Implementatieplan

Implementation Plan

This implementation plan has been formulated to improve the implementation of the guideline Safe Use of Contrast Media, part 1. In the preparation of this plan an inventory has been made of the promoting and limiting factors in the use of the recommendations. The working group of this guideline advised on the time path for its implementation and the specific actions that need to be performed by the various stakeholders.

Methods

The Working Group has made an inventory for each of its (strong) recommendations:

when the recommendations can be implemented in all hospitals.
the expected impact of implementation of the recommendation on hospital costs.
limitating conditions to implementation of recommendations.
barriers to implementation of recommendations.
actions to promote implementation of recommendations.
identification of the parties that are responsible for such actions.

Not every item could be answered for every individual recommendation. There are weakly and strongly formulated recommendations. For the weakly formulated recommendations there is more room for alternative options. The inventory is done more completely for strongly formulated recommendations.

Implementation Timeline

Strongly formulated recommendations are generally implemented in a short time, for instance in the coming 12 months. This means that these are to be implemented before August 1^st, 2018.

As there was a great demand for the revision of the Prevention of CI-AKI part of this guideline by the entire Dutch medical community, it is expected that implementation may proceed quite swiftly.

Impact on Healthcare Costs

Many recommendations have no, limited or positive consequences for healthcare costs.

The reduction in the number of patients that need preventive hydration as well as the short hydration protocol that does not need to be performed anymore in an expensive day hospital setting will have a positive effect on the reduction of healthcare costs.

A detailed summary of the recommendations and the details of their effects on healthcare cost are shown below in Table 1.

Specific Actions for Stakeholders

The actions which need to be taken by stakeholders are listed below.

The primary responsible scientific society (Radiology, NVvR):

Distribution of this guideline text among its members, via all NVvR sections.
Publication of a summary of this guideline in a peer-reviewed medical journal and on the society’s website NetRad (www.radiologen.nl).
Sharing of this guideline with their European sister organisations.
Sharing of this guideline with influential contrast media safety guideline committees from the European Society of Urogenital Radiology (ESUR), American College of Radiology (ACR), Canadian Association of Radiologists (CAR), Royal Australian and New Zealand College of Radiology (RANZCR), and Japan Radiological Society (JRS).
Checking the implementation of the recommendations of this guideline via specific audits and the routine quality visitation system of radiology groups.
Creation of a continuous modular maintenance system for this guideline and its sub guidelines.

All other directly involved scientific societies (NFN, NIV, NVVC, NVVH, NVIC, NVKC, etc.):

Distribution of this guideline text among its members.
Checking the implementation of the recommendations of this guideline via audits and the quality visitation system.
Creation of a continuous modular maintenance system for this guideline and its sub guidelines.

All local MSBs, specialist groups or individual medical professionals:

Distribution this guideline text among its members or in local working groups.
Adaptation of local patient information based on the information in this guideline.
Discussion with other involved specialities to come to a system to implement the guideline recommendations in local practices.

Healthcare system stakeholders (like the insurance companies, (organisations of) hospital administrators, Healthcare Inspection):

It is expected from hospital administrations that they reserve financial means for implementation of this guideline in their Hospital Information System and in local quality systems. In addition, it is expected from insurance companies that they compensate the costs of the care that is detailed in this guideline.

Knowledge Institute of Medical Specialists (KIMS):

Addition of this guideline to the Dutch Guideline Database (www.richtlijnendatabase.nl).
Inclusion of this implementation plan on easy to find locations.

