Think kidneys primary care and commissions workshop 240315 master slide deck final

Managing acute kidney injury alerts in
primary care event
Primary Care and Commissioners
Workshop
24th March 2015

Welcome, housekeeping and plan for the day
Annie Taylor
Communications consultant to the Think Kidneys
Programme
24.03.2015Managing acute kidney injury alerts in primary care | 2

Housekeeping

We need your help?
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 4

Programme for the day
10:00 Welcome, housekeeping and plan for the day
10:10 Setting the Scene; The ambition and the ask
10:40 The opportunity for primary care: How to get it wrong for Marjory and right for Nellie
11:15 Q & A Panel Session
11:30 Break
11:45 Preventing, Detecting and Managing Acute Kidney Injury in Primary Care - Minding the Gap; NHS England’s
guidance for general practice staff on reporting patient safety incidents; Living well with your kidneys
12:45 Q & A Panel Session
13:00 Lunch
13:40 Group work
14:40 Feedback from group work
15:10 Involving CCGs in managing acute kidney injury
15:40 What will happen next, priorities and summary of the day
16:00 Close

Acute kidney injury
The national programme
Final Version
24th March 2015
Richard Fluck
National Clinical Director for Renal, NHS England

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.

Who is most at risk?
• Two patients are admitted via accident
and emergency on a Friday night.
• George, an 86 year old man has crushing
chest pain and ECG changes consistent with a
large heart attack.
• Julia, a slim 56 year old, with long
standing diabetes, has not been feeling right -
the GP did a blood test and her serum
creatinine is 456 umol/L.
• Who should we most be worried about?

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

”One in five emergency admissions to hospital will have AKI”
"AKI is 100 times more deadly than MRSA infection”
”Around 20 per cent of AKI cases are preventable”
”costs of AKI to the NHS are £434-620m pa”

‘reducing avoidable death, long-term disability and chronic ill
health…’
• VTE prevention: estimate 25,000 deaths pa
Data derived from: Hospital Episode Statistics Annual Report 2010,
DoH VTE Prevention Programme 2010 and Selby et al 2012

The purpose of today
To develop the primary care solutions for acute kidney injury that focus on the pathway
• Prevention
• Early detection
• Effective intervention
• Enhanced recovery

www.england.nhs.uk
The pathway and commissioning levers
Risk
assessment
• CQUIN in test in
SDH
Improved
diagnosis
• Safety alert NHS
England
Treatment
• NICE guidance
• Care bundles
Recovery
• Proposed national
CQUIN
Secondary care
Primary care

Who
Who is at risk?
Determining the vulnerable population
Pre existing comorbidities

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 care?
Prevention
Treatment
Recovery

What
What do people need to know?
Education for the public
Education for patients and carers
Education for professionals

Who is at greatest risk?
• For George, his risk of death is 32.2%
• For Julia, her risk of death is 53.1%
Data adapted from Chawla et al Clin J Am Soc Nephrol 2013

24.03.2015Managing acute kidney injury alerts in primary care 20
The primary aim of
Think Kidneys is to ensure
avoidable harm related
to acute kidney injury is
prevented in all care settings

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

‘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
Managing acute kidney injury alerts in primary care
| 23

Hydration Theme
Expert
Reference Group
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

Think kidneys primary care and commissions workshop 240315 master slide deck final

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
| 26
24.03.2015

http://www.england.nhs.uk/ourwork/patientsafety/akiprogra
mme/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

| 28
Detection Alerting
Terminology ‘e-alerts’

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
| 2924.03.2015

Measurement can drive improvement
LIMS level ‘result’
Patient
management
system
Alert Response
Local systems
Message
Master patient
index
Other data systems
AKI Registry
Regional,
National
Research
QI
| 3024.03.2015

The challenge
24.03.2015 | 31
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

The challenge
24.03.2015 | 32
Understanding of the kidneys (2)
Risks to the kidney
68% alcohol
53% dehydration
22% medications
1% smoking

The challenge
24.03.2015 | 33
Understanding of the kidneys (3)
What is acute kidney injury?
15% had heard of it
16% might of heard of it
69% had never heard of it
Physical injury identified as principle reason
Only 1 in 5 guessed correct causes

Today: Think about the strategy:
Who is at risk?
When do people sustain AKI?
How should patients with AKI be
managed?
What do people need to know?
| 3424.03.2015

Today: which hat?
The ask
How should it work for primary care at three levels?
• Clinician to patient
• At a commissioning level
• At a system level
24.03.2015 | 35

