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Involving Care Homes in Think Kidneys
8 July 2015, Birmingham
Welcome
Programme for the day
10:00 Welcome, housekeeping and plan for the day
10:10 Understanding the care home environment and setting the scene for change
10:40 The only way is Essex!
11:00 Think Kidneys National Programme – about acute kidney injury
11:30 Qs & As
11:55 Coffee break
12:05 How working with care homes could change the status quo – risk, prevention & care
12:15 Group work 1 – Learning about the care home environment – challenges and influences
13:00 Lunch
13:45 Getting it right for Nellie
14:15 Group work 2 – Resources, engagement and what’s needed
15:00 Qs & As and comments
15:15 Summary of the day and an action plan
Understanding the care home
environment and setting the scene for
change
Prof Julienne Meyer CBE
Promoting Quality of Life in Care Homes
My Home Life
www.myhomelife.org.uk
Professor Julienne Meyer CBE
Promoting Quality of Life in Care Homes
So...what do we think about care
homes?
•Scandals?
•Poor quality?
•Money-grabbing?
•Undesirable?
•Less relevant?
•In decline?
Promoting Quality of Life in Care Homes
Older people in care homes
• 17, 678 care homes in UK
• 78% privately owned
• 405,000 older people (>65yr)
• Average age 85 years
• 80% cognitive impairment
• 40% depression
• 75% severely disabled
• Going into care later, sicker and more frail
• Median period (admission to death) is 15
months
Age UK (2015)
Promoting Quality of Life in Care Homes
Workforce
• ½ million employed in care
homes
• Care-assistants less than
living wage
• Lack of funding for training
• Paid less than those looking
after our rubbish
• 66% NVQ2 (4 or 5 GCSEs)
• 39% feel unappreciated by
public
Promoting Quality of Life in Care Homes
“Islands of the old”
• Unsupported, isolated, mistrusted
• Feeding the system rather than
feeding residents!
• High levels of personal stress
Promoting Quality of Life in Care Homes
Understand context, Value & respect
• >3x number of care home beds, compared with NHS beds
• Caring for some of the most vulnerable citizens in society
• Making a significant contribution to care of frail older
people in our society. Projected to increase, not decrease.
• Care homes not paid the fair rate for care by LAs and
most care home staff on minimum wage (undervalued)
• <25% registered for nursing (mainly social care workforce)
• Residents going in later with more health problems
• Workforce needs healthcare training and/or better access
to health expertise
Promoting Quality of Life in Care Homes
Common conditions
(BUPA/CPA 2011)
• Neuro condition or mental disorder (75%)
– Dementia (44%),
– Stroke (20%),
– Depression (20%),
– Epilepsy (6%)
– Parkinson’s disease (5%)
• Heart disease (21%),
• Arthritis (18%),
• Diabetes (14%),
• Fractures (12%),
• Osteoporosis (9%),
• Lung or chest disease (8%)
• Cancer (7%).
Promoting Quality of Life in Care Homes
Need for Formative Care
“For many residents, the optimum approach is that of end of life care, not conventional long-term
condition management.” BGS (2011)
• Dependent ‘dwindling’ older people not well served by the existing medical approaches.
• ‘Social watersheds’ may provide triggers for Formative Care
• Optimising of quality of life and experience (prime purpose)
• Target population (trajectory and social transitions)
• Little evidence at present (more research)
• Implementation of electronic care records and standardised assessment processes (helpful)
Bowman and Meyer, J (2014)
Promoting Quality of Life in Care Homes
Examining Renal Patients’ Death Trajectories without Dialysis
• Trajectories for stage-5 CKD
– Predictable uraemic death
– Predictable death from other causes
– Unpredictable death
• Issues of concern
• Difficulties in managing the unknown
• Number of healthcare professionals involved
• Heavy symptom burden
• Lack of professional knowledge (hard for family)
• Pressures brought to bear on families caring
Noble et al (2010)
Promoting Quality of Life in Care Homes
Quest for Quality
• A health service suitable for the
specific needs of this population.
• The residents and their relatives
must be at the centre of decisions
about care.
• A multi-disciplinary approach.
• A partnership approach with care
homes and social care
professionals.
Promoting Quality of Life in Care Homes
Explaining the barriers to and tensions in delivering effective
healthcare in UK care homes
• Older people are very complicated
• Trajectories are difficult to predict
• Don’t have the training
• Resources are tight
• Regulation is always present
• Roles and responsibilities aren’t clear
• Communication is a problem
Robbins et al (2013)
Promoting Quality of Life in Care Homes
Provision of NHS generalist and specialist services to care homes in
England: review of surveys
• GP:Care Home ratio varies between 30:1 and 1:1
• Some GPs do weekly clinics, while others visited only on request
• Up to 8 different types of nurses provide in-reach services
• 25% of trusts report unequal access to physiotherapy and occupational
therapy
• 35% report unequal access to district nursing
Iliffe et al (2015)
Promoting Quality of Life in Care Homes
Relationships, Expertise, Incentives, and Governance:
Supporting Care Home Residents’ Access to Health
Care: An Interview Study from England
Solutions have focused around:
– Remuneration – carrot
– Regulation – stick
– Parachuting in troops
– Generating social movements
Goodman et al (2015)
Promoting Quality of Life in Care Homes
• Comprehensive assessment of new residents
• Recognise end of life & plan/support
• Structured 6 monthly multidimensional review (earlier if indicated)
• Including medication review
• Including risk assessments (e.g. falls, nutrition)
• Advance care plan for acute events/end of life
• Reliable systems to support telephone consultations and out of hours events
• Regular scheduled visits by GP/Specialist Nurse, Geriatrician to Review targeted residents
• Clarification of referral pathways and response times for specialist services
• Enhanced clinical interventions e.g. fluids, IVs, palliation
• Robust interagency, interdisciplinary governance
Promoting Quality of Life in Care Homes
5 New Care Models
• Multispeciality community Providers
• Integrated primary and acute care
systems
• Urgent and emergency care
• Acute care collaboration
• Enhanced health in care homes
– NHS Wakefield CCG
– Newcastle Gateshead Alliance
– East and North Hertfordshire CCG
– Nottingham City CCG
– Sutton CCG
– Airedale NHS FT
Promoting Quality of Life in Care Homes
MHL Mission
Promoting quality of
life for those living,
dying, visiting and
working in care
homes for older
people.
