KIDNEYS KIDNEYS KIDNEYS KIDNEYS KIDNEYS KIDNEYS KIDNEYS KIDNEYS KIDNEYS.
Think Kidneys: The NHS campaign to improve the care of ......Think Kidneys • Has delivered system...
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Dr Richard Fluck National Clinical Director (Renal) NHS England [email protected] Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury Where have we got?
Transcript of Think Kidneys: The NHS campaign to improve the care of ......Think Kidneys • Has delivered system...
Dr Richard Fluck National Clinical Director (Renal)
NHS England [email protected]
Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury
Where have we got?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
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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 Injury Kidney 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
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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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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
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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
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Mortality with AKI stage
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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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‘Think Kidneys’ AKI Programme
| 12 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care
Understanding Risk
Vulnerability A fixed set of characteristics – e.g. age, comorbidities including CKDs, diabetes, drugs
Trigger An event that might precipitate AKI, e.g. surgery, sepsis
Response Mitigating the risk e.g. sick days rules, monitoring
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The vulnerable population Fixed 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
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Improving diagnosis: using changes in serum creatinine
Laboratory definition and standardisation
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National Algorithm
Based in LIMS
Compares serial creatinine measures
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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
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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
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Year 1
Discharge communication
Communication of AKI
Need for follow up
Medications
Why?
High readmission rates
Primary care knowledge
Future risk
Medicines management
‘AKI warning stage’
Patient management
system
Alert Response
Local systems
Message
Master patient index
Other data systems
AKI Registry
Regional National Research
QI
System Measurement
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Uptake of LIMS algorithm across England to date
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care
The pathway and commissioning levers
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Risk assessment
•CQUIN in test in SDH
Improved diagnosis
•Safety alert NHS England
Treatment
•NICE guidance
•Care bundles
Recovery
•National CQUIN
Primary care
Secondary care
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care
Engaging with safety and improvement partners
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Patient Safety Collaboratives
Summary AKI is:
Common 1 in 5 of all emergency
admissions 2/3 starts in the community
Costly
It increases the risk of death and harm
It costs resources
Treatable Education Early detection Better intervention
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Summary: a improvement project
Think Kidneys
• Has delivered system levers
• Providing a framework for action
• Raised the profile
• It is supportive of other change agents
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care
www.linkedin.com/company/think-kidneys
www.twitter.com/ThinkKidneys
www.facebook.com/thinkkidneys
www.youtube.com/user/thinkkidneys
www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk
Acknowledgements
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Joan Russell Head of Patient Safety NHS England [email protected] Ron Cullen Director UK Renal Registry [email protected]
Karen Thomas Think Kidneys Programme Manager UK Renal Registry [email protected]
Annie Taylor Communications Consultant to the Acute Kidney Injury National Programme [email protected] The chairs, co-chairs and teams of all the workstreams in ‘Think Kidneys’
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