Visit our website at www.thinkkidneys.nhs.uk
Contact Think Kidneys or find out more
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
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
Julie Slevin
Think Kidneys Programme Development
Officer
UK Renal Registry
Julie.slevin@renalregistry.nhs.uk

The opportunity for primary care: How to get it wrong for
Marjory and right for Nellie
Kathryn Griffith
GP and representative of the Royal College of General
Practitioners

Think Kidneys!!
How to get it wrong for Marjory
and right for Nellie!!
AKI in primary care
Kathryn E Griffith
GP Unity Health York YO10 5DE
RCGP Clinical Champion for Kidney Care
Kathryn.griffith@nhs.net

12.01.2015
Acute Kidney Injury National Programme |
Introducing the Think Kidneys campaign |
Karen Thomas
39
The primary aim of
Think Kidneys is to ensure
avoidable harm related
to acute kidney injury is
prevented in all care settings

Declaration of interests
• Dr Griffith is a principal in General Practice in York
• She completed the Bradford University course for PwSI in
Cardiology and is now a senior clinical tutor on the course
• She was a member of the KDIGO CKD Guideline Update Group
• She is RCGP Clinical Champion for Kidney Care
• She is a member of the NICE Guideline Group for the update of
the CKD and Renal Anaemia Guidelines and follows the NICE rules
for conflicts of interest
• She is Chair of the HQIP National Primary Care CKD Audit project
board

Terminology: Acute Kidney Injury?

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
alone and enjoys
life
• What can she do
to damage her
kidneys?

Marjory Aged 83
• Marjory attends the
practice for her Flu Jab
• She hasn’t had her blood
pressure taken for a
while
• You need it for QOF!!
• It is 170/90

Marjory Aged 83 Group 2
• You see her in the
practice vascular clinic
• What can you do to
damage her kidneys?

• She has dysuria and
frequency and feels
very unwell
• What can you and
she do to damage
her kidneys?

• She has chest pain
and is admitted to
hospital
• What can the
cardiologists do to
damage her
kidneys?

• She has AMI and
heart failure
• She is taking low
dose ramipril and
eplerenone
• What can you do to
damage her kidneys?

The Story of Marjory’s Kidneys

How to damage Marjory’s Kidneys
Group 1: Age 83 what can she do?
Group 2: BP 170/90 what can you do?
Group 3: Dysuria and frequency ?
Group 4: AMI What can Cardiologist do?
Group 5: Heart Failure ramipril and
eplerenone what can you do?

Marjory Aged 83 Group1
• 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

If you go down to the woods…
Cortinarius orellanine
Nephrotoxic 1-2 weeks Amanita smithani nephrotoxic 3-6 days

• Ignore her BP
• Not discuss diet and
lifestyle
• Not check kidney function
• Not check sugar
• Treat ineffectively
• Treat with large doses of

• Confirm BP 24hr
• Check U and E, sugar, ACR and dip stick
• eGFR 45ml/min and ACR 3
• Consider causes of possible CKD/AKI
• Repeat creatinine
• Consider CVD risk factors and diabetes
• Advise lifestyle advice especially salt

• She has dysuria and
frequency and feels
very unwell
• What can she and
you do to damage
her kidneys?

• 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

• On trolley in A and E for 6 hours
• Cardiogenic shock not managed
• X-ray contrast material without checking creatinine
• Cardiac surgery with bypass
• Over diuresis/ under hydration
• ACE/ARB/MRA
• Failure to monitor kidney function with change in medication or
clinical status
• Risk of Norwalk or other infections in hospital
• NSAID given for pericardial pain

Contrast induced nephropathy
• 25% increase in creatinine
Risk factors
• Systolic BP <80mmHg
• Congestive heart failure
• Age >75
• Anaemia
• Diabetes
• Large contrast volume
• Occurs when eGFR <60 worse when <20ml/min
• Reason for creatinine on scan forms

• Don’t monitor Creatinine with each dose
change
• Don’t measure BP
• Don’t weigh and continue high doses of loop
diuretic
• Give her top doses of all drugs
• Use NSAID for diuretic induced gout

• Monitor Creatinine with each dose change
• Watch BP and weight to avoid hypotension and
dehydration
• Stop diuretics when dry
• What is the evidence for top doses age 88?
• Don’t use NSAID
• Risks Aldosterone antagonists eGFR <30
• Make sure she understands CKD

SAD MAN: Drugs to be aware of if
patient is hypotensive and unwell
• S
• A
• D
• M
• A
• N

SAD MAN
• Sulphonylureas
• ACE and ARB
• Diuretics
• Metformin
• Aldosterone antagonists
• NSAID

CKD and NSAID: Nephrotoxic
• 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 Margory
Burns Black race
Trauma CKD
Nephrotoxic drugs Cancer
Poisonous plants and animals

Thank you for looking after me!