Promoting Quality of Life in Care Homes
Support
Age UK, City University, Joseph Rowntree & Dementia UK
Other key organisations:
Relatives & Residents Association
National Care Forum
English Community Care Association
National Care Association
Registered Nursing Home Association
Care Forum Wales
Scottish Care
Independent Health & Care Providers
National Care Home R&D Forum
Promoting Quality of Life in Care Homes
Phases of My Home Life
Phase One: Vision
(2005-7: HtA)
Phase 2: Dissemination
(2007-9: BUPA)
Phase 3: Implementation
(2009-13: JRF, DH, LA,
City Bridge etc)
Phase 4: Sustainability
(2013-19: Age UK, Henry Smith)
Promoting Quality of Life in Care Homes
Began small, now social movement
Secret of success?
• Evidence-based
• Relationship-centred
• Appreciative
• Making a difference
Promoting Quality of Life in Care Homes
New online tool
• Providers will also be able to
add flags to their individual
Provider Quality Profile (PQP) to
show they have adopted
recognised quality schemes
such as My Home Life, the new
NICE social care quality
standards and the Dementia
Care and Support Compact.
https://www.gov.uk/government/news/new-online-tool-to-search-and-
compare-local-care-providers
Promoting Quality of Life in Care Homes
What we know residents, relatives and staff ‘want’ and
‘what works’ in LTC
Need shared evidence-
based and relationship-
centred vision that cuts
across:
– health & social care
– policy & practice
– regulation &
commissioning
– public & private
– NCHR&D (2007)
Promoting Quality of Life in Care Homes
Relationship-centred Care
Security: to feel safe
Belonging: to feel part of things
Continuity: to experience links and
connections
Purpose: to have a goal(s) to aspire
to
Achievement: to make progress
towards these goals
Significance: to feel that you matter
as a person
Nolan et al (2006)
Positive relationships between residents,
relatives and staff and between care
homes and their local community and
wider health and social care system
Promoting Quality of Life in Care Homes
MHL Leadership Support & Community
Development (LSCD) programme
Leadership and Support for care home
managers to take forward quality
improvement (4 day work shop, supported
by action learning for one year)
Community Development for LAs/CCGs to
work in better partnership with care homes
(understand context, value & respect,
resolve local issue)
Supportive network for care homes to
share best practice and learn from each
other (reduce ‘islands of the old’)
Promoting Quality of Life in Care Homes
My Home Life:
Promoting quality of life in care homes
• Positive relationships (voice, choice
and control)
• Pivotal role of care home managers
(ongoing support)
• Consider our own attitudes, practices
and policies (reduce capacity to care)
• Stronger partnership working (agree a
vision & supportive ways of working)
• Negative press (impact on confidence)
Promoting Quality of Life in Care Homes
Commissioning Relationship-Centred Care
• Essex CC has shifted its
commissioning approach from top-
down monitoring, inspection and
regulations to one that builds
relationships, invests in the
development of care home staff and
instils a shared vision for care and
support for older people
(www.myhomelifeessex.org.uk)
Promoting Quality of Life in Care Homes
My Home Life Admiral Nurse
• Improved quality of care and well
being
• Increased staff knowledge, skills and
confidence
• Enhanced relationships between
residents, relatives and staff
• More with care home as option for
care
Promoting Quality of Life in Care Homes
The future...
•Vital part of care spectrum
•Demand increasing (40,000
beds needed in next ten years)
•Greater specialism
•Reducing pressure on NHS
•A sector that is emerging as
having the potential to deliver
quality for our frailest citizens in
community and in care homes
Promoting Quality of Life in Care Homes
References
• Age UK (2015) Later Life in the United Kingdom. London: Age UK
• BGS (2011) Quest for Quality British Geriatrics Society. British Geriatrics Society Joint Working Party Inquiry into the Quality of
Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement. BGS: London
• BUPA/CPA (2011) The Changing Role of Care Homes. Centre for Policy on Ageing: London.
• Noble H, Meyer J, Bridges J, Kelly D, Johnson B (2010) Examining renal patients' death trajectories without dialysis, End of Life Care,
4(2)26-34,
• Goodman C, Davies S L , Gordon A L , Meyer J, Dening T, Gladman JRF, Iliffe S, Zubair M, Bowman C, Victor C, Martin F C (2015)
Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents' Access to Health Care. An Interview Study
From England. Journal of the American Medical Directors Association 02/2015; DOI:10.1016/j.jamda.2015.01.072 ·
• Goodman, C; Davies, L; Gordon A L; Meyer, J; Dening, T; Gladman, JRF; Iliffe, S; Zubair, Bowman, C; Victor, C; Martin FC
(accepted) Supporting care home residents’ access to health care what works when in what circumstances: An interview study from
England JAMDA
Promoting Quality of Life in Care Homes
Contact Details
Professor Julienne Meyer
My Home Life
City University London
Adult Years Division
School of Health Sciences
Northampton Square
EC1V 0HB, London, UK
Tel: +44 (0)20 7040 5776
Email: mhl@city.ac.uk
www.myhomelife.org.uk
www.city.ac.uk/dignityincare
www.city.ac.uk/bpop
The only way is Essex!
Kieran Attreed-James &
Lesley Cruickshank
PROSPER
Promoting Safer Provision of care for Elderly
Residents
Prosper
Promoting Safer Provision of Care for Elderly Residents
36
• Funded by The Health Foundation - Closing the Gap in Patient Safety
• First time a Social Care scheme has been chosen
• Essex County Council & UCLPartners working in partnership with Essex
Residential Care & Nursing homes
• Overarching aim to reduce the number of emergency hospital admissions
• Focus on Prevention - reducing the prevalence of falls, pressure ulcers
and Urinary Tract infections across care homes.
• 38 homes involved, with another 25 homes starting June 2015
Prosper Methodology
37
• Building staff capability through education in quality improvement
methodologies – PDSA cycles (plan do study act) of small tests of
change for continuous improvement
• Using data measurement over time to inform improvement cycles –
moving homes away from feeling that data is only used for
negative reasons
• Changing staff culture & behaviour on safety from being reactive to
proactive & preventative
38
Outcome/Aim Primary Driver Secondary Driver
To achieve a 50%
reduction of UTI’s by
December 2015
Risk Identification
Risk Assessment
Reliable
implementation of
Infection Prevention &
Control procedures
Nutrition & Hydration
Education/Training
 Understand UTI risk factors
 Understand resident history, medical condition,
cognitive impairment, invasive devices.
