An Update on Think Kidneys for the UK Renal Pharmacy Group Conference Karen Thomas, Head of Programmes, UK Renal Registry 26 September 2015

1. An Update on Think Kidneys for the
UK Renal Pharmacy Group Conference
Karen Thomas, Head of Programmes, UK Renal Registry
26 September 2015

2. What is AKI?
The size and scale of the problem
The programme
Objectives
The workstreams
Where we are now
What we’ve delivered
Where next?
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An update on the Think Kidneys National Programme
Update on the Think Kidneys national programme Karen Thomas 26/09/15

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What is acute kidney injury?
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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.

4. One in five emergency admissions to hospital will have AKI
AKI is 100 times more deadly than MRSA infection
Around 20% of AKI cases are preventable
Cost of AKI to the NHS is between £434m and £620m per annum
65% of AKI starts in the community
AKI is a global challenge – the NHS is the first health system to attempt
to tackle it
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The size and scale of the problem
Update on the Think Kidneys national programme Karen Thomas 26/09/15

5. Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 5
‘40000 excess deaths pa’ (Kerr et al April 2014)

6. Recognition that AKI is an emerging healthcare issue
New technology and better information
Increasing number of people living longer with long term conditions
and therefore at increased risk of AKI
Need for education and improved outcomes for patients
Holistic approach – need to improve prevention, detection,
management and treatment of AKI
Two major drivers - NHS England Patient Safety Alert followed by the
Five Year Forward View
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What prompted Think Kidneys? The drivers
Update on the Think Kidneys national programme Karen Thomas 26/09/15

7. 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
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Update on the Think Kidneys national programme Karen Thomas 26/09/15

8. Alert issued 9 June 2014
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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9. Spring 2014
Collaboration between NHS England and the UK Renal Registry
Team of 100 experts and interested health professionals –
nephrologists, acute physicians, GPs, pharmacists, nurses etc.
Working in six workstreams
Vision, strategy and objectives
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Think Kidneys programme commences
Update on the Think Kidneys national programme Karen Thomas 26/09/15

10. Update on the Think Kidneys national programme Karen Thomas 26/09/15 11

11. Ipsos MORI survey in July 2014
2006 people interviewed at home as part of an omnibus survey
Only 49% of people know that their kidneys make urine
8% thought the kidneys pumped blood
12% were aware of role on medicines processing
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Our research and part of the challenge
Update on the Think Kidneys national programme Karen Thomas 26/09/15

12. 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
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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13. Strategy
Who is at risk?
When do people sustain AKI?
How should patients with AKI be
managed?
What do people need to know?
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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14. Responding to the Patient Safety Alert
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
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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15. ‘Think Kidneys’ AKI Programme
Update on the Think Kidneys national programme Karen Thomas 26/09/15
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16. Developed case studies of patients at risk of acute kidney injury
Communities at risk document published describing the communities
who are at risk of acute kidney injury
Acting as a portal to other areas on the website
AKI risk calculator for secondary care
AKI risk calculator for primary care
Patient leaflet
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Risk workstream
Update on the Think Kidneys national programme Karen Thomas 26/09/15

17. Develop a risk matrix – one page decision tree linked to Map of
Medicine
Develop prevention bundle / guidance for 1° and 2°care for ‘at risk’
Integration of the identification of AKI into current care planning tools
and link with Year of Care
Production of ‘stop’ card for patients
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Risk workstream – coming next…..
Update on the Think Kidneys national programme Karen Thomas 26/09/15

18. Identification of credible educational products that already exist
Identifying endorsement of educational products
Running events for primary care, pharmacists, care home stakeholder.
Developing changes to primary care curriculum with RCGP and others
Planning public campaign to increase general knowledge of kidney
function and hydration
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Education workstream….work to date
Update on the Think Kidneys national programme Karen Thomas 26/09/15

19. Discussing with GPC extending curriculum to include renal and AKI for
pharmacy
Approach nursing schools to extend curriculum to include renal and AKI
for nurses
Review primary care bundle being produced by the intervention
workstream
Identify a suitable education resource for those who have had an
episode of AKI
Develop and deliver the public campaign
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Education workstream….coming next
Update on the Think Kidneys national programme Karen Thomas 26/09/15