Real Primary Care
Getting it right for Nellie age 84
• Creatinine 89
• 3 months ago
creatinine 88
• eGFR MDRD
• 53
2

Nellie aged 84
• MI aged 76
• Breathless on
exertion
• LVSD on Echo
• Heart Failure
clinic

• Life saving drugs
• Bisoprolol 5mg
• Ramipril 5mg
• Furosemide 40mg
• Spironolactone 25mg
• Atorvastatin 20mg
• Aspirin 75mg
Nellie aged 84

• BP 108/70
• Creatinine 112
• eGFR
42ml/min/1.73m2
• CKD 3B
• Do you tell her??
Nellie aged 84

• Back from winter break
in Egypt 1 week ago
• Both had D and V
• Nellie isn’t well
• BP 70/50
• Poor urine output
• Creatinine 302
• eGFR 13ml/min
• Diagnosis?
• Why??
Nellie aged 84

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
more than 12 hours
Stage 3 Increase to more than 300% i.e.3 fold
increase from baseline or more than
354 umol/l
more than 24 hours. Or
anuria for 12 hours

Causes of AKI
Burns Black race
Trauma CKD
Nephrotoxic drugs ? Cancer
Poisonous plants and animals Doesn’t know the risks

• Refuses admission as
sister just died in
hospital
• What do you do?
Nellie aged 84

• Stop ACE and diuretics
• Push fluids + commode!
• Rapid response team
• Repeat bloods in 1
week and monitor symptoms
• 2 weeks later creatinine 170
• eGFR 26
Nellie aged 84

• Is this avoidable?
• Will she get back on all her
lifesaving drugs?
• What would have
happened over the
weekend??
• Next session and group
work!!!
Nellie aged 84

RCGP Kidney Care Network
• Improving knowledge and management in primary care
• Supporting primary care research in CKD including the National
Primary Care CKD Audit
• Developing educational programmes for patients and primary care
teams
• Working with British Kidney Patient Association
• Supporting Clinical Champion and Clinical Support Fellow
• UK wide
• Kathryn.griffith@nhs.net if you are interested!!

Question & Answer Panel Session
Kathryn Griffith
GP and representative of the Royal College of General
Practitioners
Richard Fluck
National Clinical Director for Renal
NHS England

11.30-11.45 – Tea/coffee break

Preventing, Detecting and Managing Acute Kidney
Injury in Primary Care – Minding the Gap
Tom Blakeman
GP

Preventing, Detecting and Managing
Acute Kidney Injury
in Primary Care
Minding the Gap
Dr Tom Blakeman
GP & Clinical Lecturer in Primary Care
NIHR CLAHRC for Greater Manchester
tom.blakeman@manchester.ac.uk

Outline:
A Whole Systems Approach
• Patient level:
Make kidney health (AKI) meaningful for patients
• Professional level:
Make AKI meaningful for health professionals
• Systems level:
Establish structures and processes to support
prevention and management of AKI

What is high quality care?
• Accessible
• Clinically effective
• Patient-centred
Campbell, Roland & Buetow,
Social Science & Medicine, 2000
• Safe
• Efficient
• Equitable
US Institute of Medicine

Achieving High Quality Care:
AKI - a driver of Quality across the NHS?
‘If we can get it right for AKI, we will get basic care right
across the NHS.’

Minding the Gap:
AKI Quality Framework for Primary Care
Examples Patient
Level
Professional Level Systems Level
Preventing AKI ? ? ?
Detecting & Managing
AKI
? ? ?
Post AKI care ? ? ?

AKI: A Driver of Quality across the NHS?
Doing the basics well in primary care:
• Preventing AKI:
Review appointments
• Detecting & Managing AKI:
Managing acute illness
• Post AKI care:
Post discharge care

Learning from Case Studies:
http://www.thinkkidneys.nhs.uk

Case Study:
Addressing AKI in the community
AB 68 year old man: Type 2 Diabetes, COPD & stage 3 CKD without proteinuria
Multiple medicines including repeat scripts for an ACE Inhibitor and Ibuprofen (NSAID)

Case Study:
Experiences an episode of gastroenteritis
Without GP assessment, leads to an unplanned hospital admission
Episode of illness complicated by AKI requiring a period of intensive care