 Utilise Safety Handovers/Safety Huddles
 Assess UTI risk on admission
 Reassess regularly / when a change in condition
 Communicate risk status to resident, staff and
families
 Incident Reporting / RCA
 Reinforce the use of Infection prevention and
control procedures
 Reinforce hand washing techniques
 Reinforce use of PPE
 Introduce Nutrition and Hydration tool’s
 Utilise DN’s, dietician and specialist nurse
experience
 Introduce visual cues to raise Staff awareness
 Increase nutritional intake – shakes/grazing station
 Staff education & training – IP&C, GULP tool
 Resident & family/carer education
 Utilise ‘How to guides’
Review and monitoring
 Management of catheter & continence procedures
 Infection control Champion
 Audit checks ,monitoring of competency
39
40
Check for Urine Infection
If concerned call
the Community
Matron:
Check urine colour
Good
Good
Dark
Dark
If urine is dark –
give extra fluids.
Check for bowels
open
Are any of these symptoms
present?
Urgent need to pass
urine/ incontinent
when not usually
Confused
more than usual
when not usually
Feeling feverish and
unwell
Low tummy or
suprapubic pain
Prolonged contact withurine
can encourage urine infection.
Therefore, it isimportant to
ensure that Incontinence Pads
are changed in a timely way
Clientswith urinary
catheters are likely to
have bacteria in their
urine – encourage fluids
If symptomspresent
Safety Cross
41
Implementation
42
• Good Slipper guides at
pre-assessment
• On spot debriefs
• SBAR
• Prosper Champions
• Safety Cross
• Falls checklists
• Medication Reviews
43
• Engaging whole team
• 10 min power training
• Mirrors
44
• Focus on Hydration
• Jelly
• Doily’s
Results – One Year On
45
• Interim evaluation has reported a change in staff
culture across all 38 homes participating to date.
• Improved data recording, capturing information
previously not recorded – Falls, UTI’s, pressure ulcers,
hospital admissions
• Homes are using data to inform proactive approaches
to prevention
• No statistical significant change at this stage –
challenges in collecting historical data
By Products
46
• Integrated working between Health, Social Care and
Care Homes
• Training
• Linking projects
• Community of Practice/Network meetings
• Consistent approach across CCG boundaries
• Influencing future commissioning
Prosper
47
Contact details;
Lesley Cruickshank
Prosper Project lead
Lesley.cruickshank@essex.gov.uk
07557 081571
Kieran Attreed-James
Kieran.attreed-james@essex.gov.uk
07557168059
Acute Kidney Injury (AKI)
Keeping kidneys healthy:
The AKI programme board
Dr Richard Fluck
richard.fluck@nhs.net
National Clinical Director (Renal) NHS England
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 | 50
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 51
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.
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 53
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
AKI Harmful? Who is most at risk?
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 54
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 55
‘40000 excess deaths pa’ (Kerr et al April 2014)
‘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 | 57
‘Think Kidneys’ AKI Programme
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
| 58
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 | 59
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
How
• How should AKI be managed? How does that
look in primary and secondary care?
• Prevention
• Treatment
• Recovery
What
• What do people need to know?
• Education for the public
• Education for patients and carers
• Education for professionals
Risk
Vulnerability
A fixed set of characteristics – e.g. age, co-morbidities including
CKDs, drugs
Trigger
An event that might precipitate AKI, e.g. surgery, sepsis
Response
Mitigating the risk e.g. sick days rules, monitoring
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 63
Sick day rules
Teaching
Large
group
E-
learning
Ward
based
Educational Toolkit
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
| 67The NHS campaign to improve the care of people at risk of or with, acute kidney injury
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 68
Care bundles and response
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 69
Influencing the 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.
‘AKI warning
stage’
Patient
management
system
Alert Response
Local systems
Message
Master
patient
index
Other data
systems
AKI
Registry
Regional
National Research
QI
Measurement
The pathway and commissioning levers
Risk assessment
• CQUIN in test in SDH
Improved
diagnosis
• Safety alert NHS
England
Treatment
• NICE guidance
• Care bundles
Recovery
• National CQUIN
Secondary care
Primary care
The ask for you
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 72
2/3 of AKI starts in the community
How do we help you understand the vulnerability of your
clients?
What education do you need?
What interventions can we support you with?
What are the practicalities
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
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 | 74
Questions for the speakers
Working with Care Homes to Change
the Status Quo
Mike Jones
Consultant Acute Physician
Richard John Parfitt
Born 1948
Smoked 1966-2014
Excess alcohol (and other substances)
Three myocardial infarctions (quadruple bypass 1997, stent 2011 and 2014)
But still performing
Ageing population
432,000 in care homes
The largest number of practices visiting one care home was 30.
Some GPs did weekly clinics, while others visited only on request.
Up to eight different types of nurses providing in-reach services, with
multiple different nurses often providing in-reach to the same home.
Risk, Prevention and Care
Drugs
Prescribing in care homes is a particular area of concern.
The Care Home Use of Medicines study:
256 residents across 55 homes
69.5% of residents to be subject to one or more error
mean of 1.9 errors per participant
Risk Factors
Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of
proteinuria
Age >75 years
Heart failure
Liver disease
Cardiovascular disease (previous MI, stroke, PVD)
Diabetes mellitus
Recent use of nephrotoxins, e.g. non-steroidal anti-inflammatory drugs,
angiotensin converting enzyme inhibitors, angiotensin receptor blockers
Risk Factors
Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of
proteinuria
Age >75 years
Heart failure
Liver disease
Cardiovascular disease (previous MI, stroke, PVD)
Diabetes mellitus
Recent use of ‘nephrotoxins’, e.g. non-steroidal anti-inflammatory drugs,
angiotensin converting enzyme inhibitors, angiotensin receptor blockers,
diuretics
Acute Risks
Hypotension
Sepsis
Dehydration
Diarrhoea
Decreased intake (acute illness, cognitive impairment)
High urinary output (Cf CKD, Diabetes)
Prevention
Identify patients at risk
Optimise volume status especially when losing excess (diarrhoea, heat etc)
Treat infection promptly
Avoid nephrotoxins if better alternatives
NSAIDs + ACEI bad combination
Review medications,e.g. adjust drug doses, withhold antihypertensives if
hypotensive
Summary
Care home residents are a special case. They represent the most frail, most
dependent, most vulnerable members of our society
Prevailing models of care and routine practice have been demonstrated to
be inadequate to meet their needs.
How should we modify the system to diminish the risk from AKI?
Group work 1 – Nesta Hawker
Learning from you about the care and nursing
home environment – challenges and influences
1. What motivates / influences change in clinical/care
practice?
2. What are the greatest challenges you face in care
homes?
30 mins + 15 mins feedback
Lunch
1.00pm to 1.45pm
Dr Rajib Pal
Think Kidneys!
How to get it wrong for Marjory and right for
Nellie!
