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Patient First Conference Charlie Tomson

Slides used by Think Kidneys about AKI in secondary care programme member Charlie Tomson at the Patient First conference 13th November 2015

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Acute kidney injury in secondary care
Charlie Tomson
Consultant Nephrologist, Newcastle upon Tyne
Chair, Intervention Workstream, NHS England ‘Think Kidneys’
Programme
13th November 1330-1415
No conflicts of interest to declare
13/11/2015Acute kidney injury in secondary care Charlie Tomson 2
The primary aim of
Think Kidneys is to ensure
avoidable harm related
to acute kidney injury is
prevented in all care settings
Acute kidney injury in secondary care Charlie Tomson 313/11/2015
Design principles for the Think Kidneys programme
Global
Primary, secondary and social care
Multi-professional, with patients and across specialties
Inclusive
Measurement underpins evidence
• Simplify data flows
• Use to evidence change
Strategy not tactics
| 413/11/2015Acute kidney injury in secondary care Charlie Tomson
Think Kidneys programme – what it is not about
Bad doctors or nurses
• AKI is a patient safety issue and it is recognised that clinicians need the
support of robust systems, education, risk assessment, improved
diagnosis and reliable interventions
It is not a failing of the NHS
• This is a global healthcare issue
• The NHS will have the first national system to measure the problem
and to improve outcomes for patients
13/11/2015Acute kidney injury in secondary care Charlie Tomson | 5
Think Kidneys: programme objectives
The primary aim of the National Programme is to ensure avoidable harm related to AKI is
prevented in all care settings.
It will aim to do this by ensuring that:
A variety of tools and interventions are developed and implemented to support the
prevention, early detection, treatment and enhanced recovery of patients with AKI
Patients who develop AKI are appropriately managed to reduce further deterioration, long
term disability and death
Appropriate education and training programmes are developed for all health professionals
based on best available evidence.
13/11/2015Acute kidney injury in secondary care Charlie Tomson | 6
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Patient First Conference Charlie Tomson