Case Study:
Without GP assessment leads to an unplanned hospital admission
Hospital Discharge summary included AKI and coded in GP records
Recommendation ACE Inhibitor to be stopped but no mention of NSAIDS
Neither was discontinued by the primary care team
Kidney function not rechecked post-discharge

Case Study:
Further GP appointments and treated for exacerbations of COPD

Doing the basics well:
Preventing AKI in Primary care
• Identify high risk groups
 Consider ‘sick day rules’ for high risk patient groups
 Ensure flu vaccination for high risk patient groups
• Avoid prescription of long term NSAIDs where possible
 particularly in high risk patients including those with CKD
 Avoid ‘triple whammy’ prescribing
• Consider monitor renal function one week after the introduction of medication –
with clear advice
 ACEI/ARB; Spironolactone, Loop Diuretics (CKD)

Minding the Gap:
Preventing AKI in Primary care
Key factors to consider:
• Patient level
 Develop ‘Sick day rules’ that are meaningful for patients
 Recognise the key role of carers
• Professional level
 How to discuss risk of AKI (Kidney Health) in routine practice
 Recognise the key role of practice nurses
• Systems level
 Ensure use of Read codes from April 2015 – ‘8OAG’
 Clarify roles & responsibilities e.g. pharmacists and GPs
 Resource Implementation e.g. dossette boxes & the delivery man!

Acute Kidney Injury:
NICE Guidance
‘Discuss the risk of developing acute kidney injury…with people who
are at risk of acute kidney injury, particularly those who have:
• History of AKI (QS1)
• chronic kidney disease with an eGFR less than 60 ml/min/1.73 m2
• neurological or cognitive impairment or disability, which may mean
limited access to fluids because of reliance on a carer.
Involve parents and carers in the discussion if appropriate.’
NICE clinical guideline 169
guidance.nice.org.uk/cg169

Think Kidneys:
A need for patient-centred interventions

Minding the Gap:
Headline findings
People don’t have a comprehensive
understanding of
 what their kidneys do,
 how to keep them healthy
 what acute kidney injury is
• Only 51% of the population know that
kidneys make urine
• Only 12% of participants thought that
the kidneys had a role to play in
processing medicines

Why bother talking about
kidney health with the elderly?

A Gap in care for patients with CKD:
Reticence to discuss kidney health with older
people & patients with stage 3A
‘... if you’ve got CKD or you’re young and you’ve
got proteinuria, definitely that is a really important
thing to hammer in. But yeah, 80/90 year olds, I
wouldn’t suggest we’re probably discussing it, if
they’ve got a mild CKD3.’ (GP06)

Framing CKD discussions:
‘Nothing to worry about’
‘...But just to let them know, I feel that
they should know that they’re on a
(CKD) register and tell them not to
worry. If there’s anything to worry about
we’ll let them know.’ (nurse 11)

Making kidney health meaningful:
An opportunity to broaden & tailor conversations?
Kidneys in the context of
Supporting Vascular Health
Kidneys in the context of
Managing acute illness

Addressing ‘vulnerability’
‘Having a CKD 3 register is not
necessarily there for the progressive
disease or even vascular disease,
it's looking at vulnerability. These
patients should have a card. It
should say “…Do not give me
gentamicin in casualty. Do not
allow me to get dehydrated…’
(GP05)

Minding the Gap:
Detecting AKI in Primary careKey factors to consider:
Need guidance on when to consider checking kidney function:
 Taking bloods needs to support management – both in terms of detection and
severity
 A traffic light system to support decision making?
 Need timely results – the van man!
 Need coordination with Out of Hours – Clinical Context is key
 System change needs resourcing - Cumulative workload

Assessment of acute illness
• Better assessment of acute
illness? E.g:
 Postural vital signs
 Dry Axillae
• Better documentation?

Assessment of acute illness
• Better assessment of acute
illness?
• Better documentation?

Detection:
AKI Risk Warning system
• Switched on in hospitals
9th March 2015
• Switch on in Primary Care by
Spring 2016

How to manage a patient with AKI
detected in primary care
Factors to consider:
• Is this definitely AKI?
• Is the patient acutely unwell?
• How severe is the AKI?
• What is the cause of AKI?