AKI in Care Homes
Background
GP partner in Birmingham
GP Trainer/Appraiser
Honorary Clinical Lecturer, University of Birmingham
NICE Acute Kidney Injury, GDG member
Think Kidneys Intervention work-stream member
NHS England: working group member of discharge standards
Macmillan GP Facilitator
Who is here ?
Care Home managers
Nurses
Health care Assistants
Doctors
Pharmacists
Others
Disease
Causes of AKI
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
The story of Marjory’s kidneys
What can we do to harm them?
Marjory aged 83 Group1
Marjory lives in a R/H
What can she do to
damage her kidneys?
Marjory aged 83 Group 2
Lives in a N/H
Has dementia, heart
disease, diabetes
What can you do to
damage her kidneys?
Marjory aged 83 Group 3
Lives in a R/H
She feels unwell with
urinary symptoms and
fever
What can you and she do
to damage her kidneys?
Marjory aged 83 Group 4
Lives in a N/H
“tummy bug”
What can you do to
damage her kidneys?
Marjory aged 83 Group 5
Lives in a N/H
Off her food/drink
10 different tablets
Lithium/Ramipril/
Spironolactone/Metformin/
Ibuprofen
What can you do to
damage her kidneys?
The story of Marjory’s kidneys
How to damage Marjory’s kidneys
Group 1: R/H: Age 83 what can she do?
Group 2: N/H: dementia, heart disease, diabetes
Group 3: R/H: Unwell and UTI
Group 4: N/H and “tummy bug”
Group 5: R/H: “off food/drink”, on lots of tablets
Get older!!
Pick and eat wild mushrooms
Get fat and diabetic
Eat salt and get hypertension
Eat liquorice and raise BP
Take OTC aspirin-paracetamol combination and get
analgesic nephropathy
Take OTC ibuprofen and have 3x risk AKI
Smoke and have renal arterial disease
Take too much alcohol and raise her BP
Develop renal stones with high protein diet or spinach,
nuts and rhubarb increasing oxalate levels
Take large quantities of osmotic laxatives
Marjory Aged 83 Group1
Marjory Aged 83 Group 2
Do not check BP
Unhealthy and fatty diet
Fluid restrict
Do not register with GP
Do not access GP/OOH
No blood tests
Miss off tablets
Marjory Aged 83 Group 3
Do not speak to her
Ask her NOT to drink fluids
Give her ibuprofen
Do not inform GP/OOH
Tell her that she will be fine after a
few days
Marjory Aged 83 Group 3
Not drinking risks pre renal damage
Delayed treatment risks pyelonephritis
Risk of glomerular damage with penicillins and sulphonamides
Risk of tubular damage with aminoglycosides
Risk of post renal damge with crystals in urine with high dose
sulphonamides
Risks of AKI with NSAID used as analgesics
Risk of toxicity with nitrofuratoin eGFR<60
Marjory Aged 83 Group 4
Fluid restrict her
Give ibuprofen
Give her extra meds
Do not inform senior
Do not inform GP/OOH
Do not isolate
Marjory Aged 83 Group 5
Do no talk to her
Keep her isolated
Do not encourage her to eat/drink
Do not ask her how she is feeling?
Continue all medication
Do not inform senior/GP/OOH
SAD MAN: Drugs to be aware of if patient is hypotensive and unwell
S
A
D
M
A
N
SAD MAN
Sulphonylureas e.g. gliclazide
ACE and ARB e.g. ramipril/losartan
Diuretics e.g. furosemide
Metformin
Aldosterone antagonists e.g. spironolactone
NSAID e.g. ibuprofen, naproxen
CKD and NSAID: renal risk
NSAID impact kidney function in at least 8 ways ( R Fluck)
Prostaglandins are important to maintain perfusion within the kidney
Block of prostaglandins reduces renal blood flow with fluid retention,
increased creatinine and potassium
Acute use reversible fall in GFR
Chronic use linked with hypertension and CKD progression
RECOMMEND annual U and E and BP with NSAID
RECOMMEND avoid NSAID with ACE/ARB and diuretic combination
Potential causes of AKI in Marjory
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
Real Primary Care
Getting it right for Nellie age 84 (1)
R/H
Exercise and healthy diet, fluid
intake
Non-smoker
Alcohol Xmas
Regular medication
BP/cholesterol ok
Seen by GP every 6 months
Nellie aged 84 (2)
Dementia, Diabetes, Heart Disease
N/H
Caring environment
Regular medication
Healthy diet/fluids
GP ward rounds
Good BP control/lipids ok/HbA1c ok
Lives in R/H
Suspected UTI
Encourage fluids
GP informed (or OOH)
Antibiotics
MSU sent
Script/meds collected same day, Rx
started
Feels much better 48 hrs
Nellie aged 84 (3)
Lives in N/H
“tummy bug”
Encourage fluids
Light diet
Advice from GP
Sick day rules
Likely viral gastroenteritis
Settled after 72 hours
Nellie aged 84 (4)
Lives in a N/H
Off her food/drinks
10 different tablets
Lithium/Ramipril/Spironolactone/Metformin
/Ibuprofen
Speak to her
Encourage fluids/food
Inform senior/GP/OOH
Depression
Reviewed and treated
Nellie aged 84 (5)
AKI - Acute Kidney Injury
AKI Stage Serum creatinine Urine output
Stage 1 Increase of more than or equal to
26.5 umol/l or increase of 150-200%
from baseline
Less than 0.5ml/kg/h for
more than 6 hours
Stage 2 Increase of 200-300% from baseline
i.e. 2-3 fold
Less than 0.5ml/kg/h for
more than 12 hours
Stage 3 Increase to more than 300% i.e.3 fold
increase from baseline or more than
354 umol/l
Less than 0.3ml/kg/h for
more than 24 hours. Or
anuria for 12 hours
Causes of AKI
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
11
9
The primary aim of
Think Kidneys is to ensure
avoidable harm related
to acute kidney injury is
prevented in all care settings
Thank you
Group work 2 with Nesta Hawker
1. What resources do care home staff need to help them
manage acute kidney injury?
2. How do we engage and educate staff?
3. What do you need from the Think Kidneys programme?
30m + 15m feedback
Open mic session……
What else does Think Kidneys need to
know?
08/07/2015
08/07/2015 123
The clever (academic) approach
Build a blender with rubber blades.
