Restarting vascular access and transplantation safely

Review of London kidney teams’ response to COVID-19
March-June 2020

Summary of key themes

1. Review local and national shielding guidance, and current practice, and establish a consistent approach across London for before and after surgery
2. Continue pan-London collaborative work for both vascular access and transplantation to inform and coordinate surgery re-start, and follow through with pathway quality improvements
3. Develop opportunities for improving data sharing and analysis, particularly for vascular access waiting times management and improvement plans
4. Consider joint approach to surgical training
5. Share further information to promote consistency on patient information, advice helpline, counselling and consent
6. Make clear pan-London plans to assure the continuation of vascular access and transplant surgery during resurgence or second wave pressures
7. Develop plans for more resilient and assured vascular access service including consideration of ring-fenced cold site activity to protect capacity and flow
8. Re-start collaborative work on transplant work-up, unifying pathways, clearing backlog and think about 'investigation centres'
9. Consider how to optimise swabbing of pre-emptive transplant patients

Next steps

• Review local and national shielding guidance, and current practice, and establish a consistent approach across London for pre and post-surgery
• Develop and continue with vascular access pan-London collaborative working
• Working pan- London, standardise the deceased and living donor kidney transplant work-up pathways e.g. cardiac diagnostic tests
• Develop the concept of mutual aid to accommodate the potential need for local plans to be curtailed again in a resurgence or a second surge.

Summary of discussions

What worked well?

• The Independent Sector provided green COVID-19 pathways, within the national contracts, which accelerated the surgical restart programmes
• Close working between the renal networks and NHSE&I enabled good use of the Independent Sector to restart Vascular Access and Living Donor Kidney Transplant for most units in London
• The pan-London Vascular Access collaboration has empowered clinicians and has been effective to share learning and to manage the phased restart of surgery
• Living donor transplantation was restarted after patients had been surveyed and expressed a strong wish (90%) to restart
• The renal network promoted sharing of shielding and surgical protocols across units
• The concept of mutual aid is now established
• Home delivery of immuno-suppression medication was expanded in many units

Key challenges

• Closing surgical services is relatively easy, however re-opening safely is very difficult
• Assuring equity of access has been a key challenge, particularly in the living donor cohort for complex patients and for vascular access patients already on dialysis
• Re-start plans have needed higher levels of capacity initially to reduce the backlog of activity
• Waiting time data for vascular access is not yet recorded in standard waiting lists (patient treatment list) format in many trusts
• The nature of satellite and in centre dialysis has prevented patients from meeting shielding criteria and has therefore limited their access to surgical low-risk pathways
• Guidance on isolation and shielding was not always clear, leading to issues for patients with sick pay and safety at work
• There has been a significant impact on complex patients and delays in the Deceased and living donor kidney transplant workup pathway e.g. reduced access to clean/green diagnostic facilities

What could we do better?

• Provide more complete pan-London information on surgical capacity, demand and waiting times profiles
• Plan to accommodate high risk patients and assure equity of access for vascular access and living and deceased donor kidney transplant patients
• Develop a plan that enables some continuity of surgical procedures safely if there is a second wave of infection
• Continue to work with all units in London to standardise surgical pathways
• Follow consistent shielding guidance pan-London
• Create better measures to assure equity of access
• Review good practice across London units to share transplant follow-up process e.g. St George’s ensure all transplant recipients are on home delivery from 90 days post-surgery in the absence of complications