Need guidance:
Primary care management of patient with AKI
Avoid or correct ‘dehydration’
Consider temporary cessation of medicines
If no obvious cause, consider new drugs as cause of AKI
Early review and repeat renal function
Consider seek help from nephrology on call

Post AKI care:
Driving quality – A National CQUIN for AKI
The percentage of patients with AKI treated in an acute
hospital whose discharge summary includes each of
four key items:
1. Stage of AKI
2. Evidence of medicines review having been
undertaken
3. Type of blood tests required on discharge
4. Frequency of blood tests required on discharge for
monitoring

Discussing AKI & Kidney Health in
secondary & primary care

Post AKI care
• Review medications
 Consider restart medications that have been stopped
 check kidney function 1/52 after reintroduction
 Update records if drug implicated in causing AKI (e.g. PPI & interstitial nephritis)
• Assess the degree of renal recovery
 Consider repeat renal function in patients who have not returned to baseline
 If evidence of new onset CKD, then recheck proteinuria and Creatinine at 3 months
 Consider contact nephrology for advice
• Reduce risk of further episodes of AKI
 Communication of risk and use of sick day rules – Code their use = ‘8OAG’
• Coding the occurrence of an AKI episodes
 Read codes exist for AKI 1, AKI 2, AKI 3

Case Study:
Addressing AKI in the communityAB 68 year old man: Type 2 Diabetes, COPD & stage 3 CKD without proteinuria
Further GP appointments and treated for exacerbations of COPD
No temporary cessation of medicines during these episodes of acute illness

Learning from Case Studies:
Key learning points and actions:
• Coding of AKI in GP records (even when not the
primary diagnosis)
• Establishing a register and e-alerts for patients who have
experienced AKI
• Mechanisms to ensure GP review:
 Medication review
 Check renal function
 Social and carer support
 Action plan
 Support recovery
• Resource System Change

AKI Register & e-alert

Doing the basics well
AKI Registers & e-alerts

Resourcing implementation of AKI initiatives
Summary of Key Factors to consider:
• Preventing AKI
 Takes time to communicate risk
 Ensure coordination in roles between GPs and Pharmacy
 Dealing with dossette boxes – The Delivery Man!
• Detecting & managing AKI
 Checking renal function in primary care: Timely - The Van Man!
 Coordination with Out Of Hours care
 Nursing Home Care
 Timely access with the on call Nephrology team
• Post AKI Care
 Salient discharge summaries & establishing AKI Registers in Primary Care
 Role of medicine management Pharmacists
 Integrating AKI into incentives e.g. Unplanned Admissions Enhanced Service

Minding the Gap:
AKI Quality Framework for Primary Care
Examples Patient
Level
Professional Level Systems Level
Preventing AKI √ √ √
Detecting & Managing
AKI
√ √ √
Post AKI care √ √ √

Achieving High Quality Care:
AKI = a driver of Quality across the NHS?
‘If we can get it right for AKI, we will get basic care right
across the NHS.’

NHS England’s guidance for general practice staff on
reporting patient safety incidents
Joan Russell
Head of Patient Safety
NHS England

GP e-form for reporting patient safety
incidents to NRLS • Launched 26 February - quick and easy for
practice staff to report to NRLS
• 360m patient consultations with GPs each
year but very small number of reports to
NRLS (compared to 1.5m a year from
trusts)
• Can report anonymously; and can choose
to share with local CCG to support local
learning
• Following a report a CPD / Serious Event
Analysis (SEA) template for appraisal and
revalidation is emailed to the reporter (can
also be used as evidence for CQC
inspections)www.england.nhs.uk

How we use your patient safety
incident reports to drive learning
www.england.nhs.uk
137

Looking after the kidneys
The patient view
Primary care AKI meeting
24 March 2015
Fiona Loud, Policy Director British Kidney Patient Association

Framing the message
• Low (no) awareness of kidney health or what
the kidney does
• Message can be lost in the bigger picture of
cardiovascular health, diabetes etc

Health talk
• Attitudes to monitoring kidney health
– Bill’s thoughts
– Bernard’s thoughts
• ‘Mild kidney impairment’
• Healthtalk.org
• Newly released CKD resource

Dialogue with patients
• Why this is important?
• What does it mean for you?
• What can we do about it?

Common questions – why this is
important
• What are the kidneys and what do they do?
• Why do I need to know about this?

What does it mean for me?
• Can my kidneys get better?
• How serious is this - will it mean I have to go
on dialysis?

Patient-developed description of CKD
“My kidneys are not working as well as they should,
and so are not filtering out as much waste from my
blood. This results in changes to the way my body
works and my general feeling of well being. This is
called chronic kidney disease and is a gradual
process where kidneys may continue to deteriorate
over months or years. I have to watch my diet and
blood pressure from now on.”

What can we do about it?
• Are there tests?
• What will the results of the tests mean to me?
• Why I have I been given these tablets?
– Side effects, warnings in medication leaflets
• Who else can help me – nurse, pharmacist etc
• What next?