Install a kitten detector
The simple (implementation) approach
Don’t stick a kitten in a blender
Don’t press the start button if you see a
kitten in the blender
What you might need
A chart to help you tell the difference
between a kitten and food
Education
I love my cat
Summary of the day
Next steps
Thank you
Safe journey home

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Involving care homes in Think Kidneys

  • 1. Involving Care Homes in Think Kidneys 8 July 2015, Birmingham
  • 3. Programme for the day 10:00 Welcome, housekeeping and plan for the day 10:10 Understanding the care home environment and setting the scene for change 10:40 The only way is Essex! 11:00 Think Kidneys National Programme – about acute kidney injury 11:30 Qs & As 11:55 Coffee break 12:05 How working with care homes could change the status quo – risk, prevention & care 12:15 Group work 1 – Learning about the care home environment – challenges and influences 13:00 Lunch 13:45 Getting it right for Nellie 14:15 Group work 2 – Resources, engagement and what’s needed 15:00 Qs & As and comments 15:15 Summary of the day and an action plan
  • 4. Understanding the care home environment and setting the scene for change Prof Julienne Meyer CBE
  • 5. Promoting Quality of Life in Care Homes My Home Life www.myhomelife.org.uk Professor Julienne Meyer CBE
  • 6. Promoting Quality of Life in Care Homes So...what do we think about care homes? •Scandals? •Poor quality? •Money-grabbing? •Undesirable? •Less relevant? •In decline?
  • 7. Promoting Quality of Life in Care Homes Older people in care homes • 17, 678 care homes in UK • 78% privately owned • 405,000 older people (>65yr) • Average age 85 years • 80% cognitive impairment • 40% depression • 75% severely disabled • Going into care later, sicker and more frail • Median period (admission to death) is 15 months Age UK (2015)
  • 8. Promoting Quality of Life in Care Homes Workforce • ½ million employed in care homes • Care-assistants less than living wage • Lack of funding for training • Paid less than those looking after our rubbish • 66% NVQ2 (4 or 5 GCSEs) • 39% feel unappreciated by public
  • 9. Promoting Quality of Life in Care Homes “Islands of the old” • Unsupported, isolated, mistrusted • Feeding the system rather than feeding residents! • High levels of personal stress
  • 10. Promoting Quality of Life in Care Homes Understand context, Value & respect • >3x number of care home beds, compared with NHS beds • Caring for some of the most vulnerable citizens in society • Making a significant contribution to care of frail older people in our society. Projected to increase, not decrease. • Care homes not paid the fair rate for care by LAs and most care home staff on minimum wage (undervalued) • <25% registered for nursing (mainly social care workforce) • Residents going in later with more health problems • Workforce needs healthcare training and/or better access to health expertise
  • 11. Promoting Quality of Life in Care Homes Common conditions (BUPA/CPA 2011) • Neuro condition or mental disorder (75%) – Dementia (44%), – Stroke (20%), – Depression (20%), – Epilepsy (6%) – Parkinson’s disease (5%) • Heart disease (21%), • Arthritis (18%), • Diabetes (14%), • Fractures (12%), • Osteoporosis (9%), • Lung or chest disease (8%) • Cancer (7%).
  • 12. Promoting Quality of Life in Care Homes Need for Formative Care “For many residents, the optimum approach is that of end of life care, not conventional long-term condition management.” BGS (2011) • Dependent ‘dwindling’ older people not well served by the existing medical approaches. • ‘Social watersheds’ may provide triggers for Formative Care • Optimising of quality of life and experience (prime purpose) • Target population (trajectory and social transitions) • Little evidence at present (more research) • Implementation of electronic care records and standardised assessment processes (helpful) Bowman and Meyer, J (2014)
  • 13. Promoting Quality of Life in Care Homes Examining Renal Patients’ Death Trajectories without Dialysis • Trajectories for stage-5 CKD – Predictable uraemic death – Predictable death from other causes – Unpredictable death • Issues of concern • Difficulties in managing the unknown • Number of healthcare professionals involved • Heavy symptom burden • Lack of professional knowledge (hard for family) • Pressures brought to bear on families caring Noble et al (2010)
  • 14. Promoting Quality of Life in Care Homes Quest for Quality • A health service suitable for the specific needs of this population. • The residents and their relatives must be at the centre of decisions about care. • A multi-disciplinary approach. • A partnership approach with care homes and social care professionals.
  • 15. Promoting Quality of Life in Care Homes Explaining the barriers to and tensions in delivering effective healthcare in UK care homes • Older people are very complicated • Trajectories are difficult to predict • Don’t have the training • Resources are tight • Regulation is always present • Roles and responsibilities aren’t clear • Communication is a problem Robbins et al (2013)
  • 16. Promoting Quality of Life in Care Homes Provision of NHS generalist and specialist services to care homes in England: review of surveys • GP:Care Home ratio varies between 30:1 and 1:1 • Some GPs do weekly clinics, while others visited only on request • Up to 8 different types of nurses provide in-reach services • 25% of trusts report unequal access to physiotherapy and occupational therapy • 35% report unequal access to district nursing Iliffe et al (2015)
  • 17. Promoting Quality of Life in Care Homes Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents’ Access to Health Care: An Interview Study from England Solutions have focused around: – Remuneration – carrot – Regulation – stick – Parachuting in troops – Generating social movements Goodman et al (2015)
  • 18. Promoting Quality of Life in Care Homes • Comprehensive assessment of new residents • Recognise end of life & plan/support • Structured 6 monthly multidimensional review (earlier if indicated) • Including medication review • Including risk assessments (e.g. falls, nutrition) • Advance care plan for acute events/end of life • Reliable systems to support telephone consultations and out of hours events • Regular scheduled visits by GP/Specialist Nurse, Geriatrician to Review targeted residents • Clarification of referral pathways and response times for specialist services • Enhanced clinical interventions e.g. fluids, IVs, palliation • Robust interagency, interdisciplinary governance
  • 19. Promoting Quality of Life in Care Homes 5 New Care Models • Multispeciality community Providers • Integrated primary and acute care systems • Urgent and emergency care • Acute care collaboration • Enhanced health in care homes – NHS Wakefield CCG – Newcastle Gateshead Alliance – East and North Hertfordshire CCG – Nottingham City CCG – Sutton CCG – Airedale NHS FT
  • 20. Promoting Quality of Life in Care Homes MHL Mission Promoting quality of life for those living, dying, visiting and working in care homes for older people.
