Acute Kidney Injury Capacity Survey 2011
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Acute Kidney Injury Capacity Survey 2011

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Acute Kidney Injury Capacity Survey

Acute Kidney Injury Capacity Survey
(England and Wales)
March 2011

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Acute Kidney Injury Capacity Survey 2011 Acute Kidney Injury Capacity Survey 2011 Presentation Transcript

  • Acute Kidney Injury Capacity Survey (England and Wales) March 2011
  • Principal Recommendation V: “There should be sufficient critical care and renal beds to allow rapid step up in care if appropriate” Context
  • • Structured questionnaire sent to renal unit clinical directors and Intensive Care Society local representatives • Snapshot audit of bed state on March 10th 2011 • Online completion of questionnaire using SurveyMonkey • All stages of AKI were included • Data analysis using Excel and SPSS • Full list of questions available in the Appendix Method
  • Completion – Renal units Complete data obtained from 41 trusts in England and Wales with dedicated nephrology services
  • Completion – Critical Care Complete data obtained from critical care units in 45 trusts in England and Wales
  • Hub renal unit District General Hospitals Other acute hospitals Specialist hospitals Community services The ‘hub and spoke’ model of specialist care Critical Care
  • Percentage of renal units offering outreach to other hospitals
  • How many trusts with critical care units also have a renal unit?
  • 42/45 trusts have arrangements for nephrology referral or transfer …but most have arrangements for nephrology referral or transfer
  • Models of outreach from renal units vary… • Onsite nephrologist • Visiting nephrologist • Telephone referrals • Shared care with other specialties (critical care, acute medicine etc) • 9-5 vs 24/7 cover 87% of renal units have arrangements to admit appropriate patients from other hospital sites
  • Models of inpatient kidney care vary… • 35 sites have dedicated renal beds • Median number of beds 26 (IQR 21-30) • Three sites share all their beds with other specialties, with no dedicated renal beds • Several units have a mixture of dedicated and shared beds • The median number of whole time equivalent nephrologists per renal unit is 6.8 (IQR 4.5-9.3)
  • AKI Capacity in Critical Care • Median number of Level 2 and 3 beds available per trust is 14 (IQR 12-30) • The median number of critical care beds typically available per trust for Renal Replacement Therapy (RRT) is 4 (IQR 3-8) • Both the number of critical care beds and the availability of RRT is flexible in many units, with the ability to bring in extra capacity if needed
  • A minority of renal units have dedicated High Dependency Unit (HDU) facilities
  • England Wales Glossary Inotrope/ Adrenaline, Nor-adrenaline, Vasopressor Dobutamine, Dopamine infusion NIV Non invasive ventilation IABP Intra-arterial blood pressure monitoring CVVH Continuous veno-venous haemofiltration
  • Many units share the management of patients requiring level 2 or 3 care with local critical care services “Our renal inpatient beds with level 2 care are geographically placed next to ICU. The joint venture model of looking after AKI with critical care specialists works very well with a tight interface between critical care and nephrology.”
  • Protocols and algorithms • Most units have protocols concerning contrast nephropathy prophylaxis and the management of AKI • Only a minority of units have agreed protocols concerning the transfer of patients to the renal unit, referrals from outside the unit and the step down of patients to the renal unit from critical care • Several respondents commented that they worked closely with critical care or carried out a daily ward round of critical care patients and therefore did not need written protocols concerning ICU step down
  • England Wales
  • Protocols concerning the step down of patients from ICU to Renal Units Number of trusts
  • Utilisation on 10th March 2011
  • Utilisation Renal Units 97 % median bed occupancy 23% of beds occupied by patients with AKI 57% of the patients with AKI had RRT dependent AKI Critical Care 9% of beds occupied by patients with RRT dependent AKI
  • Delayed Transfers • 66 patients were waiting transfer to a renal unit for investigation or management of AKI • The survey did not ask how long these patients were waiting, but delayed transfers and referrals were highlighted as important factors by NCEPOD into their report on deaths from AKI • 57 patients who had been admitted to renal units because of AKI were waiting transfer to a social care, rehabilitation or other clinical setting
  • Additional activity Several respondents commented that there was a significant level of additional activity not captured in the audit: patients not in dedicated beds but who were being primarily managed by the renal or critical care teams, and patients under other specialties who were under active renal review.
  • * * IQR Bed occupancy
