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NHS England Patient Safety Alert:
‘Standardising the early identification of AKI’
Dr Nick Selby
On behalf of the NHS England ‘Think Kidneys’ AKI Programme
February 2015
…to ensure avoidable harm
related to AKI is prevented in all
care settings…
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
The primary aim of the NHS England
‘Think Kidneys’ AKI Programme:
| 3
‘Think Kidneys’ Programme 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
| 4
Structure of ‘Think Kidneys’ AKI Programme
21.01.2015 | 5
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
| 5
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
| 6
NCEPOD report published in 2009
Poor assessment of risk factors for AKI
and acute illness
Delays in recognising AKI
Most patients with AKI are not cared for
by nephrologists
Post admission AKI avoidable in 21%
‘Good’ care in <50% cases
Cox Z L et al. CJASN doi:10.2215/CJN.11921112©2013 by American Society of Nephrology
Observational study of 396 pts with AKI
43% of patients had adverse drug event
Two thirds of these were preventable
Common ADEs:
Sub-therapeutic antibiotic levels
Worsening of AKI
Failure to dose adjust with respect to changing renal function
| 8
Aims
Systematically identify changes in serum
creatinine consistent with AKI
Hospital wide
Rapidly report cases to responsible
clinician
Electronic detection for AKI
Challenges
No immediate IT solution to apply
AKI criteria
Baseline creatinine in clinical
practice
Joint working needed, funding
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
| 9
| 10
Detection Alerting
Terminology ‘e-alerts’
Can alerting systems be effective?
Colpaert et al. Crit Care Med 2012; 40: 1164-70
Selby NM. Curr Opin Nephrol Hypertens. 2013;22(6):637-42
ICU setting
2593 alert messages
Alert sent by mobile phone
Increased resolution of AKI (RIFLE class R)
after alert
Electronic alerts improve VTE prophylaxis and
reduce thrombosis events
Kucher N et al. N Engl J Med 2005;352:969-977.
AKI detection in clinical practice
Winner of BUPA Foundation ‘Technology
for Healthy Outcomes’ Award 2012
Selby NM et al. CJASN 2012; 7(4): 533
First hospital wide system based on
current criteria introduced 2010
Resulted in widespread interest across
the UK in developing similar systems
VARIATION
Aims
Systematically identify changes in
serum creatinine consistent with AKI
Hospital wide
Rapidly report cases to responsible
clinician
Variation driven by practicalities
Challenges
No immediate IT solution to apply
AKI criteria
Baseline creatinine in clinical
practice
Joint working needed, funding
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
| 15
http://www.england.nhs.uk/ourwork/patientsafety/akipr
ogramme/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
Specification of the algorithm
Based on KDIGO as closely as possible
Two stage approach to determining reference creatinine:
Uses lowest creatinine within last 48hrs (for ≥27µmol/l rise) or within last 7 days
(for 50% rise or greater)
If no recent creatinine, uses median creatinine value from last 12 months
Generates a numerical test result (stage 1 , 2 or 3) that can then be sent to patient
management systems
If no reference value within 12 months: advice message (to repeat creatinine) but no
AKI stage
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
| 18
Comparisons with existing systems
AKI incidence 6.9%
4.5% for stage 1
1.4% for stage 2
1.0% for stage 3
RLH algorithm
Number of alerts in patients with
baseline creatinine available
NHS England algorithm
Number of patients with AKI
AKI stage 1 207 212
AKI stage 2 69 68
AKI stage 3 28 49
0
10
20
30
40
50
60
AKI 1 AKI 2 AKI 3
30 day mortality
Trevor Hine, Shahed Ahmed: personal communication
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
| 20
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
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
| 21
Anticipated outcomes
Improve detection of AKI in secondary care setting
• Standardisation
• Universal access
Sustainability
• Laboratory quality assurance
• Evidence generation and algorithm review
Mechanism for sending test results to primary care IT
systems
Allow ongoing innovation in alerting systems
Measurement: data transfer to UKRR
| 22
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
Measurement can drive improvement
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
LIMS level
‘result’
Patient
management
system
Alert Response
Local systems
Message
Master patient
index
Other data
systems
AKI Registry
Regional,
National
Research
QI
| 23
Tackling acute kidney injury – a multi-centre
quality improvement project
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
Will test scalability and effectiveness of a
package of interventions:
1. AKI detection and alerting
2. Education programme (hospital wide)
3. Care bundle for AKI management
Stepped wedge design
Outcome measures: implementation,
process, patient outcomes, balancing
measures
Partner organisations:
Derby Hospitals (lead organisation)
Leeds Teaching Hospitals
Bradford NHS Foundation Trust
Frimley Park Hospital
Ashford and St Peters Hospital
UK Renal Registry
| 24
Summary
Patient safety alert is first major output of the NHS England
‘Think Kidneys’ AKI Programme
Designed to eliminate variation in uptake and methodology of
clinical AKI detection systems
Several anticipated outcomes:
• Improve clinical outcomes
• Framework for national prospective AKI measurement
| 25
The NHS campaign to improve the care of people at risk of or with, acute kidney injury
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
Robert Hill
Co-chair of Detection Workstream
Richard Fluck
National Clinical Director for Renal
NHS England
richard.fluck@nhs.net
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
| 26

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NHSE safety alert

  • 1. NHS England Patient Safety Alert: ‘Standardising the early identification of AKI’ Dr Nick Selby On behalf of the NHS England ‘Think Kidneys’ AKI Programme February 2015
  • 2.