  • 21. Promoting Quality of Life in Care Homes Support Age UK, City University, Joseph Rowntree & Dementia UK Other key organisations: Relatives & Residents Association National Care Forum English Community Care Association National Care Association Registered Nursing Home Association Care Forum Wales Scottish Care Independent Health & Care Providers National Care Home R&D Forum
  • 22. Promoting Quality of Life in Care Homes Phases of My Home Life Phase One: Vision (2005-7: HtA) Phase 2: Dissemination (2007-9: BUPA) Phase 3: Implementation (2009-13: JRF, DH, LA, City Bridge etc) Phase 4: Sustainability (2013-19: Age UK, Henry Smith)
  • 23. Promoting Quality of Life in Care Homes Began small, now social movement Secret of success? • Evidence-based • Relationship-centred • Appreciative • Making a difference
  • 24. Promoting Quality of Life in Care Homes New online tool • Providers will also be able to add flags to their individual Provider Quality Profile (PQP) to show they have adopted recognised quality schemes such as My Home Life, the new NICE social care quality standards and the Dementia Care and Support Compact. https://www.gov.uk/government/news/new-online-tool-to-search-and- compare-local-care-providers
  • 25. Promoting Quality of Life in Care Homes What we know residents, relatives and staff ‘want’ and ‘what works’ in LTC Need shared evidence- based and relationship- centred vision that cuts across: – health & social care – policy & practice – regulation & commissioning – public & private – NCHR&D (2007)
  • 26. Promoting Quality of Life in Care Homes Relationship-centred Care Security: to feel safe Belonging: to feel part of things Continuity: to experience links and connections Purpose: to have a goal(s) to aspire to Achievement: to make progress towards these goals Significance: to feel that you matter as a person Nolan et al (2006) Positive relationships between residents, relatives and staff and between care homes and their local community and wider health and social care system
  • 27. Promoting Quality of Life in Care Homes MHL Leadership Support & Community Development (LSCD) programme Leadership and Support for care home managers to take forward quality improvement (4 day work shop, supported by action learning for one year) Community Development for LAs/CCGs to work in better partnership with care homes (understand context, value & respect, resolve local issue) Supportive network for care homes to share best practice and learn from each other (reduce ‘islands of the old’)
  • 28. Promoting Quality of Life in Care Homes My Home Life: Promoting quality of life in care homes • Positive relationships (voice, choice and control) • Pivotal role of care home managers (ongoing support) • Consider our own attitudes, practices and policies (reduce capacity to care) • Stronger partnership working (agree a vision & supportive ways of working) • Negative press (impact on confidence)
  • 29. Promoting Quality of Life in Care Homes Commissioning Relationship-Centred Care • Essex CC has shifted its commissioning approach from top- down monitoring, inspection and regulations to one that builds relationships, invests in the development of care home staff and instils a shared vision for care and support for older people (www.myhomelifeessex.org.uk)
  • 30. Promoting Quality of Life in Care Homes My Home Life Admiral Nurse • Improved quality of care and well being • Increased staff knowledge, skills and confidence • Enhanced relationships between residents, relatives and staff • More with care home as option for care
  • 31. Promoting Quality of Life in Care Homes The future... •Vital part of care spectrum •Demand increasing (40,000 beds needed in next ten years) •Greater specialism •Reducing pressure on NHS •A sector that is emerging as having the potential to deliver quality for our frailest citizens in community and in care homes
  • 32. Promoting Quality of Life in Care Homes References • Age UK (2015) Later Life in the United Kingdom. London: Age UK • BGS (2011) Quest for Quality British Geriatrics Society. British Geriatrics Society Joint Working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement. BGS: London • BUPA/CPA (2011) The Changing Role of Care Homes. Centre for Policy on Ageing: London. • Noble H, Meyer J, Bridges J, Kelly D, Johnson B (2010) Examining renal patients' death trajectories without dialysis, End of Life Care, 4(2)26-34, • Goodman C, Davies S L , Gordon A L , Meyer J, Dening T, Gladman JRF, Iliffe S, Zubair M, Bowman C, Victor C, Martin F C (2015) Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents' Access to Health Care. An Interview Study From England. Journal of the American Medical Directors Association 02/2015; DOI:10.1016/j.jamda.2015.01.072 · • Goodman, C; Davies, L; Gordon A L; Meyer, J; Dening, T; Gladman, JRF; Iliffe, S; Zubair, Bowman, C; Victor, C; Martin FC (accepted) Supporting care home residents’ access to health care what works when in what circumstances: An interview study from England JAMDA
  • 33. Promoting Quality of Life in Care Homes Contact Details Professor Julienne Meyer My Home Life City University London Adult Years Division School of Health Sciences Northampton Square EC1V 0HB, London, UK Tel: +44 (0)20 7040 5776 Email: mhl@city.ac.uk www.myhomelife.org.uk www.city.ac.uk/dignityincare www.city.ac.uk/bpop
  • 34. The only way is Essex! Kieran Attreed-James & Lesley Cruickshank
  • 35. PROSPER Promoting Safer Provision of care for Elderly Residents
  • 36. Prosper Promoting Safer Provision of Care for Elderly Residents 36 • Funded by The Health Foundation - Closing the Gap in Patient Safety • First time a Social Care scheme has been chosen • Essex County Council & UCLPartners working in partnership with Essex Residential Care & Nursing homes • Overarching aim to reduce the number of emergency hospital admissions • Focus on Prevention - reducing the prevalence of falls, pressure ulcers and Urinary Tract infections across care homes. • 38 homes involved, with another 25 homes starting June 2015
  • 37. Prosper Methodology 37 • Building staff capability through education in quality improvement methodologies – PDSA cycles (plan do study act) of small tests of change for continuous improvement • Using data measurement over time to inform improvement cycles – moving homes away from feeling that data is only used for negative reasons • Changing staff culture & behaviour on safety from being reactive to proactive & preventative
  • 38. 38 Outcome/Aim Primary Driver Secondary Driver To achieve a 50% reduction of UTI’s by December 2015 Risk Identification Risk Assessment Reliable implementation of Infection Prevention & Control procedures Nutrition & Hydration Education/Training  Understand UTI risk factors  Understand resident history, medical condition, cognitive impairment, invasive devices.  Utilise Safety Handovers/Safety Huddles  Assess UTI risk on admission  Reassess regularly / when a change in condition  Communicate risk status to resident, staff and families  Incident Reporting / RCA  Reinforce the use of Infection prevention and control procedures  Reinforce hand washing techniques  Reinforce use of PPE  Introduce Nutrition and Hydration tool’s  Utilise DN’s, dietician and specialist nurse experience  Introduce visual cues to raise Staff awareness  Increase nutritional intake – shakes/grazing station  Staff education & training – IP&C, GULP tool  Resident & family/carer education  Utilise ‘How to guides’ Review and monitoring  Management of catheter & continence procedures  Infection control Champion  Audit checks ,monitoring of competency
  • 39. 39
  • 40. 40 Check for Urine Infection If concerned call the Community Matron: Check urine colour Good Good Dark Dark If urine is dark – give extra fluids. Check for bowels open Are any of these symptoms present? Urgent need to pass urine/ incontinent when not usually Confused more than usual when not usually Feeling feverish and unwell Low tummy or suprapubic pain Prolonged contact withurine can encourage urine infection. Therefore, it isimportant to ensure that Incontinence Pads are changed in a timely way Clientswith urinary catheters are likely to have bacteria in their urine – encourage fluids If symptomspresent
  • 42. Implementation 42 • Good Slipper guides at pre-assessment • On spot debriefs • SBAR • Prosper Champions • Safety Cross • Falls checklists • Medication Reviews
  • 43. 43 • Engaging whole team • 10 min power training • Mirrors
  • 44. 44 • Focus on Hydration • Jelly • Doily’s
  • 45. Results – One Year On 45 • Interim evaluation has reported a change in staff culture across all 38 homes participating to date. • Improved data recording, capturing information previously not recorded – Falls, UTI’s, pressure ulcers, hospital admissions • Homes are using data to inform proactive approaches to prevention • No statistical significant change at this stage – challenges in collecting historical data
  • 46. By Products 46 • Integrated working between Health, Social Care and Care Homes • Training • Linking projects • Community of Practice/Network meetings • Consistent approach across CCG boundaries • Influencing future commissioning
  • 47. Prosper 47 Contact details; Lesley Cruickshank Prosper Project lead Lesley.cruickshank@essex.gov.uk 07557 081571 Kieran Attreed-James Kieran.attreed-james@essex.gov.uk 07557168059
  • 48. Acute Kidney Injury (AKI) Keeping kidneys healthy: The AKI programme board Dr Richard Fluck richard.fluck@nhs.net National Clinical Director (Renal) NHS England
  • 49. 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
  • 50. 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 | 50
  • 51. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 51 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.