Table 1 Implementation of recommendations

Recommendation	Timeline for implementation <1 year, 1-3 year or 3-5 years	Expected effect on healthcare costs	Boundary conditions for implementation (within the indicated timeline)	Potential barriers for implementation	Actions that need to be undertaken for implementation	Parties responsible for actions	Other remarks
Risk factors
Optimal nephrology care should be the primary goal in all chronic kidney disease patients, especially with attention to medication-use. Patients with an eGFR <30 ml/min/1.73m² should be referred to a nephrologist.	<1 year	Cost decrease if patients are referred to a nephrologist on time	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Provide hydration in hypovolemic patients before any examination using intravascular iodine-containing CM.	<1 year	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Consult a nephrologist for patients with an eGFR <30 ml/min/1.73m.	1-3 years	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
For patients undergoing intravascular iodine-containing contrast medium administration: Consider patients with an eGFR < ml/min/1.73m² at risk for PC-AKI.	1-3 years	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Apply the same recommendations, indicated for patients with bilateral kidneys, to patients with a solitary kidney subjected to iodine-containing contrast administration.	1-3 years	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Consider that low osmolar contrast media and iso-osmolar contrast media have the same safety profile.	1-3 years	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use prediction tools to estimate the risk of PC-AKI, since their validity and effect on clinical outcome is unclear.	1-3 years	Cost decrease if patients are hydrated when needed – reduces risk of costly complications	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
eGFR measurement
Determine eGFR in each patient scheduled for Computed Tomography or Angiography with or without intervention with use of intravascular iodine-containing contrast media. The measurement of eGFR is valid: -For 7 days when the patient has an acute disease or an acute deterioration of a chronic disease. -For 3 months when the patient has a known chronic disease with stable renal function. -For 12-13 months when the patient was previously healthy.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Determine eGFR within 2-7 days after intravascular contrast administration in every patient for whom preventive measures against PC-AKI were taken.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
If PC-AKI is diagnosed (by KDIGO criteria), follow the patient for at least 30 days post-diagnosis and re-assess serum creatinine.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Measure the serum or plasma creatinine using a selective (enzymatic) method.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Implement the creatinine based CKD-EPI formula for estimation of the eGFR.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Consider correcting the eGFR for BSA in the CKD-EPI formula in case that the patient specific body surface area (BSA) is known.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Optimal hydration strategy
For patients undergoing intravascular administration of iodine-containing medium with an eGFR <30 mL/min/1.73m² either one of the following options can be used: 1) Prehydrate with 3ml/kg/h NaHCO₃ 1.4% for 1h pre-CM administration 2) Pre- and posthydrate with 3ml/kg/h NaHCO₃ 1.4% for 1h pre-CM and 1ml/kg/h for 6h post CM administration.	1-3 years	Decrease of healthcare costs is expected, mainly due to decrease in hospital admission time	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use hydration with controlled diuresis for the prevention of PC-AKI in patients undergoing (cardiac) angiography with or without intervention, unless it is performed in a research setting.	1-3 years	Decrease of healthcare costs is expected, mainly due to decrease in hospital admission time	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use oral hydration as the sole means of prevention of PC-AKI.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Measures other than hydration to prevent PC-AKI
Consider giving short term (48 hours) high dose atorvastatin or rosuvastatin in addition to hydration in statin-naïve patients with eGFR <60 ml/min/1.73m² undergoing coronary angiography with or without percutaneous coronary intervention.	1-3 years	No significant effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use NAC for the prevention of PC-AKI in patients with a normal or impaired (eGFR <60 ml/min/1.73m²) kidney function.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use vitamin C exclusively for the prevention of PC-AKI in patients with a normal or impaired (eGFR <60 ml/min/1.73m²) kidney function.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not routinely withhold ACE-inhibitors, Angiotensin receptor blockers or diuretics prior to intravascular contrast administration.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Withhold NSAIDs prior to intravascular iodine-containing contrast medium administration.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
The working group recommends nephrology consultation before administering iodine-containing contrast in patients with eGFR <30 mL/kg/1.73m2 to individualize continuation or discontinuation of ACE-inhibitors, angiotensin II receptor blockers, diuretics or nephrotoxic drugs and weigh this against the potential benefits and harm of the administration of iodine-containing CM.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use prophylactic dialysis in patients with chronic kidney disease stage 4-5 receiving intravascular contrast for coronary angiography with or without percutaneous intervention, to lower the risk of post contrast acute kidney injury.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not use prophylactic hemofiltration routinely in patients with chronic kidney disease stage 4-5 receiving intravascular contrast for coronary angiography with or without percutaneous intervention.	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Do not adapt the schedule of chronic dialysis to the performance of a contrast-enhanced imaging study (or in other words: the scheduling of a contrast-enhanced imaging study does not need to be adapted to the dialysis schedule of the patient).	<1 year	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Metformin
Continue metformin in all patients with an eGFR 30- 44 ml/min/1.73m² scheduled for imaging to whom intravascular iodine-containing contrast medium is administrated.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals
Discontinue metformin in all patients with an eGFR <30 ml/min/1.73m² to whom intravascular iodine-containing contrast medium is administrated as soon as this level of kidney dysfunction is detected and inform the requesting physician.	1-3 years	No effect on costs is expected	None expected	Lack of knowledge	Dissemination of guideline	Scientific societies participating in guideline working group Hospitals Educators in teaching hospitals