for Boehringer Ingelheim, AstraZeneca, NAPP and VP UK. JJ: advisory board for NAPP, payment for educational non-promotional meeting. JB: honoraria for speaker engagements or travel from Astellas, AstraZeneca, Vifor, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer. Grant funding through the University of Leicester from National Institute of Health Research, Kidney Research UK, the British Heart Foundation and Yakult Honsha.
Funding This project was supported by grants from the Diabetes Care Trust and Diabetes UK.