  • 52.
  • 53. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 53 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
  • 54. AKI Harmful? Who is most at risk? 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 54
  • 55. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 55 ‘40000 excess deaths pa’ (Kerr et al April 2014)
  • 56.
  • 57. ‘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 | 57
  • 58. ‘Think Kidneys’ AKI Programme The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 58
  • 59. 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 | 59
  • 60. 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
  • 61. How • How should AKI be managed? How does that look in primary and secondary care? • Prevention • Treatment • Recovery
  • 62. What • What do people need to know? • Education for the public • Education for patients and carers • Education for professionals
  • 63. Risk Vulnerability A fixed set of characteristics – e.g. age, co-morbidities including CKDs, drugs Trigger An event that might precipitate AKI, e.g. surgery, sepsis Response Mitigating the risk e.g. sick days rules, monitoring 28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 63
  • 66.
  • 67. 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 | 67The NHS campaign to improve the care of people at risk of or with, acute kidney injury
  • 68. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 68 Care bundles and response
  • 69. 21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 69 Influencing the 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.
  • 70. ‘AKI warning stage’ Patient management system Alert Response Local systems Message Master patient index Other data systems AKI Registry Regional National Research QI Measurement
  • 71. The pathway and commissioning levers Risk assessment • CQUIN in test in SDH Improved diagnosis • Safety alert NHS England Treatment • NICE guidance • Care bundles Recovery • National CQUIN Secondary care Primary care
  • 72. The ask for you 28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 72 2/3 of AKI starts in the community How do we help you understand the vulnerability of your clients? What education do you need? What interventions can we support you with? What are the practicalities
  • 73. 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
  • 74. 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 | 74
  • 75. Questions for the speakers
  • 76. Working with Care Homes to Change the Status Quo Mike Jones Consultant Acute Physician
  • 77.
  • 78.
  • 79. Richard John Parfitt Born 1948 Smoked 1966-2014 Excess alcohol (and other substances) Three myocardial infarctions (quadruple bypass 1997, stent 2011 and 2014) But still performing
  • 80. Ageing population 432,000 in care homes The largest number of practices visiting one care home was 30. Some GPs did weekly clinics, while others visited only on request. Up to eight different types of nurses providing in-reach services, with multiple different nurses often providing in-reach to the same home. Risk, Prevention and Care
  • 81. Drugs Prescribing in care homes is a particular area of concern. The Care Home Use of Medicines study: 256 residents across 55 homes 69.5% of residents to be subject to one or more error mean of 1.9 errors per participant
  • 82. Risk Factors Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria Age >75 years Heart failure Liver disease Cardiovascular disease (previous MI, stroke, PVD) Diabetes mellitus Recent use of nephrotoxins, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers
  • 83. Risk Factors Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria Age >75 years Heart failure Liver disease Cardiovascular disease (previous MI, stroke, PVD) Diabetes mellitus Recent use of ‘nephrotoxins’, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, diuretics
  • 84. Acute Risks Hypotension Sepsis Dehydration Diarrhoea Decreased intake (acute illness, cognitive impairment) High urinary output (Cf CKD, Diabetes)
  • 85. Prevention Identify patients at risk Optimise volume status especially when losing excess (diarrhoea, heat etc) Treat infection promptly Avoid nephrotoxins if better alternatives NSAIDs + ACEI bad combination Review medications,e.g. adjust drug doses, withhold antihypertensives if hypotensive
  • 86. Summary Care home residents are a special case. They represent the most frail, most dependent, most vulnerable members of our society Prevailing models of care and routine practice have been demonstrated to be inadequate to meet their needs. How should we modify the system to diminish the risk from AKI?
  • 87. Group work 1 – Nesta Hawker Learning from you about the care and nursing home environment – challenges and influences 1. What motivates / influences change in clinical/care practice? 2. What are the greatest challenges you face in care homes? 30 mins + 15 mins feedback
  • 89. Dr Rajib Pal Think Kidneys! How to get it wrong for Marjory and right for Nellie! AKI in Care Homes
  • 90. Background GP partner in Birmingham GP Trainer/Appraiser Honorary Clinical Lecturer, University of Birmingham NICE Acute Kidney Injury, GDG member Think Kidneys Intervention work-stream member NHS England: working group member of discharge standards Macmillan GP Facilitator
  • 91. Who is here ? Care Home managers Nurses Health care Assistants Doctors Pharmacists Others
  • 93. Causes of AKI Exposures Susceptibilities Sepsis Dehydration or volume depletion Critical illness Advanced age Circulatory shock Female gender Burns Black race Trauma CKD Cardiac surgery especially bypass Chronic heart, lung or liver disease Major surgery Diabetes mellitus Nephrotoxic drugs Cancer Radiocontrast agents Anaemia Poisonous plants and animals
  • 94. The story of Marjory’s kidneys What can we do to harm them?
  • 95. Marjory aged 83 Group1 Marjory lives in a R/H What can she do to damage her kidneys?
