My enthusiasm for my work and commitment to providing the best care to my patients, team and renal services has remained unchanged since I started working in the renal and transplant department at St George's Hospital, London, 24 years ago.
Specialising in transplantation for the past 18 years, I have taken every opportunity to develop and improve the pre- and post-transplant services by leading relevant audits, service evaluations, and quality improvement (QI) projects, working in collaborative research with medical colleagues and implementing the recommendations and findings. This has all had a profound impact on the care we offer to our patients and their families. I also enjoy sharing the excellent work we do at St George's locally, regionally and nationally.
I lead my team by example, making sure we are all working towards the same goal, which is to deliver excellent patient care. Recognising team members' strengths and supporting them in their weaknesses helps to build staff morale and confidence, which are necessary to enhance teamwork in our specialist area.
I think that the judges in the BJN Awards 2024 recognised both my nursing and leadership skills, as well as my passion for research and spearheading QI projects, such as streamlining the transplant work-up pathways, especially leading the recent innovation of our electronic referral system for transplant work-up. This was created with the dual goals of reducing waiting times and increasing workflow efficiency (Azamar-Alonso et al, 2019) and integrating this with our Tableau information reporting portal. This allows us to access the referral data instantly for audit and QI purposes and appears to be the first such innovation in renal departments nationally.
Electronic referral system
An earlier audit (Kidney Transplantation: Pitfalls and Ways to Improve) (Fernandez, and Banerjee, 2016) was presented at UK Kidney Week 2016. This showed that waiting for two referrals – a clinic letter to start the work-up and a referral letter to see the surgeon following completion of the work-up – contributed to a delay in the patient's transplant work-up timeline of up to 48 working days.
Working together with the South London Renal Clinical Alliance and the Kidney Quality Improvement Partnership to improve the transplant recipient work-up timeline, possible use of the e-referral system was highlighted. It was concluded that using the e-referral system between members of the multidisciplinary team (MDT) might reduce delays in workup assessment before kidney transplantation.
Hence, I pursued developing this and negotiated with our transplant consultant lead surgeon to use the same e-referral on the pre-transplant assessment (PTA) to cut down the waiting time for the referral letter to the surgeon. The surgeon would be provided with the completed workup sheet and investigation results by the transplant co-ordinator at their PTA clinics. A supplementary nephrology letter would be necessary for patients with complex medical histories.
Developing this project in our department was a challenge, as this was the first e-referral system to be implemented in the renal department. This meant I had to find my way through every step, including contacting the IT department and presenting my request to the Clinical Information Change Group in March 2020. My proposal was accepted, and I was assigned to work with one of the clinical information change managers (CICMs); however, due to the pandemic, this request was not a priority. At the beginning of 2021, I re-engaged with the CICM, who agreed to restart developing the e-referral.
Using my networking and collaborative working skills, we were able to create a quick reference guide for service users, provide staff demonstrations via Microsoft Teams and face-to-face training, and to offer continuous support with the help of the IT team and user champions of the Cerner Millennium patient management system (iCLIP). The new ‘Refer to renal transplant’ e-referral system was launched in May 2021.
Refer to renal transplant e-form
Working with a specialist CICM made developing the refer to renal transplant e-form easier. Having envisioned what we needed and how it would help both the patient and the service also helped the process.
The renal transplant e-referral form was designed to cater to the needs of the service and goes with the flow of the work-up pathway. This is accessed via our electronic patient record, iCLIP, under the ‘Order’ tab, which is the same tab for ordering blood or tests, for example.
Referrers, such as nephrologists and clinical nurse specialists, can refer their patients. Date and time, referrer's name, and recent blood test are automatically populated on the e-referral form, while information on the referring clinic, medical history, cardiac risk assessment and potential donor are to be completed by the referrer.
The transplant and living donor co-ordinator's names and contact details are on the bottom of the form to remind the referrer to give these to the patient so they can pass on the details to their potential donors who need to contact the co-ordinator to express their intention to donate as soon as possible.
