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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
Secondary care considerations
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.
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
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 4
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
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
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
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
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
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
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
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 | 12
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 | 13
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 | 14
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 | 15
National Algorithm
Based in LIMS
Compares serial creatinine measures
| 16The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care
Considerations
17
Is it enough to do a test?
| 18The 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.
| 19
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
| 20
Care bundles and response
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
STOP-AKI Aintree University Hospital, Liverpool
| 21The 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
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 | 22
Year 1
Discharge communication
Communication of AKI
Need for follow up
Medications
Why?
High readmission rates
Primary care knowledge
Future risk
Medicines management
The impact of AKI on people with diabetes
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 23
Clin J Am Soc
Nephrol. 2011
Nov;6(11):2567-
72. doi:
10.2215/CJN.01
120211. CV1,
Christianson A,
Himmelfarb J,
Leonard AC.
‘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
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 | 25
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
| 26The 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’
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 27

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AKI - Secondary care considerations

  • 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 Secondary care considerations
  • 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. 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 | 12
  • 13. 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 | 13
  • 14. 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 | 14
  • 15. 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 | 15
  • 16. National Algorithm Based in LIMS Compares serial creatinine measures | 16The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
  • 17. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations 17
  • 18. Is it enough to do a test? | 18The 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.
  • 19. | 19 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
  • 20. | 20 Care bundles and response The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
  • 21. STOP-AKI Aintree University Hospital, Liverpool | 21The 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
  • 22. 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 | 22 Year 1 Discharge communication Communication of AKI Need for follow up Medications Why? High readmission rates Primary care knowledge Future risk Medicines management
  • 23. The impact of AKI on people with diabetes The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 23 Clin J Am Soc Nephrol. 2011 Nov;6(11):2567- 72. doi: 10.2215/CJN.01 120211. CV1, Christianson A, Himmelfarb J, Leonard AC.
  • 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. 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 | 25
  • 26. 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 | 26The 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’
  • 27. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 27

Editor's Notes

  1. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals
  2. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals
  3. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals
  4. Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals