Post on 21-Mar-2017
Dr Richard Fluck National Clinical Director (Renal)
NHS Englandrichard.fluck@nhs.net
Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury
Secondary care considerations
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 2
What is acute kidney injury?
Acute kidney injury (AKI) is a rapid
deterioration of renal function,
resulting in inability to maintain
fluid, electrolyte and acid-base
balance. It normally occurs in the
context of other serious illness (e.g.
sepsis) on a background of risk.
KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney International Supplement 2012; 2(1): 1-138
How is AKI defined?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 3
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 4
Who is most at risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 5
Two patients are admitted via accident and emergency on a Friday night.
George, an 86 year old man has crushing chest pain and ECG changes consistent with a large heart attack.
Julia, a slim 56 year old, with long standing diabetes, has not been feeling right - the GP did a blood test and her serum creatinine is 456 umol/L.
Who should we most be worried about?
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Why is it important?Associated with other serious illness
“Force multiplier” for poor outcomes
Potential to improve care
Reduce avoidable harm - death and morbidity
Reduce cost
Important marker of illness
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
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Mortality with AKI stage
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
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NCEPOD report published in 2009
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Poor assessment of risk factors for AKI and acute illness
Delays in recognising AKI
Most patients with AKI are not cared for by nephrologists
Most patients with AKI are not cared for by nephrologist
‘Good’ care in <50% cases
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Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
For George, his risk of death is 32.2%
For Julia, her risk of death is 53.1%
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Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Our shared purpose: reduce harm related to AKI
Who is at risk?
When do people sustain AKI?
How should patients with AKI be
managed?
What do people need to know?
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Understanding RiskVulnerability
A fixed set of characteristics – e.g. age, comorbidities including CKDs, diabetes, drugs
TriggerAn event that might precipitate AKI, e.g. surgery, sepsis
ResponseMitigating the risk e.g. sick days rules, monitoring
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The vulnerable populationFixed factors
The elderly
The frail
Existing comorbidities
Chronic kidney disease
Previous history of acute kidney injury
Modifiable risk factors
Drugs
NSAID – auto-regulation
Diuretics – volume status
ACEi/ARB and other BP targeted medications – BP and auto-regulation
Metformin – side effects enhanced
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Reducing risk: Sick day guidance (a.k.a rules)
Previous history of acute kidney injury
Bristol CLAHRC undertaking formal evidence review
Plan to use this to build consensus with other stakeholders e.g. British Hypertension Society, British Society for Heart Failure
Interim position statement prepared for Think Kidneys website - bit.ly/TK-Sick-Day-Rules
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 14
Improving diagnosis: using changes in serum creatinine
Laboratory definition and standardisation
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 15
National Algorithm
Based in LIMS
Compares serial creatinine measures
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The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
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Is it enough to do a test?
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In conclusion, this randomised, controlled study did not show a meaningful benefit of an electronic alert system for acute kidney injury in patients in hospital.
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Detect Alert
Lets talk about ‘alerts’
Respond
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
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Care bundles and response
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
STOP-AKI Aintree University Hospital, Liverpool
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Change package
Automated test-alert
Care bundle
Education package
Results
Mortality reduced from 26% to 19%
Length of stay reduced by 2.7 days
Chong et al ASN November 2015
Abstract presentation
The national CQUIN and recovery
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 22
Year 1
Discharge communication
Communication of AKI
Need for follow up
Medications
Why?
High readmission rates
Primary care knowledge
Future risk
Medicines management
The impact of AKI on people with diabetes
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Clin J Am Soc Nephrol. 2011 Nov;6(11):2567-72. doi: 10.2215/CJN.01120211. CV1, Christianson A, Himmelfarb J, Leonard AC.
‘AKI warning stage’
Patient management
system
Alert Response
Local systems
MessageMaster patient index
Other data systems
AKI Registry
RegionalNational Research
QI
System Measurement
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SummaryAKI is:
Common1 in 5 of all emergency
admissions2/3 starts in the community
CostlyIt increases the risk of death and harmIt costs resources
TreatableEducationEarly detectionBetter intervention
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www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk
Acknowledgements
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Joan RussellHead of Patient SafetyNHS Englandjoan.russell@nhs.net
Ron CullenDirectorUK Renal RegistryRon.Cullen@renalregistry.nhs.uk
Karen ThomasThink Kidneys Programme ManagerUK Renal RegistryKaren.Thomas@renalregistry.nhs.uk
Annie TaylorCommunications Consultant to the Acute Kidney Injury National Programmeanniemtaylor331@gmail.com
The chairs, co-chairs and teams of all the workstreams in ‘Think Kidneys’
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