20. Visited LIMS suppliers to discuss compliance with algorithm
requirements
Responded to enquiries from the UK Renal Registry email helpline
Set up a JISCMAIL internet discussion forum - archived and monitored
discussions
Published best practice guidance document for implementing the AKI
warning algorithm - on the Think Kidneys website. Followed with ‘top
tips’ publication
Monitored the integrity of the algorithm and implementation issues on
the ground via the algorithm sub-group
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Detection workstream…..success so far
Update on the Think Kidneys national programme Karen Thomas 26/09/15

21. Identify potential refinement for the algorithm based on data
associated with the AKI Warning Alert
Produce secondary care case studies of implementation of the
algorithm
Working with primary care IT suppliers to ensure they can deliver the
warning stage test results
Work with Intervention workstream on how warning stage test results
trigger interruptive alerts - inform by gathering case studies
Liaise with implementation workstream to ensure appropriate
commissioning of additional laboratory and other services
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Detection workstream….coming next
Update on the Think Kidneys national programme Karen Thomas 26/09/15

22. Setting minimum standard content for discharge summary – linked to
NHS England work on discharge standards
Production of the secondary care bundle
Medicines management toolkit published - comprehensive advice for
prescribers on drug treatment, dose adjustment and drug withdrawal in
the context of AKI
Sick day rules position statement –
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Intervention workstream…. work to date
Update on the Think Kidneys national programme Karen Thomas 26/09/15

23. Sick day rules
Bristol CLAHRC undertaking formal evidence review
Plan to use this to build consensus with other stakeholders e.g. British
Hypertension Society, British Society for Heart Failure
Interim position statement prepared for Think Kidneys website
bit.ly/TK-Sick-Day-Rules
Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 24

24. As health professionals one of our key aims is to reduce the risk of
avoidable harm to our patients. Some people are at increased risk of
Acute Kidney Injury (AKI), for example those with Chronic Kidney Disease
(CKD), heart failure, or those taking particular medications (1).
Many health care professionals provide advice to such patients that
certain drugs should be temporarily discontinued during acute
intercurrent illnesses, particularly where there is disturbed fluid balance.
This advice is commonly described as ‘sick day rules’ or to take a ‘drug
holiday’.
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Sick Day Rules position statement
Update on the Think Kidneys national programme Karen Thomas 26/09/15

25. There are three main reasons for providing such advice:
1. Non-steroidal anti-inflammatory drugs impair renal
autoregulation by inhibiting prostaglandin-mediated vasodilatation
of the afferent arteriole and may increase the risk of AKI
2. Drugs that lower blood pressure, or cause volume contraction,
might increase the risk of AKI by reducing glomerular perfusion.
3. Drugs might accumulate as a result of reduced kidney function in
AKI, increasing the risks of adverse effects
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Sick Day Rules position statement
Update on the Think Kidneys national programme Karen Thomas 26/09/15

26. The theory
The evidence on implementation and effectiveness
Welcome comment and debate
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Sick Day Rules position statement
Update on the Think Kidneys national programme Karen Thomas 26/09/15

27. Medicines management toolkit being developed for primary care
Advice on dietetic management of inpatients with AKI being created
Complex pathophysiology - effects of venous congestion, systemic
hypotension, effective hypovolaemia, ARAS, renal autoregulation etc.
on GFR
Formal literature search under way: this will be used to generate
consensus statement (BSH, BHS, RA, RCGP, others)
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Intervention workstream…. What next?
Update on the Think Kidneys national programme Karen Thomas 26/09/15

28. Developed and implemented a CQUIN for secondary care. Now in
second year
Developed and implemented a local enhanced service for primary care
Working with number of CCGs to develop commissioning drivers
Development of a commissioning lever for use with care homes.
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Implementation workstream….work to date
Update on the Think Kidneys national programme Karen Thomas 26/09/15

29. Reformed group as commissioner expert group
Develop commissioning tools - for DGH without renal unit, care homes,
community pharmacists etc.
Development of a commissioner tool kit for the Think Kidneys website
to include
• Case studies of lessons learnt from the CCGs implementing commissioning levers
• Examples of commissioning levers to cover the patient pathway
• Links to available data on performance and outcomes
• Map of activity with links to enable connections
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Implementation workstream….next steps
Update on the Think Kidneys national programme Karen Thomas 26/09/15