  • 1. Acute kidney injury in secondary care Charlie Tomson Consultant Nephrologist, Newcastle upon Tyne Chair, Intervention Workstream, NHS England ‘Think Kidneys’ Programme 13th November 1330-1415 No conflicts of interest to declare
  • 2. 13/11/2015Acute kidney injury in secondary care Charlie Tomson 2 The primary aim of Think Kidneys is to ensure avoidable harm related to acute kidney injury is prevented in all care settings
  • 3. Acute kidney injury in secondary care Charlie Tomson 313/11/2015
  • 4. Design principles for the Think Kidneys programme Global Primary, secondary and social care Multi-professional, with patients and across specialties Inclusive Measurement underpins evidence • Simplify data flows • Use to evidence change Strategy not tactics | 413/11/2015Acute kidney injury in secondary care Charlie Tomson
  • 5. Think Kidneys programme – what it is not about Bad doctors or nurses • AKI is a patient safety issue and it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions It is not a failing of the NHS • This is a global healthcare issue • The NHS will have the first national system to measure the problem and to improve outcomes for patients 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 5
  • 6. Think Kidneys: programme objectives The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. It will aim to do this by ensuring that: A variety of tools and interventions are developed and implemented to support the prevention, early detection, treatment and enhanced recovery of patients with AKI Patients who develop AKI are appropriately managed to reduce further deterioration, long term disability and death Appropriate education and training programmes are developed for all health professionals based on best available evidence. 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 6
  • 7. Think Kidneys: programme objectives Ensuring that commissioners, health care professionals and managers are aware of the importance and risks of AKI, and that appropriate local strategies to reduce the burden of AKI are developed. Developing a national registry and audit for AKI leading to an improvement strategy on a national and local basis to reduce variation in care. Involving patients and the public in understanding the risk of AKI and preventative measures through education and appropriate access to personal information. Supporting the development of a commissioning structure to allow local service configuration to provide quality care to individuals with AKI. Identifying the research agenda for AKI (including basic science, clinical care and service delivery). 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 7
  • 8. Think Kidneys: programme ambition This transformation will lead to well informed, proactive multi-professional teams, supporting patients, carers and the public. They will understand risk, prevention, recognition and recovery for their patients and for their organisations and be provided with appropriate tools and resources. Patients and their carers will understand their personal risk, be empowered to understand when to seek support and be provided with appropriate access. At organisational and national level agreed data will be collected and continuous national audit will be embedded into the learning process. Research and quality improvement for AKI will be established and robust. As AKI is a global health care issue, the NHS has the opportunity to lead on improving outcomes, providing systems and evidence for improvement in healthcare. 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 8
  • 9. 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 9 Hydration Theme Expert ReferenceGroup Algorithm Sub-Group NHS England Patient Safety Steering Group UK Renal Registry Risk workstream Education workstream Detection workstream Intervention workstream Implementation workstream Measurement workstream Acute Kidney Injury National Programme Board
  • 10. Outline AKI e-alerts from the lab Educational packages to support responders to e-alerts 'hardwired' elements supporting clinical response to e-alerts, for instance required fields within the EPR to denote certain actions taken in response Automated audits of key elements of the expected response to an AKI alert Audits of the number of patients developing AKI 1,2,3 within the Trust and evidence of quality improvement packages to reduce these numbers Specified minimum content for discharge summaries on patients both with in-hospital AKI or admitted with community-acquired AKI 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 10
  • 11. Why are we here? Acute Kidney Injury is associated with more potentially avoidable harm than VTE. We know how to reduce some of this harm. Are English NHS Trusts doing all they can to identify patients with AKI and provide the best possible treatment? 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 11
  • 12. Conceptual framework: AKI 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 12
  • 13. 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 13
  • 14. The Patient Safety Notice 9/6/14 13/11/2015Acute kidney injury in secondary care Charlie Tomson 14
  • 15. Key deliverables Integrate the AKI detection algorithm into Laboratory Information Management Systems Produce ‘test results’ flagging up patients whose creatinine measurements suggest AKI Send test result to patient management systems 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 15
  • 16. AKI e-Alerts For adults: serum creatinine compared with reference values RV1, RV2 RV1 = lowest value within the last 7 days RV2 = median of all results within 8-365 days AKI stage 1 = D of >26 micmol/L over <48h, OR increase of >=1.5x, <=2.0x over baseline AKI stage 2 = increase of >=2.0x and <=3.0x over baseline AKI stage 3 = SCr >354 micmol/L and >1.5x increase, OR increase >=3.0x over baseline 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 16
  • 17. e-Alerts Laboratories in all English NHS Trusts should be sending e-Alerts for stage 1,2,3 AKI to requestors alongside measurements of serum creatinine Requires software changes in Laboratory Information Management Systems 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 17
  • 18. Hands up Do you work in a Trust that has implemented the patient safety alert? i.e. does your Trust clinical biochemistry department use the national algorithm to detect changes in serum creatinine to detect possible AKI, and send test results indicating this to clinicians in secondary care? 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 18
  • 19. Response to e-Alerts - 1 Exclude false positive test results, e.g. Recent completion of pregnancy Progressive chronic kidney disease Trimethoprim use Recent iv fluid therapy causing falsely low ‘baseline’ creatinine measurements 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 19
  • 20. Exclusion of false positives Requires an integrated Trust IT system with access to results from neighbouring Trusts Graphical plotting of kidney function over time Access to clinical information about previous episodes of care 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 20
  • 21. Response to e-Alerts – 2 Clinical assessment of fluid status (e.g. a written statement of whether the patient is hypovolaemic,hypervolaemic, or normovolaemic)* Urinalysis* Review of drug treatment* Ultrasound scan* * - and appropriate clinical response e.g. fluids, referral, changes to BP-lowering drugs, urology referral 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 21
  • 22. Appropriate clinical response Ensure that the alert reaches an appropriate ‘first responder’ Provide first responder with educational resources, including advice on when to seek specialist advice 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 22
  • 23. Acute care toolkit 12 Acute kidney injury and intravenous fluid therapy
  • 24. Assessing fluid status Prior to any prescription of IV fluids, the patient should have a volume assessment that includes the following parameters • Capillary refill • Pulse rate • Blood pressure (including postural drop) • Jugular venous pressure • Respiratory rate • Oedema – pulmonary or peripheral • Passive leg raising test • Fluid balance chart review • Weight (trend important) 13/11/2015 Acute kidney injury in secondary care Charlie Tomson 24
  • 25. Algorithm for initial fluid resuscitation 13/11/2015 Acute kidney injury in secondary care Charlie Tomson 25
  • 26. Medicines management 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 26
  • 27. Medicines management 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 27 https://www.thinkkidneys.nhs.uk/aki/medicines-optimisation-toolkit-for-aki/
  • 28. Hands up Has your Trust audited the management of patients with AKI stage 1? AKI stage 2? AKI stage 3? 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 28
  • 29. Sending data to UK Renal Registry All English Trusts should be submitting data to the national AKI Registry maintained by the UKRR on all patients with AKI warning stage test results Will facilitate a national measurement strategy to inform quality improvement 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 29
  • 30. CPA accredited laboratories sending data 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 30 April 11 April 11 Target 123 May 16 May 7 Total 43 June 22 June 7 % 35.0% July 27 July 3 August 24 August 7 September 27 September 3 October 30 October 1 November November December December Number of labs submitting data by month Number of labs submitting data for the first time Total number of labs submitting data 0 5 10 15 20 25 30 35 April May June July August September October Number of labs submitting data by month 0 2 4 6 8 10 12 April May June July August September October Number of labs submitting data for the firsttime 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
  • 31. Transfer of care/summaries at discharge Should include mention of AKI in all qualifying patients Clear information on cause, management, changes in drug treatment, recommended follow-up Hospital or primary care Patients with AKI are at higher risk of subsequent repeat AKI, cardiovascular events, CKD, ESRD 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 31
  • 32. National CQUIN 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 32 https://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf
  • 33. Hands up Is AKI on your Trust’s Risk Register? Failure to recognise? Failure to treat? Excess costs of care/length of stay? Reputational damage? Failure to communicate to primary care? 13/11/2015Acute kidney injury in secondary care Charlie Tomson | 33
  • 34. How to find out more 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 | 34 Contact Think Kidneys 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 13/11/2015Acute kidney injury in secondary care Charlie Tomson