Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care

Background
An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data within the electronic health record (EHR). This patient safety tool notifies GP practices when falling eGFR values are identified. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, the option for specialist advice, and written reflection on management.

Aim
To identify practitioner perceptions of trigger tool use and value from interview data, and compare these with the written reflections on clinical management recorded within the tools.

Method
Eight semi-structured interviews with 6 GPs, 1 pharmacist and 1 practice manager were recorded and transcribed. Thematic analysis of the interview transcripts was undertaken using framework analysis. The free-text reflective comments recorded in the trigger tools of 1,921 cases were organised by referral category ‘yes’ and ‘no’, with each category stratified by age into ‘younger’ and ‘older’ cases. Subsequently the themes arising from the interviews were compared with the descriptive analysis of the reflective comments.

Findings
Three themes emerged from interviews: Getting started, Patient safety and Practitioner and Practice learning. Well organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The trigger tool was seen to contribute to patient safety, and as a tool for learning about CKD management, both individually and as a practice. Reflective comments from 1,921 trigger tools were examined, these supported the theme of patient safety from the interviews. However the free text data, stratified by age, challenged the expectation that younger cases would have higher referral rates, driven by a higher level of risk for CKD progression.
Conclusion
Building electronic trigger tools from the EHR can identify patients with a falling eGFR prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the trigger tool supported the patient safety agenda and in addition encouraged team and individual learning about CKD management.