  • Limitations • No data were returned from 16 hub renal units • Only a snapshot of activity • The variation in models of care makes defining the scope of renal services difficult. This survey is likely to underestimate the total volume of AKI related activity that renal and critical care units are responsible for
  • Key findings • There is much variation in the model of nephrology AKI management across England • HDU level care is only available in a minority of units but close working with critical care is common • 23% of renal inpatients had AKI in the snapshot bed state survey – of these, 57% had dialysis dependent AKI • 9% of critical care beds were occupied with patients with dialysis dependent AKI • Although most renal units have clinical protocols, only a minority have protocols concerning the transfer and referral of patients
  • Back to NCEPOD “Every hospital should have a written guideline detailing how the three clinical areas where patients with AKI are treated (critical care unit, the renal unit and the non- specialist ward) interact to ensure delivery of high quality, clinically appropriate care for patients with AKI. (Clinical Directors and Medical Directors)” Only a minority of renal units are currently meeting this recommendation. Clear guidelines concerning the referral and transfer of patients with AKI should help to ensure that patients with AKI are managed in a timely and appropriate manner
  • Acknowledgements This survey was kindly facilitated by the Renal Association and The Intensive Care Society
  • Appendix 1 – list of Renal Unit questions 1. Please provide the following information: SHA region Name of Acute Trust Date of completion of form Job Title of Person Completing Form 2. Does the renal unit offer an outreach service at other hospital sites within your trust? If yes, how many other acute receiving hospital sites within your trust does the renal unit provide an outreach service for? 3. Does the renal unit offer an outreach service at other hospital sites in other trusts? If yes, how many other acute receiving hospital sites in other trusts does the renal unit provide an outreach service for? 4. Does the renal unit have an arrangement to admit patients from other hospitals or trusts? 5. If possible, please name these hospitals or trusts 6. Please provide the following information: Number of dedicated inpatient renal beds Of these, how many are routinely resourced to offer Level 2/HDU care? Number of dedicated renal surgical/transplant beds Number of inpatient beds plumbed for haemodialysis or haemodiafiltration
  • 7. What is the maximum number of inpatient renal beds where you would be routinely able to provide the following interventions if required?" CVVH Intra-arterial blood pressure monitoring Non-Invasive Ventilation (e.g. CPAP or BIPAP) Vasopressor or inotrope infusions 8. Does the acute trust have a dedicated Medical Admissions Unit? 9. Is there a Medical Admissions Unit on the same hospital site as the Renal Unit? 10. Do you have documented protocols or written agreements for AKI that address the following issues? Referrals from other clinical units or hospitals Transfers from other clinical units or hospitals Step down from ICU to Renal Unit Clinical management of AKI AKI prophylaxis for people at risk of contrast nephropathy 11. How many consultants provide care for patients admitted to the renal unit? Consultant nephrologists Substantive University Appointments at Consultant Nephrologist Level 12. Please provide the information for bed occupancy at 8am (or equivalent morning reporting time) on 10th March 2011: Number of inpatient renal beds occupied Number of inpatient renal beds where the primary cause of admission to the renal unit is AKI Number of patients in renal inpatient beds receiving RRT for AKI How many patients are currently awaiting transfer to the renal unit for management or investigation of AKI? How many patients whose main reason for admission to the renal unit was AKI (including those in whom the main problem was AKI but who have has now recovered) are currently awaiting transfer to another clinical area outwith the renal unit or awaiting a social care package
  • Appendix 2 – list of Critical Care questions 1. Please provide the following information: Region Name of Acute Trust Name of Hospital Date of completion of form Job Title of Person Completing Form 2. Does the trust have a renal unit providing inpatient care? If yes, is the renal unit based in the same hospital as this critical care unit? Are local mechanisms or agreements in place for arranging clinical advice and review by a nephrologist? Are there local mechanisms or agreements in place to transfer patients to a renal unit for ongoing renal replacement therapy? 3. Please provide the following information: Number of adult critical care (Level 2 or 3) beds available in the trust Maximum number of patients in critical care beds (Level 2 or 3) able to receive RRT on the same day?
  • 4. Do you have a written protocol or agreed arrangements concerning step down of patients to renal units? 5. Please provide the following information about bed utilisation: % of patients in critical care beds (level 2 or 3) currently receiving renal replacement therapy for AKI Number of patients in critical care beds currently waiting step down to a renal unit