Improving documentation of decisions on transplant status

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Improving our documentation of decisions on transplant status for patients with eGFR of less than 20

Dorset County Hospital,​ part of the South West Transplant First KQuIP project

Quality Improvement Leads: Kathleen O'Neill   Gemma Fox

At the beginning of this project, we were uncertain of the reasons for the delays in our kidney donor and recipient pathways, and wanted to find out more through consistent measurement of data, the mapping of processes and the introduction of interventions.​

A driver diagram was used to highlight the primary and secondary drivers, and this led us to develop the change ideas for all units.

At Dorset County Hospital, while concentrating on what the problem areas were, we initially focused on a ‘quick win’ of aiming for all patients with an eGFR <20 to a have documented transplant status. The project concept was presented to the Multi-Disciplinary Team (MDT) to engage the wider renal team in supporting the project.

The plan for the first Plan, Do Study, Act (PDSA) cycle was for:​

  • Low clearance nurses to identify patients without status in clinic and remind consultants to document.​
  • Transplant nurses to document status when asked to make patient education appointments.​
  • Monthly review identifying all patients without status and disseminating this to respective consultants to prompt action.​

These actions resulted in a significant improvement in the recording of transplant status between Q1 (59.92%) to Q3 (87.43%) in 2019.​ This has also promoted more appropriate referrals for transplant assessment and greater transplant specialist nurse communication, as well as increased involvement within the teams.​

Post-COVID-19 –There have been delays in patients having appointments for tests etc, but this hasn’t affected them being considered suitable for a transplant. ​

The Dorset County Hospital team presented a poster at UK Kidney Week. You can see the poster below:

Want to know more? Get in touch with the QI team

Kathleen O'Neill   Gemma Fox


NICE accredited clinical practice guidelines 

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25th Annual Report

Analyses about the care provided to patients at UK renal centres.

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2022 UKRR AKI Report

A report on the nationwide collection of AKI warning test scores. 

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