Dr Al-Sayed et al (The Christie NHS Foundation Trust) share their successful QI project to improve patient care in AKI as part of NQICAN Patient First 2016 presentation.

1. The Christie NHS Foundation Trust
Patient First: Preventing Harm Improving care - Quality Improvement Theatre
Clinicians and QI staff -
creating effective partnerships
Quality Improvement Initiative:
Acute Kidney Injury (AKI) Care in Acute Oncology
Dr Tamer Al-Sayed MB ChB FRCP (London) MRCP (Nephrology) SCE (Acute Medicine)
PGCE (PG Medical Education) GC (Medical Physiology & CV/Advanced Renal Specialisation)
Consultant in Acute & Renal Medicine
Acute Kidney Injury Clinical Lead & Sepsis Co-Chair
Honorary Senior Lecturer, Department of Health & Medical Sciences,
The University of Manchester
&
Joanne Woolley, Clinical audit manager
The Christie NHS Foundation Trust
22-23 Nov 2016, London

2. The Christie NHS Foundation Trust
The partnership
• Multiple National drivers: need for compliance with
best practice
• Local clinical concerns: priority for improvement and
innovation
• Clinical audit / QI team support for:
• Development of working group with Executive lead
• Use of AKI alert data collected for national purposes
• Data collection to support patient safety and quality monitoring
• Raising awareness, communicating progress
• Transfer to the electronic patient record and AKI dashboard
• Ongoing review and development

3. The Christie NHS Foundation Trust
Acute Kidney Injury (AKI) at The Christie
• The Christie NHS FT -
comprehensive cancer centre
• largest single site cancer centre in
Europe treating more than 44,000
patients a year
• 18 months ago, new Acute
medicine role appointed
“As a Consultant treating acutely
unwell patients, I have worked
with an expert team to develop
guidelines for staff and patients in
the treatment of acute kidney
injury (AKI)” Dr Al-Sayed

4. The Christie NHS Foundation Trust

5. The Christie NHS Foundation Trust
The Culture of Audit
• Feeds into clinical effectiveness and research
committee
• Common goal – striving for excellence
• One big team
• Bidirectional interactions
• Strong clinical governance leadership
• Clinical audit a pivotal aspect of quality assurance
• Proactive
• Co-dependent

6. The Christie NHS Foundation Trust
The Christie Experience
• Collaboration with UHSM & AKI working party
• Clinical guidelines developed
• Hotline triage tool
• Audit tool
• New fluid balance forms on OAU
• Patient information leaflet
• NHS Think Kidneys – Showcased work
• Local teaching
• Regional posters and presentations
• NPSA award nomination
• RCP Excellence in patient care submission
• Development of e-learning tool

7. The Christie NHS Foundation Trust
NCEPOD & NICE
• For Better, for worse? – 2008
• Adding insult to injury – AKI 2009
• A time to intervene – 2012
• Just say sepsis – 2015
• NICE AKI guidance 2012
• NICE IV Fluid guidance 2013
• NPSA June 2014 & August 2016

8. The Christie NHS Foundation Trust
Key performance indicators
– facets of a care bundle
• Urine output
• Urinalysis
• Fluid balance
• Critical perfusion pressure
• Oxygenation
• Treatment of sepsis – door to needle times
• Discontinuing toxic medications
• Hand over
• Data recording – audit & governance

9. The Christie NHS Foundation Trust
Telephone triage for patients with suspected AKI
DIARRHOEA
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
• What chemotherapy is the patient on and when was the last treatment/tablet?
• Are they receiving radiotherapy and when was their last treatment?
• Number of recent episodes?
• How often do the bowels usually move?
• How many stools a day is the patient passing or how much stoma output is there above normal amount?
• Are stools/stoma output formed, loose or watery? Any faecal incontinence or urgency? Nocturnal movements?
• Is there any abdominal pain e.g., cramping pains coming in waves?
• For how many days has the patient had diarrhoea? Is it interfering with activities of daily living?
• Are they able to eat and drink normally? Are they passing plenty of clear urine?
• Do they have any other chemotherapy related toxicities, e.g. mouth ulcers, N/V, red hands/feet, stomatitis, mucositis?
• Any recent antibiotics or recent hospital admissions?
• Have they taken any laxatives or anti-sickness medication or any anti-diarrhoeal medication in the last 24 hours? What?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?
Is the patient taking:
•NSAIDs e.g. Diclofenac, Ibuprofen
•ACE inhibitors e.g. Ramipril, Lisinopril.
NB if patient taking any of the above drugs advise to omit until management plan agreed