30. The UKRR applied for National Information Governance Board’s approval to collect
patient identifiable data for AKI patients in England
Developed final specification for the master patient index (MPI) enabling the UKRR
to identify core information about the extent of AKI in England
Ensured data transfer between Trusts and UKRR was feasible; tested data and refined
format; ensured alert and creatinine files were received by UKRR
Analysis in 3 phases –
1. Reporting of data completeness,
2. Adding of date of admission to core data set and establishing link with HES,
3. Reporting data at patient level, CCG level, Trust level including incidence, progression of AKI and
other outcomes
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Measurement workstream….work to date
Update on the Think Kidneys national programme Karen Thomas 26/09/15

31. Discuss with HSCIC future linkage to obtain other core data items
Link UKRR AKI dataset of RRT requirement in UK to obtain data
regarding need for RRT and non-recovery of AKI
Link with National Diabetes and CKD audit during 2016
Identify which Trusts compliant with the Patient Safety Alert, then work
with Detection to check variability and reliability of data collected
Analyse demographic information demonstrating size of at risk group
by linking with other registries/networks
Identify whether interventions have had an impact
Consider downstream consequences for AKI
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Measurement workstream….next steps
Update on the Think Kidneys national programme Karen Thomas 26/09/15

32. National campaign to educate the public, patients and carers as well as
health and care professionals
Established Care Home Working Group
Raising awareness of our work across health and social care
Paediatric nephrology and mental health issues
Working with CPPE on the autumn education campaign for pharmacists
and pharmacy technicians
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Focus now……
Update on the Think Kidneys national programme Karen Thomas 26/09/15

33. Working with CPPE and RPS on the autumn education campaign for all
pharmacists and pharmacy technicians
Six week campaign, including developing and delivering a learning
programme on AKI to every pharmacist and pharmacy technician in
England
Encouraging people to engage in the learning and to apply changes
to their practice, to improve patient care, placing the learning
programme at the centre of our wider campaign
Launch at the Pharmacy Show – 18/19 October. ‘All about kidneys’
quiz on the 28 October 2015 as part of the regular e-challenge quiz
app
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CPPE education – challenge yourself
Update on the Think Kidneys national programme Karen Thomas 26/09/15

34. The learning programme will be mailed to all pharmacy professionals in
England during November and will include the Think Kidneys leaflet for
pharmacists
Asking pharmacists to plan how they engage their patients to raise
awareness of AKI and what they can do as part of both their New
Medicine Service and the Medicines Use Review service
The ‘pledge’
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CPPE education – challenge yourself
Update on the Think Kidneys national programme Karen Thomas 26/09/15

35. The Think Kidneys programme is
supporting the CPPE to highlight
the risks of acute kidney injury to
pharmacy professionals working
in all sectors of practice
Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 36
Acute kidney injury: challenge yourself and your team
A CPPE learning campaign

36. CPPE education – challenge yourself
Launching - The Pharmacy Show on 19 October 2015, for 6 weeks
1. Challenge One - Watch the Think Kidney animation on the CPPE and Think Kidneys
websites, showing simple interventions to prevent AKI
2. Challenge Two - Test your knowledge – an e-quiz to test current knowledge
3. Challenge Three - Learn and engage – start work on the distance learning pack
Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 37

37. CPPE acute kidney injury campaign
Thursday 12 November - Twitter chat with @WePharmacists
Use the hashtags, #thinkkidneys and #CPPEAKI to join in the discussions
4. Challenge Four - Discuss with your team - getting the whole team engaged
5. Challenge Five - Planning a change – create a poster, listen to a podcast, etc.
6. Challenge Six - Make your pledge – link on the Think Kidneys website. The aim is to
achieve the ambition of the pledge in time for World Kidney Day on 10th March, 2016
Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 38

38. Information for pharmacists on AKI,
signposting to the website for
further information
www.thinkkidneys.nhs.uk
Update on the Think Kidneys national programme Karen Thomas 26/09/15 | 39
Think Kidneys pharmacy leaflet

39. Think Kidneys is the NHS campaign to improve the care of people at risk
of, or with, acute kidney injury
AKI is common
• 1 in 5 emergency admissions has AKI
• around 65% starts in the community
AKI is costly
• increasing the risk of harm and death
• it uses valuable resources
AKI is preventable and treatable
• education
• better detection
• early intervention
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Summary
Update on the Think Kidneys national programme Karen Thomas 26/09/15

40. Karen Thomas
Think Kidneys Programme Manager
Head of Programmes
UK Renal Registry
Karen.Thomas@renalregistry.nhs.uk
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Thank you……….Questions?
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
Update on the Think Kidneys national programme Karen Thomas 26/09/15