  • 96. Marjory aged 83 Group 2 Lives in a N/H Has dementia, heart disease, diabetes What can you do to damage her kidneys?
  • 97. Marjory aged 83 Group 3 Lives in a R/H She feels unwell with urinary symptoms and fever What can you and she do to damage her kidneys?
  • 98. Marjory aged 83 Group 4 Lives in a N/H “tummy bug” What can you do to damage her kidneys?
  • 99. Marjory aged 83 Group 5 Lives in a N/H Off her food/drink 10 different tablets Lithium/Ramipril/ Spironolactone/Metformin/ Ibuprofen What can you do to damage her kidneys?
  • 100. The story of Marjory’s kidneys
  • 101. How to damage Marjory’s kidneys Group 1: R/H: Age 83 what can she do? Group 2: N/H: dementia, heart disease, diabetes Group 3: R/H: Unwell and UTI Group 4: N/H and “tummy bug” Group 5: R/H: “off food/drink”, on lots of tablets
  • 102. Get older!! Pick and eat wild mushrooms Get fat and diabetic Eat salt and get hypertension Eat liquorice and raise BP Take OTC aspirin-paracetamol combination and get analgesic nephropathy Take OTC ibuprofen and have 3x risk AKI Smoke and have renal arterial disease Take too much alcohol and raise her BP Develop renal stones with high protein diet or spinach, nuts and rhubarb increasing oxalate levels Take large quantities of osmotic laxatives Marjory Aged 83 Group1
  • 103. Marjory Aged 83 Group 2 Do not check BP Unhealthy and fatty diet Fluid restrict Do not register with GP Do not access GP/OOH No blood tests Miss off tablets
  • 104. Marjory Aged 83 Group 3 Do not speak to her Ask her NOT to drink fluids Give her ibuprofen Do not inform GP/OOH Tell her that she will be fine after a few days
  • 105. Marjory Aged 83 Group 3 Not drinking risks pre renal damage Delayed treatment risks pyelonephritis Risk of glomerular damage with penicillins and sulphonamides Risk of tubular damage with aminoglycosides Risk of post renal damge with crystals in urine with high dose sulphonamides Risks of AKI with NSAID used as analgesics Risk of toxicity with nitrofuratoin eGFR<60
  • 106. Marjory Aged 83 Group 4 Fluid restrict her Give ibuprofen Give her extra meds Do not inform senior Do not inform GP/OOH Do not isolate
  • 107. Marjory Aged 83 Group 5 Do no talk to her Keep her isolated Do not encourage her to eat/drink Do not ask her how she is feeling? Continue all medication Do not inform senior/GP/OOH
  • 108. SAD MAN: Drugs to be aware of if patient is hypotensive and unwell S A D M A N
  • 109. SAD MAN Sulphonylureas e.g. gliclazide ACE and ARB e.g. ramipril/losartan Diuretics e.g. furosemide Metformin Aldosterone antagonists e.g. spironolactone NSAID e.g. ibuprofen, naproxen
  • 110. CKD and NSAID: renal risk NSAID impact kidney function in at least 8 ways ( R Fluck) Prostaglandins are important to maintain perfusion within the kidney Block of prostaglandins reduces renal blood flow with fluid retention, increased creatinine and potassium Acute use reversible fall in GFR Chronic use linked with hypertension and CKD progression RECOMMEND annual U and E and BP with NSAID RECOMMEND avoid NSAID with ACE/ARB and diuretic combination
  • 111. Potential causes of AKI in Marjory Exposures Susceptibilities Sepsis Dehydration or volume depletion Critical illness Advanced age Circulatory shock Female gender Burns Black race Trauma CKD Cardiac surgery especially bypass Chronic heart, lung or liver disease Major surgery Diabetes mellitus Nephrotoxic drugs Cancer Radiocontrast agents Anaemia Poisonous plants and animals
  • 112. Real Primary Care Getting it right for Nellie age 84 (1) R/H Exercise and healthy diet, fluid intake Non-smoker Alcohol Xmas Regular medication BP/cholesterol ok Seen by GP every 6 months
  • 113. Nellie aged 84 (2) Dementia, Diabetes, Heart Disease N/H Caring environment Regular medication Healthy diet/fluids GP ward rounds Good BP control/lipids ok/HbA1c ok
  • 114. Lives in R/H Suspected UTI Encourage fluids GP informed (or OOH) Antibiotics MSU sent Script/meds collected same day, Rx started Feels much better 48 hrs Nellie aged 84 (3)
  • 115. Lives in N/H “tummy bug” Encourage fluids Light diet Advice from GP Sick day rules Likely viral gastroenteritis Settled after 72 hours Nellie aged 84 (4)
  • 116. Lives in a N/H Off her food/drinks 10 different tablets Lithium/Ramipril/Spironolactone/Metformin /Ibuprofen Speak to her Encourage fluids/food Inform senior/GP/OOH Depression Reviewed and treated Nellie aged 84 (5)
  • 117. AKI - Acute Kidney Injury AKI Stage Serum creatinine Urine output Stage 1 Increase of more than or equal to 26.5 umol/l or increase of 150-200% from baseline Less than 0.5ml/kg/h for more than 6 hours Stage 2 Increase of 200-300% from baseline i.e. 2-3 fold Less than 0.5ml/kg/h for more than 12 hours Stage 3 Increase to more than 300% i.e.3 fold increase from baseline or more than 354 umol/l Less than 0.3ml/kg/h for more than 24 hours. Or anuria for 12 hours
  • 118. Causes of AKI Exposures Susceptibilities Sepsis Dehydration or volume depletion Critical illness Advanced age Circulatory shock Female gender Burns Black race Trauma CKD Cardiac surgery especially bypass Chronic heart, lung or liver disease Major surgery Diabetes mellitus Nephrotoxic drugs Cancer Radiocontrast agents Anaemia Poisonous plants and animals
  • 119. 11 9 The primary aim of Think Kidneys is to ensure avoidable harm related to acute kidney injury is prevented in all care settings Thank you
  • 120. Group work 2 with Nesta Hawker 1. What resources do care home staff need to help them manage acute kidney injury? 2. How do we engage and educate staff? 3. What do you need from the Think Kidneys programme? 30m + 15m feedback
  • 121. Open mic session…… What else does Think Kidneys need to know?
  • 123. 08/07/2015 123 The clever (academic) approach Build a blender with rubber blades. Install a kitten detector The simple (implementation) approach Don’t stick a kitten in a blender Don’t press the start button if you see a kitten in the blender What you might need A chart to help you tell the difference between a kitten and food Education
  • 124. I love my cat
  • 125. Summary of the day Next steps Thank you Safe journey home