Death Audit 2012Aled Lewis

Hemakumar Mallappa

Background Audit started with 2010 cohort in North Wales

Aims to assess number of deaths of RRT patients

if death within 1 year, was conservative management more appropriate?

location of death, and palliative care involvement

subjective assessment if death was expected and/or preventable

documentation of cause of death

Extended to all Wales 2011

Difficulty comparing data, and depth of information

Data unadjusted therefore comparisons impossible between units

Definitions Prevalent population

All patients on RRT surviving for >90 days from start of modality during the year in question

But Renal Registry definition All patients aged >18 years, alive and receiving RRT on 31st

December who had been on RRT for at least 90 days at a UK adult centre

UK Renal Registry 15th Annual Report

Figure 5.26. One year death rate per 1,000 patient years by UKcountry and age group for prevalent dialysis patients, 2010 cohort

UK Renal Registry 15th Annual Report

Figure 1.1. RRT incidence rates in the countriesof the UK 1990–2011

UK Renal Registry 15th Annual Report

Figure 2.1. Prevalence rates per million populationby age group and UK country on 31/12/2011

UK Renal Registry 15th Annual Report

Figure 5.24. One year survival of prevalent dialysis patients by centre adjusted to age 60, 2010 cohort

UK Renal Registry 14th Annual Report

Figure 6.24. One year survival of prevalent dialysis patients in each centre adjusted to age 60, 2010

Unit Prevalent Rates 2012South East

South West

Bangor Wrexham

Glan Clwyd

HD 491 357 86 103 90

PD 77 70 15 22 20

Tx 824 275 68 138 83

Total 1392 702 169 263 193

Deaths 113 * 74 14 * 29 19

*transplant deaths not documented

Prevalence figures from November 2012 Wales RRT Capacity Data, Kieron Donovan/WRCN

South East 99 HD, 14 PD =113 deaths

Mean age 72.14 years

Mean length of RRT 4.32 years

20 dialysis withdrawals

16 deaths within 1 year of starting modality

63 patients had previous RRT modality

South West 62 HD, 7 PD, 5 transplant = 74 deaths

Mean age 73.3 years

Mean length of RRT 4.98 years

13 dialysis withdrawals

13 deaths within 1 year of starting modality

17 patients had previous RRT modality

25 deaths predictable

3 preventable

Bangor 10 HD, 4 PD = 14 deaths

Mean age 73.9 years

Mean length of RRT 4.18 years

5 dialysis withdrawals

0 deaths within 1 year of starting modality

7 patients had previous RRT modality

9 deaths predictable

0 preventable

Wrexham 19 HD, 4 PD, 6 transplant = 29 deaths

Mean age 68.9 years

Mean length of RRT 6.91 years

7 dialysis withdrawals

4 deaths within 1 year of starting modality

11 patients had previous RRT modality

16 deaths predictable

2 preventable

Glan Clwyd 12 HD, 3 PD, 4 transplant = 19 deaths

Mean age 70.86 years

Mean length of RRT 8.2 years

10 dialysis withdrawals

3 deaths within 1 year of starting modality

10 patients had previous RRT modality

12 deaths predictable

2 preventable

Deaths Within 1 Year

South East 16 deaths within 1 year- all HD

Mean age 72.01 years

3 previous RRT modalities

9 unknown/unexpected

7 expected, with 4 withdrawal of dialysis

South West 13 deaths within 1 year (12 HD, 1 PD)

Mean age 78.3 years

1 previous RRT modality

5 predictable, 3 withdrawal of dialysis

11 deaths in hospital, 2 at home

Palliative care involved in 3 deaths

1 preventable

Bangor No deaths within 1 year

Wrexham 4 deaths within 1 year (3 HD, 1 PD)

Mean age 76.5 years

No previous RRT modality

All predictable, 2 withdrawal of dialysis

3 deaths in hospital, 1 at home

Palliative care involved in 2 deaths

None preventable

Glan Clwyd 3 deaths within 1 year ( All HD)

Mean age 69.54 years

1 previous RRT modality

2 predictable, 1 withdrawal of dialysis

2 deaths in hospital, 1 at home

Palliative care involved in 1 death

None preventable

Preventable Deaths

South East

South West 3 deaths preventable

1. 60 year old, HD via AVF 27 months

High grade lymphoma and PVD

2. 45 year old, transplant for 58 months

Metastatic carcinoma

3. 76 year old, HD via AVF 3 months

Ischaemic limb, known PVD and DM

Bangor No deaths preventable

Wrexham 2 deaths preventable

1. 84 year old, HD via permcath 19 months

DM and previous CVA

Fall, fractured NOF

CDT+ve, following sepsis

2. 59 year old, HD via AVF 14 months

DM and IHD

Sepsis due to VRE after starting methotrexate (not in dialysis centre)

Glan Clwyd 2 deaths preventable

1. 55 year old, failing transplant with AVF (312 months)

DM- collapse at home with hypoglycaemia

Delayed presentation with hypoglycaemic brain injury

Treatment withdrawn on ITU

2. 84 year old, HD via permcath (42 months)

Severe OA- total hip replacement

Died on ITU post-op, pneumonia and CCF

Summary Difficult to define prevalent RRT population

Impossible to compare death rates between units, but may provide early indication of high death rates in individual units

Allows comparison of RR data, more detailed assessment of comorbidity data, and further feedback if information requested

Importance of ongoing RRT education to inform on conservative management

Action points Move to incident death reporting

Document pre-emptive transplant rate and conservative management numbers

Consider earlier decision on withdrawal of dialysis, and palliative care involvement (?Advance Care Plan for all RRT patients)

Support discharge home if palliative care (55 withdrawals, 13 deaths at home)

Any Questions?