Dr Nick Selby - AKI detection, alerting and intervention-محول.pptx

1. Dr Nick Selby
Associate Professor of Nephrology
Centre for Kidney Research and Innovation
Division of Health Sciences and Graduate Entry
Medicine University of Nottingham
Royal Derby Hospital
AKI detection,
alerting and
intervention

2. Royal
Derby
Hospital
5-15% of hospital admissions,
mortality ~25% and >35% in
AKI3
High
incidence,
poor
outcomes
No
specific
therapies
Variation
in
care

3. Royal
Derby
Hospital
AKI is distributed across all
specialties
Only 7.5% of patients under nephrology
Selby NM et al CJASN 2012; 7(4):

4. What is
AKI?
R
o
N
y
u
a
m
lDberboyfpatients
H
p
o
e
s
p
ri
a
t
n
a
n
lum
sustaining each
stage of AKI in
1000-bedded
hospital
414
AKI stage Serum creatinine criteria Urine output criteria
1
272
7
An increase of more than
26mol/l above baseline (within
48hrs)
OR
An increase of more than or equal to
1.5 to 2 fold from baseline
<0.5mg/kg/hr for at
least 6hours
2
782
An increase of more than or equal to
2
to 3 fold from baseline
<0.5mg/kg/hr for at least
12hours
3
636
total
:
An increase of more than 3 fold
from baseline
OR
AKI with creatinine 355mol/l
OR
N
o
Initiation of RRT
<0.3mg/kg/hr for at
least 24hours
OR
Anuria for >12hours
mention
of cause

5. Royal
Derby
Hospital
Why such small changes in
creatinine?
• Even small changes in renal function are
significant
• Multiple studies with same findings
• Findings persist after adjustment for co-
morbidities
Chertow G M et al. JASN 2005;16:3365-3370
©2005 by American Society of Nephrology
26-35mol/l 88-167mol/l
44-80mol/l >176mol/l
>44µmol/l
increase in
s.creat – 6
fold increase
in odds of
death

6. Royal
Derby
Hospital
Small changes in creatinine can reflect
larger changes in GFR
20% drop in
GFR

7. Royal
Derby
Hospital
Normal physiological
response?
‘…thousands of genes respond specifically to
volume depletion (v-AKI) or to ATN, but very few
responded to both. The activated gene sets
comprised different, functionally unrelated signal
transduction pathways.
Hence, v-AKI and ATN are biologically
unrelated…’

8. Royal
Derby
Hospital
Selby NM et al. CJASN 2012;
First hospital wide e-alert system
based on current criteria introduced
2010
Resulted in widespread interest
across the UK in developing
similar systems
VARIATIO
N
Electronic detection of
AKI

9. Royal
Derby
Hospital

10. Royal
Derby
Hospital
NHS England
algorithm
http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/a
ki- algorithm/
• Based on
KDIGO
criteria
• Defines baseline
on individual
basis
• Programmed
within laboratory
software
• AKI warning

11. Royal
Derby
Hospital
NHS England algorithm
performance
Sawhney NDT 2015
Sawhney PLOS One
2015
• Tested against ICD-
10 coded AKI and
clinician adjudicated
AKI in GLOMMS
database
• Out-performed
other creatinine
based algorithms

12. Royal
Derby
Hospital
Sawhney et al PLOS One
‘We should be mindful that
restricting alerts to stages 2-3
may identify fewer CKD
patients, but including stage 1
provides more sensitive and
timely alerting’

13. Royal
Derby
Hospital
Detec
t
Aler
t
Detection of AKI: not in
isolation
Respo
nd

14. Royal
Derby
Hospital
• Alert design limited; no
supporting interventions
No change in physician behaviour
• Single centre – likely control
group contamination
• Detection algorithm insensitive as
compared to NHSE algorithm
• Context very different from UK
‘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’
Wilson et al. Lancet 2015; 385:

15. Royal
Derby
Hospital
Care bundles for
AKI
What is a care
bundle?
…A structured method of
improving processes of care
and patient outcomes...
• A small, straight-forward set
of evidence-based
practices:

 For a defined patient segment
or population
All or none approach: every
patient, every time
• When implemented
collectively, improves
outcomes beyond that
expected if implemented
individually.
How do they
work?
How should AKI be
managed?

16. Royal
Derby
Hospital
AKI care bundle and
alert
Care bundle components:
1. Diagnosis of cause of AKI
made
2. Urinalysis
3. Assessment of volume
status
4. Medication review
5. Inform patient of diagnosis
6. Seek advice when needed
Better outcomes with care
bundle
• Propensity score
matching from 3717
AKI episodes
• Mortality 24.4% versus
20.4%, p<0.001

17. Royal
Derby
Hospital
Aintree
experience
• Risk assessment tool
• e-alert (updated to NHSE algorithm)
• Intervention bundle, guidelines, outreach
team
• Awareness and education of staff and
patients
QJM
2017

18. Royal
Derby
Hospital
Manchester
experience
• e-alert
• Checklist
• AKI nurse team
• Pharmacy involvement
• Education and
awareness
BMJ Quality Improvement Reports
Reductions
in:
• Incidence of hAKI
• AKI mortality
• Length of stay in AKI
pts.
• AKI days (duration)

19. Royal
Derby
Hospital
Tackling acute kidney injury – a
multi-
centre pragmatic clinical
trial
• Will test scalability of a complex intervention:
• AKI detection and alerting
• Education programme (hospital wide)
• Care bundle for AKI management
• Cluster randomised stepped wedge design
• Outcome
measures:
• Implementation and qualitative
evaluation
• Process measures
• Patient outcomes
Partner organisations:
Derby Hospitals (lead
organisation)
Leeds Teaching Hospitals
Bradford NHS Foundation
Trust Frimley Park Hospital
Ashford and St Peters
Hospital Surrey Pathology
Services
UK Renal Registry
NHS England
www.tacklingaki.o @Tackling

