1. Dr Richard Fluck
National Clinical Director (Renal)
NHS England
richard.fluck@nhs.net
Think Kidneys: The NHS campaign to improve the care
of people at risk of or with, acute kidney injury
Where have we got?

2. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 2
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.

3. KDIGO Clinical Practice Guideline for Acute Kidney Injury
Kidney International Supplement 2012; 2(1): 1-138
How is AKI defined?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 3

4. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 4

5. Who is most at risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 5
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?

6. | 6
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
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

7. | 7
Mortality with AKI stage
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

8. | 8
NCEPOD report published in 2009
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Poor assessment of risk factors for
AKI and acute illness
Delays in recognising AKI
Most patients with AKI are not cared
for by nephrologists
Most patients with AKI are not cared
for by nephrologist
‘Good’ care in <50% cases

9. | 9
Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
For George, his risk of death is 32.2%
For Julia, her risk of death is 53.1%

10. | 10
Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

11. Our shared purpose: reduce harm related to AKI
Who is at risk?
When do people sustain AKI?
How should patients with AKI be
managed?
What do people need to know?
| 11The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

12. ‘Think Kidneys’ AKI Programme
| 12The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. PreventingHarm. ImprovingCare

13. Understanding Risk
Vulnerability
A fixed set of characteristics – e.g. age, comorbidities including
CKDs, diabetes, drugs
Trigger
An event that might precipitate AKI, e.g. surgery, sepsis
Response
Mitigating the risk e.g. sick days rules, monitoring
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 13

14. The vulnerable population
Fixed factors
The elderly
The frail
Existing comorbidities
Chronic kidney disease
Previous history of acute kidney
injury
Modifiable risk factors
Drugs
NSAID – auto-regulation
Diuretics – volume status
ACEi/ARB and other BP
targeted medications –
BP and auto-regulation
Metformin – side effects
enhanced
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 14

15. Reducing risk: Sick day guidance (a.k.a rules)
Previous history of acute kidney injury
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
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 15

16. Improving diagnosis: using changes in serum creatinine
Laboratory definition and standardisation
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 16

17. National Algorithm
Based in LIMS
Compares serial creatinine measures
| 17The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

18. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care
Considerations
18

19. Is it enough to do a test?
| 19The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
In conclusion, this
randomised, controlled
study did not show a
meaningful benefit of an
electronic alert system
for acute kidney injury in
patients in hospital.

20. | 20
Detect Alert
Lets talk about ‘alerts’
Respond
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

21. | 21
Care bundles and response
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

22. STOP-AKI Aintree University Hospital, Liverpool
| 22The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Change package
Automated test-alert
Care bundle
Education package
Results
Mortality reduced from 26% to 19%
Length of stay reduced by 2.7 days
Chong et al ASN
November 2015
Abstract
presentation

23. The national CQUIN and recovery
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 23
Year 1
Discharge communication
Communication of AKI
Need for follow up
Medications
Why?
High readmission rates
Primary care knowledge
Future risk
Medicines management

24. ‘AKI warning
stage’
Patient
management
system
Alert Response
Local systems
Message
Master
patient
index
Other data
systems
AKI
Registry
Regional
National Research
QI
System Measurement
24

25. Uptake of LIMS algorithm across England to date
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. PreventingHarm. ImprovingCare

26. The pathway and commissioning levers
| 26
Risk assessment
•CQUIN in test in SDH
Improved diagnosis
•Safety alert NHS
England
Treatment
•NICE guidance
•Care bundles
Recovery
•National CQUIN
Primary care
Secondary care
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. PreventingHarm. ImprovingCare

27. Engaging with safety and improvement
partners
| 27The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. PreventingHarm. ImprovingCare
Patient Safety
Collaboratives

28. Summary
AKI is:
Common
1 in 5 of all emergency
admissions
2/3 starts in the community
Costly
It increases the risk of death and
harm
It costs resources
Treatable
Education
Early detection
Better intervention
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 28

29. Summary: a improvement project
Think Kidneys
• Has delivered system
levers
• Providing a framework
for action
• Raised the profile
• It is supportive of other
change agents
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. PreventingHarm. ImprovingCare

30. 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
| 30The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Joan Russell
Head of Patient Safety
NHS England
joan.russell@nhs.net
Ron Cullen
Director
UK Renal Registry
Ron.Cullen@renalregistry.nhs.uk
Karen Thomas
Think Kidneys Programme Manager
UK Renal Registry
Karen.Thomas@renalregistry.nhs.uk
Annie Taylor
Communications Consultant to the Acute
Kidney Injury National Programme
anniemtaylor331@gmail.com
The chairs, co-chairs and teams of all the
workstreams in ‘Think Kidneys’

31. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 31