Measurement for Improvement - Management of Acute Kidney Injury in primary care

Measurement for ImprovementManagement of Acute Kidney Injury in

primary careMeasurement for improvement event

16.03.2016 Charlie TomsonConsultant Nephrologist, Freeman Hospital Newcastle upon TyneChair, Intervention Workstream, NHS England/UKRR Think Kidneys Programme@CharlieTomsoncharles.tomson@nhs.net

What would excellent care of AKI in primary care deliver?

Community-acquired AKI:

Early recognition

Appropriate treatment referral and follow-up

Reduced morbidity and mortality

Hospital-managed AKI:

Appropriate post-discharge management

Appropriate follow-up

Reduced morbidity, ESRD, late referral, and mortality

Frequency of AKI in primary care

Based on reports from 6 centres, using the AKI algorithm for generation of AKI warning stage test results:

Likely incidence 0.5-1.0 cases/WTE GP/month• Assumes 1500 patients/WTE GP

~70% AKI stage 1

~20% AKI stage 2

~10% AKI stage 3

Prognosis of AKI in adults managed in 1o care (not admitted)

Hobbs H et al. BMC Nephrol 2014;15: 206

NICE standards (AKI: CG 169):

Measure serum creatinine and compare with baseline in adults with acute illness and

• CKD G3-5 (eGFR<60); Heart failure; Liver disease; Diabetes; Previous history of AKI; age>65

• Oliguria (less than 0.5 ml/lg/h)

• Limited access to fluids caused by neurological/cognitive dysfunction

• Hypovolaemia

• “Drugs with nephrotoxic potential” (NSAIDs, aminoglycosides, ACEI, ARB, diuretics)

• Use of iodinated contrast within the last week

• Symptoms or history of urological conditions or disease that might cause obstruction

• Sepsis; falling early warning scores

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NICE standards (CKD: CG182)

1.1.28 Offer testing for CKD using eGFRcreatinine and ACR to people with any of the following risk factors:

…..acute kidney injury

Acute kidney injury and CKD

1.3.9 Monitor people for the development and progression of CKD for at least 2-3 years after acute kidney injury, even if serum creatinine has returned to baseline

1.3.10 Advise people who have had acute kidney injury that they are at increased risk of CKD developing or progressing

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Think Kidneys: Best Practice Guidance

Publication 04.04.2016

Aims:

•Put the test result in a clinical context

•Treat the patient not the test result

•Maximise clinical utility

•Minimise information overload and burden

•Ensure primary care engagement

Proposed audit measures: structures

• Practice systems to ensure that AKI warning stage test results are seen and responded to by the appropriate clinician, including response to critical test results

• Establish an AKI register and ‘alerts’ to identify and support management of patients who have had a history of AKI

Proposed audit measures: prevention

• Use of NSAIDs amongst patients with CKD (NICE CKD CG182 2014)• ??high risk subset e.g. those also on diuretics, ACEI/ARB or both

• Communicate and code risk of AKI (NICE QS76) in patients with• Previous history of AKI• CKD3 (eGFR<60 over >=3/12)• Neurological or cognitive impairment

• Carer status clarified and coded

• Up to date with immunisation

• Avoid combination of ACEI and ARB in patients with CKD (NICE CKD CG182 2014)

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Proposed audit measures: post-AKI care

• Denominator: patients with a discharge diagnosis of AKI

• Numerators: proportion coded with• AKI diagnosis• AKI stage• Cause • Given information about AKI and risk of CKD and coded ‘at risk’ of AKI• Proportion who have had a medication review within ??4/52 of discharge• Proportion of patients previously coded as hypertensive who have had BP rechecked

within ?? 4/52 of discharge• Proportion who have had repeat serum creatinine/eGFR within 3/12 of discharge• Proportion who have had a urine albumin:creatinine within 3/12 of discharge• Proportion who have had repeat eGFR/UACR at 1,2 and 3 years post discharge

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Proposed audit measures: outcomes

• Further episodes of AKI

• New cases of CKD at 12 months

• CKD progression at 12 months

• Community-acquired AKI admission

• Readmission within 90 days

• Heart failure admission

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For each patient with AKI • Where were they managed?

– Acute trust– Community

• Which CCG were they in?

• Which acute hospital (if admitted)?

• Mortality

• Did their creatinine return to baseline?– If so, when?

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What can the Measurement Workstream deliver?

For each CCG• Proportion of patients with AKI who are admitted

• Mortality

– Age, AKI stage, measures of clinical complexity

• Return of creatinine to baseline level

– Time to return

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What can the Measurement Workstream deliver?

Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas

How to find out moreKaren ThomasThink Kidneys Programme ManagerUK Renal RegistryKaren.Thomas@renalregistry.nhs.uk

Teresa WallaceThink Kidneys Programme CoordinatorUK Renal RegistryTeresajane.Wallace@renalregistry.nhs.uk

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Contact Think Kidneys

Richard FluckNational Clinical Director for RenalNHS EnglandRichard.fluck@nhs.net

Joan RussellHead of Patient SafetyNHS EnglandJoan.russell@nhs.net

Ron CullenDirectorUK Renal RegistryRon.cullen@renalregistry.nhs.uk

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www.thinkkidneys.nhs.uk