What I can do
• Simple tips
• Watch the wee
• Drinking enough – of the right stuff (i.e.
not alcohol)
• Medicine/tablets
• Ask for advice especially if sick
• Blood pressure/blood
sugar/smoking/diet if appropriate

What you can do
• Open the dialogue
• Signpost
• Educate
• Feed back on blood tests
• Reiterate to check understanding
• Avoiding language barriers

Lay description of AKI
My kidneys have suddenly stopped working
properly; this can happen if someone is being
treated as an emergency, has a big problem like
pneumonia or some types of cancer. While this is
being concentrated on my kidneys are really
struggling because of e.g. dehydration, or
medicines which need adjustment. So it’s like a
heart attack, but on the kidneys, and is every bit as
damaging…

After AKI
• Risk of another episode
• Residual damage
• What to tell the pharmacist/other health
professionals in future
• Bring the partner/family/care home into the
discussion as appropriate

Kidney Management – how much
clinician time in one year?

Reality of self-care in long term
conditions
Another 727 hours/month and 8030 hours/year to self-care

The Person with the condition
retains:
• Choices
• Control
• Consequences
– But still needs empathy
– AKI is a big shock

Signposting
• Kidney charity sites
• Counselling
• Patient information (mainly in development)
• www.Thinkkidneys.nhs.uk
• NHS Choices
• www.Britishkidney-pa.co.uk
– Advocacy, grants, counselling, service improvement, information

12.45 – 13.00 Question & Answer Panel Session
Kathryn Griffith, GP and representative of the Royal
College of General Practitioners
Richard Fluck, National Clinical Director for Renal, NHS
England
Tom Blakeman, GP
Joan Russell, Head of Patient Safety, NHS England
Fiona Loud, Policy Director, BKPA

13.00-13.40 – Lunch break

The purpose of today
To develop the primary care solutions for acute kidney injury that focus on the pathway
• Prevention
• Early detection
• Effective intervention
• Enhanced recovery

13.40-14.40 Group work
Group 2 – Primary Care
Group 3 – Primary Care
Group 4 – Commissioners
Group 5 – Commissioners
Group 6 - Commissioners
Group 7 – Improvement organisations
Group 8 – Improvement organisations

Group work instructions
On your name badge you will have a group number for this task –
find that table with your group number on it.
Once in your group you will find a series of questions for your group
and a pre-printed template that will need to be completed.
A facilitator will be in your group to assist with the timing of this task
You will be required to provide a summary of your discussions in a
feedback session lasting no more than 3 mins
Managing acute kidney injury alerts in primary care 24.03.2015

Groups 2 & 3 – Primary Care
What are we going to do to ensure AKI is properly managed across the
patient pathway in both primary and secondary care, considering the
following :-
Out of hours
Detection of AKI
Patients at risk

Groups 2 & 3 – Primary Care
What support do we need from the acute sector? How can secondary care
help primary care manage AKI more effectively ie - Minding the Gap? –
Things to consider :-
Discharge
Admission advice
General AKI advice
Guidelines
What support do we need from the national programme? What should we
ask of them? i.e. education/awareness raising
What should they ask of us?

What are we going to do to ensure AKI is properly managed across the patient pathway in both primary and
secondary care, considering the following – out of hours, detection of AKI, patients at risk
What support do we need from the acute sector? – How can secondary care help primary care manage AKI more
effectively ie minding the gap?
What should the national programme ask of us?
What support do we need from the
national programme? – What should we
ask of them? ie education/awareness
raising
PRIMARY CARE – GROUP:

Group 4, 5 & 6 - Commissioners
What are we going to do to ensure AKI is properly managed in primary care? Things to
consider :-
What are your plans for monitoring prevalence of AKI?
What are the challenges?
What are your plans for reviewing management of AKI and performance in your CCG area
To help overcome the challenges we have a plan to develop national commissioning
guidance. What would you want to be included in the commissioning guidance for AKI in
primary care?
What support do we need from the acute sector?
What support do we need from the national programme? What should we ask of them?
24.03.2015Managing acute kidney injury alerts in primary care

What are we going to do to ensure AKI is properly managed in primary care? What are your plans for reviewing
management of AKI and performance in your CCG area?
What are your plans for monitoring prevalence of AKI? What are the challenges?
To help overcome the challenges we have a plan to develop national commissioning guidance. What would you
want to be included in the commissioning guidance for AKI in primary care?
ask of them? ie education/awareness
raising
COMMISSIONERS – GROUP:
What support do we need from the acute
sector?

