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‘Think Kidneys': Improving the management of acute kidney injury in the NHS

Renal Association
Renal Association
Renal AssociationSupporting the Acute Kidney Injury Programme at Renal Association

‘Think Kidneys': Improving the management of acute kidney injury in the NHS Presented by Dr Richard Fluck, National Clinical Director (Renal) – NHS England

‘Think Kidneys': Improving the management of acute kidney injury in the NHS

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Acute Kidney Injury (AKI)
Keeping kidneys healthy:
The AKI programme board
Dr Richard Fluck
richard.fluck@nhs.net,
National Clinical Director (Renal)
NHS England
‘Think Kidneys': Improving the management of acute kidney injury in the NHS
What do they do?
Public understanding of the kidneys
IPSOS Mori poll 2014 general population
51% knew kidneys make urine
8% thought the kidneys pumped blood
12% were aware of role on medicines processing
– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE
GENERAL POPULATION Selby et al
The challenge
Risks to the kidney
68% alcohol
53% dehydration
22% medications
1% smoking
– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION
Selby et al
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 4
Five Year Forward View
Radical upgrade in public health and prevention
Greater personal control of care
Break down barriers in system
One size does not fit all
New models of care, integration
Enablers
National leadership, local flexibility, innovation, IT
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 5
Five Year Forward View
Radical upgrade in public health and prevention
Greater personal control of care
Break down barriers in system
One size does not fit all
New models of care, integration
Enablers
National leadership, local flexibility, innovation, IT
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 6
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‘Think Kidneys': Improving the management of acute kidney injury in the NHS