20. Royal
Derby
Hospital
Stepped wedge
design
Centre
1
(Frimley
)
Centre 2
(Bradford
)
Centre
3
(ASPH)
Centre
4 (LGI)
Centre
5 (LSJ)
Randomisatio
n happened
on 11th May
2015
Baseline
 Data collection
Intervention
 Data collection
Intervention
 Data collection
Intervention
 Data collection
Intervention
 Data collection
Intervention
 Data collection
Post intervention

21. Royal
Derby
Hospital
Stepped wedge cluster
randomised study
design
• Avoids contamination of groups
• Overcomes ethical problems w.r.t. failure
to address variation in care - all centres
are exposed to intervention
• Improvement over time-series design;
differentiation between treatment effect
vs. time-related factors
• Designed within CONSORT 2010
Cluster RT
guidance
• Allows quality improvement approach

22. Royal
Derby
Hospital
Data
collection
1. Patient outcome data
• IT based
• All patients with one or more results from laboratory detection of
AKI
• Detection runs in control periods but results not visible to end-
users
• Data specification developed
2. Audit of process of care
• Recurrent audit throughout project (7 cycles in total)
• 30 cases per centre audited per cycle
• Audit standards and data collection variables constant between
centres
• Requires manpower to deliver
1. Qualitative
• Why do elements of the intervention work/not work?
• Can we develop a ‘how to’ guide for scaling/implementing

23. Royal
Derby
Hospital
Outcom
es
Primary endpoint: 30 day mortality rate in patients with AKI
Secondary endpoints
a) Patient outcome measures:
1. Incidence of hospital acquired AKI (h-AKI)
2. Incidence of AKI progression (AKI that increases by ≥1 stage from that
at first detection)
3. Incidence of individual AKI stages
4. Length of hospital stay of patients with AKI
b) Measures of basic care:
• Clinical audit of metrics of basic care
c) Qualitative data

24. Royal
Derby
Hospital
Sample size
calculation
• Assumptions used were very conservative
• The annual number of admissions in the 5 institutions is
~434,000
Data from HSCIC
• Assumptions:
 AKI incidence of 2.5% of admissions
 30-day mortality of 16%
 Power was set at 80%, alpha at 0.05 and a range of values
for inter class correlation (ICC) between 0.01-0.2 was
considered.
 Cases from transition block (initial 3mnth implementation) not
included
• With a trial duration of two years and one centre per
randomisation step, 10,850 patients required to detect a
decrease in mortality from 16% to 12.8%.

25. Royal
Derby
Hospital
Improvements in delivery of
care
0
20
40
60
80
100
A K I R ec ognitio n
%
o
f
A
K
I
p
a
tie
n
ts
p<0.0 01
0
20
40
60
80
1 0 0 100
C a re b un d le u s a g e
%
o
f
A
K
I
p
a
tie
n
ts
0
20
40
60
80
M e d ic a tio n re v ie w
%
o
f
A
K
I
p
a
tie
n
ts
p<0.0 01
0
20
40
60
80
100
S p e c ia lis t re fe rra l
%
o
f
A
K
I
p
a
tie
n
ts
p=0.3 1
0
20
40
60
80
10 0
F lu id a s s e s m e n t p e rfo rm e d
%
o
f
A
K
I
p
a
tie
n
ts
Fluid
assessment*
p<0 .0 01
0
20
40
60
80
10 0
R e n a l Im a g in g R e q u e s te d
%
o
f
A
K
I
p
a
tie
n
ts
p=0.5 8
0
20
40
60
80
10 0
U rin a ly s is p e rfo rm e d
%
o
f
A
K
I
p
a
t
ie
n
ts
p<0.0 01
0
20
40
60
80
100
U re th ra l c a th e te ris a tio n fo r re a s o n s
o th e r th a n re lie f of o b s tru c tio n
%
o
f
A
K
I
p
a
tie
n
ts
p=0.3
N=104
2
AKI recognition* Care bundle use* Medicines
review*
Urinalysi
s*
Renal
imaging
Specialist
referral
Urethral
catheter
* = significant
increase

26. Royal
Derby
Hospital
Outcom
es
24,059 AKI episodes in
20,719 patients
7.6 cases/100 admissions
With intervention:
• No difference in 30d
mortality (OR 1.07, 95% CI
0.93-1.24).
• Hospital length of stay (LoS)
was reduced
• Duration of AKI was shorter
• The incidence of AKI was
11.6%
higher in the
intervention period
(p<0.001).
Hospital length of
stay
AKI
duration

27. Royal
Derby
Hospital
CKD is common post
AKI
Chawla L et al. NEJM 2014;
371:58-66
• ARID study
• 866 matched patients (AKI
and controls)
• Mean eGFR results at
baseline, during
hospitalisation, then at 3
months and 1 year after
• Bidirectional relationship of
AKI and CKD

28. Royal
Derby
Hospital
Research
agenda
• Can we improve
patient phenotyping?
 better ways of
describing aetiology
or mechanisms of AKI
• Can we stratify
individual patients,
especially those with
AKI stage 1?
• Can we predict those
at higher risk of non-
recovery?
New
therapies

29. Royal
Derby
Hospital
Conclusio
ns
• AKI is common, harmful and in some cases
preventable
• AKI is a clinical diagnosis, which includes
determination of its cause
• Electronic detection is a tool – effectiveness
depends on how it is implemented
• Evidence growing to support combined
approach to reduce harm associated with AKI
nicholas.selby@nottingham.a
c.uk