Groups 7 & 8 – Improvement organisations
What can we do to support the implementation
of Think Kidneys ?
What support do we need from the national
programme? – What should we ask of them?
24.03.2015Managing acute kidney injury alerts in primary care

What can we do to support the implementation of Think Kidneys?
ask of them?
IMPROVEMENT
ORGANISATIONS - GROUP:

28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 168
Am I in the right group?
Group 2
Tom Blakeman
Sandhya Dhingra
Medhat Guindy
Berenice Lopez
Fiona Loud
Rajib Pal
Carol Picken
Daniel Vernon
Stuart Wright
Group 3
Ama Basoah
Linda Bisset
John Corlett
Kathryn Griffith
Anjana Hari
Dan Lasserson
Victoria Lloyd
Pauline Miller
Group 4
Khalada Abdullah
Sally Bassett
Emma Evans
Naveed Ghaffar
Sarah Harding
Sheila McCorkindale
Rumit Shah
Nigel Taylor
Charlie Tomson
Group 5
Carmel Ashby
Lindsey Britten
Samantha Glynn-Atkins
Joanne Gutteridge
Nesta Hawker
Mike Jones
Sue Renwick
Gang Xu
Group 6
Emma Alcock
Ramaswamy Diwaker
Linda Hunter
Abid Mumtaz
Deborah Oliver
Joan Russell
Janet Wilson
Group 7
Lorraine Burey
Martin Cassidy
Rebecca Elvey
Richard Fluck
Simon Fraser
Richard Healicon
Sara Owen
Pauline Smith
Group 8
Hester Benson
Ron Cullen
Fiona Cummings
Katy Gordon
Susan Howard
Aly Hulme
Tracie Keats
Neil Sandys

Involving CCGs in managing acute kidney injury
Nesta Hawker
Regional Programme of Care Manager Internal Medicine
(North)
NHS England - Regional Team

www.england.nhs.uk
• Part of the national Think Kidney programme
• Commissioning – part of House of Care
• CCGs commission majority of pathway of AKI
Implementation Work Stream

www.england.nhs.uk
• Aim to test out commissioning levers e.g. CQUINS
• Access to advice and input from national experts to
develop the commissioning levers
• Southern Derby CCG testing commissioning levers in
primary and secondary care
• To develop a commissioner toolkit for the Think Kidney
website
• Lessons learnt
• Examples of commissioning levers along the pathway
Implementation Work Stream

An example from Southern Derbyshire
Carmel Ashby
Assistant Head of Clinical Quality & Patient Safety –
Primary Care
Southern Derbyshire CCG

NHS Southern Derbyshire Clinical Commissioning Group
Southern Derbyshire CCG
AKI Primary Care Event
Carmel Ashby
Assistant Head of Clinical Quality &
Patient Safety – Primary Care

Why we got involved
• Strong drive to improve services especially
patient safety
• NCEPOD report ‘Adding Insult to Injury’
• Individual commitment
• CCG Board sign up: Patient Story: Board
briefings

Structure
• Steering group established: strong multi agency
team
• Governance through CCG Quality Assurance
Committee and Contract Monitoring Group
• CQUIN developed during January 2014:
2 part secondary care assessment on
admission and discharge information
High priority given = £1 million

Progress
• Secondary care CQUIN year one almost complete.
Year 2 CQUIN agreed (to continue improvements
and complement national mandated indicator)
• Primary care planning:
Locally Commissioned Service Framework (LCSF)
• Baseline survey undertaken by clinical staff – 467
GPs and Practice Nurses responded
• Number of respondents
• Key messages

Progress (cont)
Programme of education & awareness raising sessions
Strategic Clinical Network funding (AKI/CKD)
Quality Forum – PC/SC input
Academic detailing – working
Promoting to practices, to include all staff, GPs,
PNs/APNs, practice managers etc. delivered in range
of settings
 Evaluation framework – building on GP survey

Progress (cont)
Policies, Procedures & Guidelines on AKI
guidelines to support care planning on discharge
Shared Care Pathology website
Sick day rules
• Information
Read codes approved

Lessons Learnt
 Senior Leadership
 Ambition and Innovation to improve
patient care
 Bringing together a strong team who
were committed to a shared vision
 Moving at pace using contractual levers

Contact Details
Lynn Woods - lynn.woods@southernderbyshireccg.nhs.uk
Sally Bassett - sally.bassett@southernderbyshireccg.nhs.uk
Nick Selby - nick.selby@nhs.net
Nitin Kolhe - nitin.kolhe@nhs.net

