MO887THE IMPACT OF A MULTI-DISCIPLINARY CLINIC ON THE OUTCOMES OF INCIDENT DIALYSIS PATIENTS IN A REGIONAL HOSPITAL IN SINGAPORE
Authors: Lai Boon Cheok , Chawla Mayank , Baikunje Shashidahar , Yeoh Lee Ying , Tan Marie , K.g Elianna 
Published: May 2021

Abstract

Background and Aims
Institution of a pre-dialysis programme has been shown to improve the outcome of the chronic kidney disease (CKD) patients approaching end stage renal disease (ESRD). A renal multidisciplinary clinic (MDC) aimed at reducing unprepared dialysis initiation is known to reduce morbidity in such patients and reduce the risks of complications once the patient initiates dialysis. The design of this service is of paramount importance to ensure efficient delivery and to achieve optimal utilization of the resources.
The number of patients requiring urgent initiation of dialysis is alarmingly high in Singapore as compared to elective initiation, and our hospital was no exception when we started the renal service in 2018. Patients with unplanned initiation of RRT either because of lack of referral/late referral, infrequent follow up with the nephrologist or because of other factors such as inadequate knowledge of disease trajectory, or poor compliance to medications, tended to have worse outcomes.

Method
We recruited the patient who initiated dialysis between July 2018 to July 2020 in our Quality Improvement (QI) project.
In the MDC group, the patient will be reviewed by a dedicated team of nephrologists, renal coordinators (RC) and medical social workers (MSW) and comprises of 2 mutually exclusive components: low clearance clinic (LCC) and transitional care clinic (TCC).
In the MDC, nephrologist takes a lead role for the patient’s overall medical assessment and treatment. Renal coordinator provides the CKD and dialysis education to empower patient to make the correct RRT choice. MSW provides psychosocial support and financial counselling.
The LCC became operational from 07th September 2018 while the TCC was initiated on 12th July 2019. CKD patients who are deemed likely to need RRT in the coming one year by the primary nephrologist are scheduled to attend LCC. Upon initiation of haemodialysis, all patients are referred to the TCC in the first month of their discharge.
In the conventional group, we recruited the patient who have not attended MDC before or after dialysis initiation.
Retrospectively, their data including baseline demographic and morbidity parameters were collected in the MDC group and conventional group.
Morbidity outcome like definitive dialysis access, needs of intensive care unit (ICU) admissions, complications like catheter related blood stream infections (CRBSI) and other infections, stroke and myocardial infarction (MI) were analysed.

Results
There are 130 patients initiated on RRT between July 2018 to July 2020. The percentage of patient started dialysis with a definitive access was greater in the MDC group (25%) as compared to the conventional group (9%) (p=0.03). Although statistically not significant, the incidence of intensive care unit (ICU) admission was also lower in the MDC group (10%) than the conventional group (31%) (p=0.06).
After initiation of dialysis, the patients in the MDC group had lower rates of CRBSI (5.6%) than the conventional group (14%) (p=0.17). These patients also had lower rates of other infections and major adverse cardiovascular outcomes (13% in MDC group versus 37% in conventional group) (p=002). The rate of recurrent admission, defined as frequent admissions up to 3 times per year, was lower as well in the MDC group (13%) as compared to the conventional group (35%) (p=0.003).

Conclusion
This QI project has demonstrated the benefit of MDC in improving the lives of the incident dialysis patients. Moving forward, we aim to continue to evolve this clinic in order to match the changing needs of our patients, with a view to increase its uptake, and to increase the percentage of patients having elective starts with a definitive dialysis access to at least 65% as per target set in NKF-KDOQI 2009 guidelines, in order to help them achieve the maximum benefit out of this endeavour.