The transplant co-ordinator reviews the iCLIP for any new referrals at least twice a day. She will review the e-referral form, complete the decision form by clicking ‘Accept’ or ‘Reject’, and provide the reason for the latter. This will allow her to start the transplant workup immediately – without having to wait for the clinic letter – by reviewing patients' electronic documentation This is followed by a telephone consultation with the patient and booking tests to start the work-up process.
When the workup is completed, and the nephrologist has reviewed the test results and is happy with the patient's condition at that time, the co-ordinator will request the PTA appointment at the same time as asking for a supporting letter from the nephrology consultant, if necessary. The waiting time varies depending on the availability of surgical appointments; however, it has cut down the need to wait for a nephrology PTA referral letter prior to requesting the PTA appointment, as was the case before.
The surgeon will access the same e-referral, and will be provided with a completed workup sheet and the relevant test results on the day of the surgical clinic. They will modify the e-referral form to complete the surgical PTA part. This surgical decision will be accessed by the co-ordinator and actioned accordingly.
Successful innovation
Integrating this e-referral e-form with our Tableau information reporting portal allows us to review the referral data instantly as the reports are updated daily. The reports are also designed as a snapshot of the work-up timeline. This means there is no need to complete the previous time-consuming 18-week pathway spreadsheet.
I am currently working with the CICM to add an ‘Activation date’ on the e-referral form, so that the number of days from decision date to activation date can be extracted, which is the whole transplant work-up timeline. This novel idea has been a successful innovation and is an excellent tool to improve current practice, leading to increased workflow efficiency and outstanding patient care. Hence this has sparked interest nationally. The two significant characteristics of a successful innovation are to be usable and desirable (Kelly and Young, 2017) and this is certainly true in this case.
‘I believe the judges in the BJN Awards 2024 recognised both my nursing and leadership skills, as well as my passion for research and spearheading QI projects’
QI projects
My passion and dedication to outstanding patient care means that I always take on projects that help my patients and their experience. Some of the QI projects I have led include:
- Streamlining the transplant work-up pathway to ensure patients' work-ups are updated monthly
- Developing a robust pathway for reviewing patients for discussion at our cardio-renal MDT quarterly meetings
- Developing a transplant decision documentation pathway so renal patients without a transplant decision will be reviewed quarterly
- Setting up a nurse-led clinic for transplant follow-up in the community health centre
- Streamlining the post-transplant follow-up pathway
- Creating a standard operating procedure for completion of post-transplant follow-up NHS Blood and Transplant forms
- Revising patient information leaflets
- Leading both acute and chronic post-transplant MDT meetings
- Leading COVID-19 staff PCR testing and contributing to developing protocols, pathways and patient information during the pandemic.
Spreading the word
I have also presented at local, regional, national and international meetings on topics, including:
- Embedding patient decision aids at St George's
- Using a dobutamine stress echocardiogram (DSE) in identifying cardiac arrhythmia, cardiovascular events and the role of subsequent cardiovascular angiography
- The benefits of a cardio-renal MDT meeting to manage very high-risk cardiac patients on kidney transplant waiting lists
- Kidney transplantation workup: pitfalls and ways to improve
- Long-term post-transplant follow-up: an exploration in outsourcing.
I have also co-authored two articles with medical colleagues (Ramphul et al, 2018; Junarta et al, 2020).
Other achievements
As a research champion, I was one of the first nurses to have successfully completed the Chief Nurse Research Fellowship programme and the Postgraduate Certificate in Healthcare Research Skills and Methods. I am currently working on a service evaluation project. I am the nurse representative on our Nursing, Midwifery and Allied Health Professionals Steering Group and have co-developed a plan for junior nurses to get involved in and understand the value of evidence-based practice, which is currently being incorporated into the band 5 development programme.
Pride and gratitude
I am extremely grateful for the unwavering support of my team, colleagues, consultants, and, most especially, my family for always having my back. I'd like to thank St George's Hospital for the many opportunities I have been given over the past 24 years. I am incredibly proud to be part of our amazing renal and transplant family and of the work that we do, which strives to continuously deliver excellent service to our patients.
It was a fantastic and humbling experience winning the Renal Nurse of the Year Gold Award in the BJN Awards 2024.