An example from NHS South Sefton CCG
Nigel Taylor
GP/Clinical Lead
NHS South Sefton CCG

http://www.cmscnsenate.nhs.uk
AKI ALERTS IN PRIMARY CARE
THE CHESHIRE AND MERSEYSIDE EXPERIENCE
Dr Nigel Taylor GP, Clinical Lead South Sefton CCG
Birmingham 24th March 2015
Cheshire and Merseyside
Strategic Clinical Networks &
Senate

http://www.cmscnsenate.nhs.uk
• Declarations of interest.
• Employers:- South Sefton CCG and Liverpool Community Health.
• Memberships:- Diabetes UK and the Primary Care Diabetes Society
for a number of years.
• I have chaired meetings for a number of companies which have
included:-BMS; Schering; Pfizer; MSD; Sanofi; AstraZeneca; Lilly and
Boehringer SB Communications. I have received travel awards from
Sanofi and Takeda and attended Pioneers in Diabetes meetings as a
delegate

• Rationale
• Action Taken
• Future Plans
• Barriers
NHS | Presentation to National AKI Meeting 24th March 2015184

• RATIONALE
• Problem Identified
• AKI-Common in Hospital
• Bad Outcomes
• Suggested look at beyond confines of hospital
• More in Primary Care but milder forms
• Possibly amenable to minimal interventions

• AKI Alerts
• Local Foundation Trust system generated a total
of 6198 alerts - approx 1030 per month.
• 546 were from GPs - approx 90 per month. 64 -
AKI 3 alerts - rest were AKI1 and 2
• 1029 alerts from AED
• 3514 alerts from Inpatients
• 765 alerts from Outpatients

• Total Number of AKI Alerts in Primary Care for University Hospital Aintree Catchment for
six months 1/8/14 to 31/1/15 = 546 (AKI 1 & AKI 3)
• Further 1029 Alerts from A&E.
• South Sefton CCG-Population approx 155,000
• 33 GP Practices
• AKI 1- CCG Total for six months 287 (Range 1 to 27) i.e. 48 for one month.
• AKI 3- CCG Total for six months 35 (Range 1 to 5)i.e. 6 in one month.
• AKI 1,2 & 3= 0.4 per 1000 per month.
NHS | Presentation toNational AKI Meeting 24th March 2015187

NHS | Presentation to [National AKI Meeting 24th March 2015188
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
AKI 1
AKI 1

[XXXX Company] | [Type Date]189
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
AKI 3
AKI 3

• ACTIONS: GP-what to do if alert-assessment & prevention.
• Discharge letter for those with AKI on their diagnosis.
• Patient & Carer Information
• Education-Primary Care
• Royal Liverpool Hospital-Pilot with GP Practices on AKI Alerts-Only
sending alerts to individual practice-identifying how many are serious &
how many need to come into hospital.
• Plan to Link Alert to Guidance Documents

• Future Plans:-
• More Education for Nursing and Care Homes & Carers
• Community Pharmacists
• Drug Holiday Information
• Direct Link for health care professionals on results
• http://www.cmscnsenate.nhs.uk/strategic-clinical-network/our-
networks/cardiovascular/within-network/kidney/kidney-network-group/
• AQuA -Secondary Care-CCG Standards-Primary Care?

• BARRIERS:-
• Phlebotomy Services
• GP feeling of ensuing Tidal Wave and being swamped.
• Siloed working-Primary Care; Secondary Care Community & Voluntary Sector.
• Overall Population Unawareness (74% no knowledge of kidney disease-recent
Kidney Research UK commissioned UKGov poll of 2000 people)..
• Common & deadly-need to look for diagnosis-it is not going to overwhelm the
system but need to treat. It is possible to get good outcomes

If this works for Secondary Care then we can make it work for Primary
Care.193

| Presentation to National AKI Meeting 24th March 2015194

• Acknowledgements:-
• Dr Abraham, Clinical Lead Cheshire & Mersey
Renal Network;
• Members to the Cheshire and Merseyside Renal
Network;
• Dr Peter Chamberlain GP Quality and Strategy
Lead South Sefton CCG:
• Dr Chandrasekar, Consultant Nephrologist,
University Hospital Aintree.

What will happen next, priorities and summary of the day
Richard Fluck
National Clinical Director for Renal, NHS England
Tom Blakeman
GP
Dan Lasserson
GP

25/03/2015 197
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

16.00 – Close and thanks for attending
Safe journey home

Think kidneys primary care and commissions workshop 240315 master slide deck final

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