  • 1. Acute Kidney Injury (AKI) Keeping kidneys healthy: The AKI programme board Dr Richard Fluck richard.fluck@nhs.net, National Clinical Director (Renal) NHS England
  • 3. What do they do? Public understanding of the kidneys IPSOS Mori poll 2014 general population 51% knew kidneys make urine 8% thought the kidneys pumped blood 12% were aware of role on medicines processing – Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al
  • 4. The challenge Risks to the kidney 68% alcohol 53% dehydration 22% medications 1% smoking – Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 4
  • 5. Five Year Forward View Radical upgrade in public health and prevention Greater personal control of care Break down barriers in system One size does not fit all New models of care, integration Enablers National leadership, local flexibility, innovation, IT 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 5
  • 6. Five Year Forward View Radical upgrade in public health and prevention Greater personal control of care Break down barriers in system One size does not fit all New models of care, integration Enablers National leadership, local flexibility, innovation, IT 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 6
  • 7. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 7 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.
  • 8. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 8 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 1911-1986
  • 9. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 9 AKI Harmful? Who is most at risk? 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?
  • 10. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 10 ‘40000 excess deaths pa’ (Kerr et al April 2014)
  • 12. ”One in five emergency admissions to hospital will have AKI” "AKI is 100 times more deadly than MRSA infection” ”Around 20 per cent of AKI cases are preventable” ”costs of AKI to the NHS are £434-620m pa”
  • 13. Strategy Who is at risk? When do people sustain AKI? How should patients with AKI be managed? What do people need to know? The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 13
  • 14. The pathway and commissioning levers Risk assessment • CQUIN in test in SDH Improved diagnosis • Safety alert NHS England Treatment • NICE guidance • Care bundles Recovery • Proposed national CQUIN Secondary care Primary care
  • 15. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 15 Who? Who is at risk? Determining the vulnerable population Pre existing comorbidities
  • 16. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 16 When? When do people sustain AKI? How is early diagnosis supported? 60% of AKI arises in the community A trigger event e.g. infection, sickness, cardiac event
  • 17. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 17 How? How should AKI be managed? How does that look in primary and secondary care? Prevention Treatment Recovery
  • 18. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 18 What? What do people need to know? Education for the public Education for patients and carers Education for professionals
  • 19. 28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 19 What can we do? Early detection, better treatment
  • 21. ‘Think Kidneys’ objectives Develop and implement tools and interventions for prevention, detection, treatment and enhanced recovery Promote effective management of AKI Provide evidence-based education and training programmes Highlight importance of AKI to commissioners, health care professionals and managers The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 21
  • 22. ‘Think Kidneys’ AKI Programme The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 22
  • 24. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 24 System levers Safety collaboratives: AHSN/SCN Sign up for safety Health Foundation Forward view: into action 2015/16 NHS England is proposing to introduce new national CQUIN indicators to tackle sepsis and acute kidney injury; and a new quality premium indicator to tackle resistance to antibiotics.
  • 25. Method by which NHS can rapidly alert the healthcare system to patient safety risks, or to provide guidance on preventing harm What are NHS patient safety alerts? Level 3: Directive: requires specific action(s) within timeframe Level 2: Specific resource and information sharing Level 1: Warning of emerging risk | 25The NHS campaign to improve the care of people at risk of or with, acute kidney injury
  • 26. Specific actions: Work with LIMS provider to integrate NHSE AKI detection algorithm into Laboratory Information Management System (LIMS) Ensure test results are sent:  To hospital patient management systems  Into a data message for transmission to a central point (UK Renal Registry) Educate primary care physicians as to the use of AKI detection The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 26
  • 27. http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/ aki-algorithm/ ACB scientific committee •Met July 2013 • Biochemists, nephrologists and software providers • Algorithm and minutes available online Renal Association guidelines committee • Met October 2013 • Nephrologists, biochemists, acute physicians, ICU, patients • Ratified algorithm • Guidelines to be produced British Association Paediatric Nephrologists • Met Sept 2013 • Paediatric nephrologists, biochemists • Ratified algorithm with one adaptation for paeds National groups
  • 29. ‘AKI warning stage’ Patient management system Alert Response Local systems Message Master patient index Other data systems AKI Registry Regional National Research QI Measurement
  • 30. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 30 Care bundles and response
  • 31. Length of stay as per care bundle completion P = 0.098 † mean 10.5 11 11.5 12 12.5 13 Within 24 hours Not completed Length of stay in days† 11.2 12.5 Kolhe et al EDTA Congress May 2015
  • 32. AKI progression to higher stages (Stage 1 &2) 0 1 2 3 4 5 6 7 8 9 Completed Not completed Carebundlecompletion 3.9 % 8.1 % Percentage P = 0.02
  • 33. 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 At discharge At 30-day At 60-day 0.641 (0.46, 0.891) 0.707 (0.527, 0.950) 0.704 (0.526, 0.941) †Adjusted for age, gender, type of admission, AKI stages, ethinicity & comorbidities Odd ratio Adjusted odds for death when care bundle completed within 24 hours†
  • 35. P=0.005 Post AKI 3 month albuminuria was associated with CKD progression at 1 year Horne et al EDTA 2015 SuO035
  • 36. Summary AKI is Common • 1 in 5 of all emergency admissions • 2/3 starts in the community It is costly • It increases the risk of death and harm • It costs resources It is treatable • Education • Early detection • Better intervention
  • 37. Karen Thomas Think Kidneys Programme Manager UK Renal Registry Karen.Thomas@renalregistry.nhs.uk Teresa Wallace Think Kidneys Programme Coordinator UK Renal Registry Teresajane.Wallace@renalregistry.nhs. uk The chairs and co-chairs of all the workstreams in ‘Think Kidneys’ Joan Russell Head of Patient Safety NHS England joan.russell@nhs.net Ron Cullen Director UK Renal Registry Ron.Cullen@renalregistry.nhs.uk 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 The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 37

Editor's Notes

  1. Estimated 350,000 to 750,000 cases of AKI every year
  2. We found the incidence of AKI-D increased more than twelve folds from 15.9 cases per million people (pmp) to 208.7 cases pmp with a steep rise from 2006-07 onwards
  3. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals
  4. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals
  5. How did we get here? What does it mean? What opportunities are there? Raises profile of AKI and the need to develop systems to detect early and treat, provides a mechanism that hospitals with no systems or rudimentary solutions in place can use to improve Gives laboratories a clear idea of what to demand from their LIMS suppliers
  6. So what does it mean going forward? It’s not about: Ignoring innovation Intransigence to change Neglecting existing good practice Imposing a Tertiary Care model Reducing variation in the detection of AKI between Trusts Providing a firm basis for outcome research Providing information resources to enable Trusts to implement the national AKI programme Continuous stepwise improvement of the AKI algorithm in co-operation with LIMS providers
  7. In Cox Proportional Hazards analysis, completion of CB within 24 hours of admission was associated with significantly lower hazard ratio of death after a median follow-up of 134 days of 0.771 (95% CI 0.620, 0.958) as compared to patients who did not have CB completed within 24 hours