CARI - Caring for Australasians with Renal Impairment

Guidelines are an important aspect of quality patient care. They provide clinicians with recommendations that help them to practice evidence based medicine. The overall purpose of clinical guidelines is to improve health outcomes and to encourage the appropriate use of resources.

Guidelines are static entities if not put into practice. It takes a motivated team to change practice and incorporate a guideline into daily patient care. An essential part of the guideline development process is the formulation of a dissemination and implementation strategy.

CARI Guidelines staff have been and are continuing to research the best methods for ensuring the use of guidelines in clinical practice. Implementation projects are undertaken to assess both the impact of CARI Guidelines on clinical practice as well as the barriers faced by renal units in the implementation of CARI Guidelines. As Implementation projects progress, CARI will revise the guideline development process and develop tools to assist in guideline implementation.

Criteria used to identify which recommendations should be actively implemented include:

The presence of a strong evidence base supporting the recommendation
Clinical importance
Existence of a clear evidence/practice gap
Patient burden of disease is high
Ability to measure a change in practice
Feasibility of development of an implementation strategy

Implementation projects are conducted according to three prime steps namely:

Phase I. Establish current practices and protocols
Phase II. Conduct implementation trial
Report findings

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.

Appropriate vascular access- baseline and implementation

The Vascular Access Implementation Project was initiated in 2007. This project aims to implement two CARI Guidelines on vascular access, namely: Timing of access formation and Choice of type of access. Nine renal units in 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 to access creation at each of their units and to develop strategies and procedures to improve the number of arterio-venous fistulas created for new haemodialysis patients.

The baseline phase was run over a six-month period from January to June 2008. This was followed by the intervention phase, which commenced in July 2008 and will finish in June 2009.

Barriers to organ donation

With the aid of a seed grant from the National Institute for Clinical Studies (NICS), CARI held a consultation process in October 2005 with representatives from all sectors of the organ donation process. The organ donation process was mapped and barriers to increasing donation rates were documented.

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