Getting Research into Practice: ensuring the use of Guidelines in clinical practice

Implementation Projects: Vascular Access & Iron

The Vascular Access Implementation Project was initiated in 2007. This project aims to implement two CARI Guidelines for vascular access, namely: Timing of access formation and Choice of type of access. Nine renal units within Australia and New Zealand are taking part in this study. The units are working together with the CARI Guidelines project officer to identify the barriers for access creation at each of their units and to develop strategies and procedures to improve the number of fistulas created for incident haemodialysis patients.

The baseline phase took effect over a six month period from January to June 2008. During this period we identified barriers and enablers to access creation as well as collect baseline data for each unit. The data was analysed and consensus was reached with the units to implement strategies to improve arteriovenous fistula creation. The intervention phase was conducted over 12 months.

Project Members

Chief Investigator – Dr Kevan Polkinghorne
Project Coordinator – Pamela Lopez-Vargas

Participating Units – Project Leaders and Access Coordinators

Concord Repatriation and General Hospital – Dr Martin Gallagher & Catherine Stevens
Gold Coast Hospital – Dr Murthy Divi & Dianne Du Toit
John Hunter Hospital – Conjoint A/Professor Alastair Gillies & Tara Csuka
Liverpool Hospital – Conjoint A/Professor Michael Suranyi & Noermir Gonzalez
Middlemore Hospital – Dr Hla Thein & Peta Kelly
Monash Medical Centre – Dr Kevan Polkinghorne & Mechelle Seneviratne
Nambour General Hospital – Dr Nicholas Gray & Sandra Glass
Royal Melbourne Hospital – North West Dialysis Service – Assoc. Professor Eugenia Pedagogos & Jayne Amy
Royal Prince Alfred Hospital – Dr Paul Snellling & Catherine Stevens

Iron Guideline – baseline and post implementation results

In 2004, the first stage of an Iron implementation project was commenced. This involved performing a clinical audit of 6 renal centres for their practices and procedures regarding Iron levels for their patients and comparison of these results against the CARI Guidelines on iron and haemoglobin targets in use at that time. We found that there was considerable variability in achievement of iron and haemoglobin targets, with 30-68% falling within ferritin targets of 300-800 µg/L; 65-73% within transferrin saturation (TSAT) targets of 20–50 % and 25-32% of patients in the haemoglobin targets of 110-120g/L, across the units. Barriers to implementation include lack of knowledge, lack of awareness or trust in the CARI Guideline, inability to implement the guideline, as well as inability to reach agreement within a unit to a uniform protocol. Factors that were associated with achievement of targets set by the CARI Guidelines included having a nurse-driven iron management protocol, use of an iron management decision aid, presence of fewer nephrologists per dialysis unit, and whether the unit’s protocol aimed at actively keeping iron levels within target range (“proactive”) or only reacting if out of range (“reactive”). More details about this project can be found in the published paper:

Irving MJ, Craig JC, Gallagher M, McDonald S, et al, Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis. MJA 2006:185(6):310-314.

In 2005, the second stage of this project was begun. Six renal units were monitored for their iron management and ferritin, haemoglobin, TSAT and epoetin use. Three of the 6 units actively made changes in their iron management practices to reflect the guidelines. Strategies to implement the CARI iron guideline differed in each unit. Each unit focussed on their management of in-centre haemodialysis patients. Wide variation of iron indices was observed across the units. Statistically significant improvements in median ferritin levels were seen across the study. Based on our observations, the variation in results between the 3 units are due to differences in the upper management support for the project, workplace culture and selection of opinion leaders to oversee the practice change. This study shows that with a senior, motivated, opinion leader implementation of a guideline can indeed be successful. Support from an external body such as CARI may assist units to change.

A paper outlining further results of this study is currently being written.

Results from this project were presented at the ANZSN meeting in September 2007 and the 4th Guidelines International Network conference held in August 2007 in Toronto, Canada.