  • 3. …to ensure avoidable harm related to AKI is prevented in all care settings… The NHS campaign to improve the care of people at risk of or with, acute kidney injury The primary aim of the NHS England ‘Think Kidneys’ AKI Programme: | 3
  • 4. ‘Think Kidneys’ Programme 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 | 4
  • 5. Structure of ‘Think Kidneys’ AKI Programme 21.01.2015 | 5 The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 5
  • 6. 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 | 6
  • 7. NCEPOD report published in 2009 Poor assessment of risk factors for AKI and acute illness Delays in recognising AKI Most patients with AKI are not cared for by nephrologists Post admission AKI avoidable in 21% ‘Good’ care in <50% cases
  • 8. Cox Z L et al. CJASN doi:10.2215/CJN.11921112©2013 by American Society of Nephrology Observational study of 396 pts with AKI 43% of patients had adverse drug event Two thirds of these were preventable Common ADEs: Sub-therapeutic antibiotic levels Worsening of AKI Failure to dose adjust with respect to changing renal function | 8
  • 9. Aims Systematically identify changes in serum creatinine consistent with AKI Hospital wide Rapidly report cases to responsible clinician Electronic detection for AKI Challenges No immediate IT solution to apply AKI criteria Baseline creatinine in clinical practice Joint working needed, funding The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 9
  • 11. Can alerting systems be effective? Colpaert et al. Crit Care Med 2012; 40: 1164-70 Selby NM. Curr Opin Nephrol Hypertens. 2013;22(6):637-42 ICU setting 2593 alert messages Alert sent by mobile phone Increased resolution of AKI (RIFLE class R) after alert
  • 12.
  • 13. Electronic alerts improve VTE prophylaxis and reduce thrombosis events Kucher N et al. N Engl J Med 2005;352:969-977.
  • 14. AKI detection in clinical practice Winner of BUPA Foundation ‘Technology for Healthy Outcomes’ Award 2012 Selby NM et al. CJASN 2012; 7(4): 533 First hospital wide system based on current criteria introduced 2010 Resulted in widespread interest across the UK in developing similar systems VARIATION
  • 15. Aims Systematically identify changes in serum creatinine consistent with AKI Hospital wide Rapidly report cases to responsible clinician Variation driven by practicalities Challenges No immediate IT solution to apply AKI criteria Baseline creatinine in clinical practice Joint working needed, funding The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 15
  • 16.
  • 17. http://www.england.nhs.uk/ourwork/patientsafety/akipr ogramme/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
  • 18. Specification of the algorithm Based on KDIGO as closely as possible Two stage approach to determining reference creatinine: Uses lowest creatinine within last 48hrs (for ≥27µmol/l rise) or within last 7 days (for 50% rise or greater) If no recent creatinine, uses median creatinine value from last 12 months Generates a numerical test result (stage 1 , 2 or 3) that can then be sent to patient management systems If no reference value within 12 months: advice message (to repeat creatinine) but no AKI stage The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 18
  • 19. Comparisons with existing systems AKI incidence 6.9% 4.5% for stage 1 1.4% for stage 2 1.0% for stage 3 RLH algorithm Number of alerts in patients with baseline creatinine available NHS England algorithm Number of patients with AKI AKI stage 1 207 212 AKI stage 2 69 68 AKI stage 3 28 49 0 10 20 30 40 50 60 AKI 1 AKI 2 AKI 3 30 day mortality Trevor Hine, Shahed Ahmed: personal communication
  • 20. 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 | 20 The NHS campaign to improve the care of people at risk of or with, acute kidney injury
  • 21. 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 | 21
  • 22. Anticipated outcomes Improve detection of AKI in secondary care setting • Standardisation • Universal access Sustainability • Laboratory quality assurance • Evidence generation and algorithm review Mechanism for sending test results to primary care IT systems Allow ongoing innovation in alerting systems Measurement: data transfer to UKRR | 22 The NHS campaign to improve the care of people at risk of or with, acute kidney injury
  • 23. Measurement can drive improvement The NHS campaign to improve the care of people at risk of or with, acute kidney injury LIMS level ‘result’ Patient management system Alert Response Local systems Message Master patient index Other data systems AKI Registry Regional, National Research QI | 23
  • 24. Tackling acute kidney injury – a multi-centre quality improvement project The NHS campaign to improve the care of people at risk of or with, acute kidney injury Will test scalability and effectiveness of a package of interventions: 1. AKI detection and alerting 2. Education programme (hospital wide) 3. Care bundle for AKI management Stepped wedge design Outcome measures: implementation, process, patient outcomes, balancing measures Partner organisations: Derby Hospitals (lead organisation) Leeds Teaching Hospitals Bradford NHS Foundation Trust Frimley Park Hospital Ashford and St Peters Hospital UK Renal Registry | 24
  • 25. Summary Patient safety alert is first major output of the NHS England ‘Think Kidneys’ AKI Programme Designed to eliminate variation in uptake and methodology of clinical AKI detection systems Several anticipated outcomes: • Improve clinical outcomes • Framework for national prospective AKI measurement | 25 The NHS campaign to improve the care of people at risk of or with, acute kidney injury
  • 26. 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 Robert Hill Co-chair of Detection Workstream Richard Fluck National Clinical Director for Renal NHS England richard.fluck@nhs.net 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 | 26