10. The Christie NHS Foundation Trust
VOMITING
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
•Frequency (number of episodes in last 24/48 hours) and nature of nausea with or without vomiting?
•Assess bowel movements; Any symptoms that suggest constipation? Any diarrhoea?
•What food and fluids have you been taking over last few days?
•Any signs of dehydration e.g. decreased urine output, fever, thirst, dry mucous membranes etc.
•What is the underlying cancer diagnosis?
•What is the extent of the disease? – e.g. known metastases to brain, bone, liver etc.
•What medication is the patient taking i.e. antiemetics and has there been any recent changes?
•Increasing abdominal pain?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?
Is the patient taking:
•NSAIDs eg Diclofenac, Ibuprofen
•ACE inhibitors eg Ramipril, Lisinopril.
NB if patient taking any of the above drugs advise to omit until management plan agreed
Review prescribed
antiemetic medication;
Assess patient compliance
Phone / review the patient
in 24 hours
As for grade 1
Advise to get GP review
consider changing antiemetic
including route of admin.
Phone / review the patient in
24 hours
If symptoms worsen or are
associated with other toxicities
consider admission.
Urgent review required or discuss with Acute
Physician on MAU.

11. The Christie NHS Foundation Trust
Time Oral Intake Running
Total
IV 1 IV 2/ Other Running
Total
Total
Intake
07: 00
08: 00
09: 00
10: 00
11: 00
12: 00
13: 00
14: 00
15: 00
16: 00
17: 00
18: 00
19: 00
20: 00
21: 00
22: 00
23: 00
24: 00
01: 00
02: 00
03: 00
04: 00
05: 00
06: 00
TOTAL
INTAKE
Urine Running
Total
Other Other Running
Total
Total
Output
TOTAL
OUTPUT
Balance from
previous day:
Cumulative
balance:
Weight:
Balance from
previous day:
Cumulative
balance:
Weight:
BALANCE
Developed by Katerina Pearson, OAU Sister

12. The Christie NHS Foundation Trust
AKI alert and guidance on blood result

13. The Christie NHS Foundation Trust
Change in biochemical assay

14. The Christie NHS Foundation Trust
AKI alerts post change in algorithm
• Initial audit identified need for change in algorithm to
improve accurate classification of AKI stage
• Increased numbers identified; level 3 maintained

15. The Christie NHS Foundation Trust
AKI alerts: quality monitoring
and improvement
• Adherence to care bundle and root cause analysis
• Policy, guidance, education, awareness raising

16. The Christie NHS Foundation Trust
Assessing risk factors on admission

17. The Christie NHS Foundation Trust
Monitoring compliance with care bundle
• Early increased compliance since pilot, eg.:
• Ultrasound KUB <24hours: up from 51% to 60%
• Stop nephrotoxic medications: up from 54% to 63%
• Urine dipstick and analysis: up from 54% to 67%

18. The Christie NHS Foundation Trust
Strong Leadership
Focus within The Christie:
• Governance – clinical audit leadership and
steering
• Clinical specialist leadership
• Executive board membership
• Embedding data collection into clinical
systems
• Empowering staff to collect data
• Assigning trainees with current projects

19. The Christie NHS Foundation Trust
Sharing & Promoting Best Practice
• Executive dissemination
• Education – Presentations
• Non-medical prescribers
• Acute Oncology Masterclass for NW AON
• Morbidity & Mortality Grand Round
• Representation at the GM, Lancashire & South
Cumbria Strategic Clinical Network
• National patient safety presentations
• GP correspondence
• Link with sepsis and IV fluid groups

20. The Christie NHS Foundation Trust
Practical Solutions – Real Problems
• Clinical audit will assure delivery and
quality of this entire project through
robust long term data collection &
analysis
• AKI Dashboards – safety thermometer
• EPR – AKI documentation
• e-prescribing – medicines optimization
• e-learning tools
• AKI discharge summaries for GP & patients

21. The Christie NHS Foundation Trust
Simple is Effective
 Maximising the utility of clinical audit
 A fully integrated team
 Pioneering in Cancer Care in the UK
 Innovative & Expert real time cross disciplinary team
working beyond historical barriers
 The power of a culture shift
 A new tradition
 Medicines optimization
 Proactivity at the front door
 Maximising patient outcomes

22. The Christie NHS Foundation Trust
References & Resources
• AKI toolkit 12 – RCP Oct 2015
• AKI APP – RCPE
• NICE AKI Guidance 2012
• NCEPOD – Adding Insult to Injury 2009
• NHS ‘Think Kidneys’ programme
• Academy of Medical Royal Colleges
• Royal College of Radiology – Contrast Nephropathy
• Society of Intensive Care Medicine
• Society for Acute Medicine
• Royal College of Nursing
• Royal Society of Medicine – Nephrology section
• Renal Association/British Renal Society website