Background

180 end-stage renal disease (ESRD) patients undergo kidney transplantation at the Toronto General Hospital Multi-Organ Transplant Unit yearly. 30% develop delayed graft function (DGF), defined as the need for dialysis within 7 days post-transplantation. This rate may increase, as the current organ shortage encourages the selection of increasingly marginal quality renal allografts. Patients with DGF often have their admission prolonged over due to the need for biopsies and continued dialysis. In addition, their care involves the complex interplay of multiple services resulting in additional redundancies and delays. Standardizing and streamlining the discharge pathway of kidney transplant recipients with DGF could lead to more consistent quality of care while reducing length of stay and its associated costs.

Methods

We retrospectively reviewed charts of kidney transplant recipients between 1 January 2014 and 31 December 2015. Baseline characteristics between DGF and non-DGF recipient groups were compared using the t-test for categorical variables, and linear regression for continuous variables. Stakeholders involved in the frontline care of kidney recipients were surveyed and engaged in process mapping of discharge pathways, and in-depth root cause analyses of delays in discharge. Change interventions were then selected as per the Method for Improvement, and evaluated through sequential Plan-Do-Study-Act (PDSA) cycles. Length and cost of stay, early hospital readmission (EHR) rates, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores were compared pre- and post-interventions.

Results

86 patients in our cohort developed DGF. The median length of stay for the DGF group was 14.0 days (IQR 10.0-22.0), 6.0 days longer than that of the non-DGF group (median LOS 8.0, IQR 6.0-1.0). Delays in obtaining biopsies, patient deconditioning, and suboptimal communication between transplant and dialysis units were identified as significant drivers for prolonged length of stay, prompting the implementation of automated alerts for timely consultation, and standardized handover forms. LOS post-intervention was decreased, with unchanged EHR rates and HCAHPS scores, resulting in cost-saving.

Conclusion

Application of the Method for Improvement can easily identify inefficiencies, allowing greater simplification and uniformity of care, and leading to the more effective and safer discharge of DGF patients.

CITATION INFORMATION: Chan E, Kim J. Streamlining Discharge Pathways in Kidney Transplant Recipients with Delayed Graft Function. Am J Transplant. 2017;17 (suppl 3).

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