Acute Kidney Injury:The Wessex Experience

Mark UniackeConsultant in Renal and Transplantation

Wessex Kidney CentreChair

Wessex AKI Clinical ForumWessex Strategic Clinical Network

Outline

1. AKI is everyone’s business.

2. The Challenge.

3. The Wessex AKI Clinical Forum.

4. The impact.

5. The Future.

AKI is everyone’s business

Distribution of AKI episodes across acute specialties, stratified by AKI stage.

Selby N M et al. CJASN 2012;7:533-540

AKI is not just a hospital concern

Portsmouth data:

375 prospectively acquired AKI cases (2010/2011)

AKI was found on admission and hence community acquired in 68%- community AKI was more severe by staging- sepsis was an important trigger

In those without CKD at baseline community acquired AKI was associated with a higher hospital and 6 month mortality (OR 3.5, 95% C.I. 1.135 – 10.6, p=.03)

The challenge

Community Hospital

Community -acquired AKI

Predisposing factorse.g. CKD, ACE inhibitors, diuretics, BPH

Protective factorse.g. Vaccination, hydration, antibiotics

Precipitating factors Pre-renal: e.g. D+V, sepsis, trauma, GI blood lossRenal: glomerulonephritisPost-renal: obstruction

Elective hospital admission

Other condition requiring hospital admission - no AKI on admission

Hospital discharge

Predisposing factorse.g. CKD, cardiac surgery

Protective factorse.g. good fluid balance

Precipitating factors Pre-renal: e.g. hypovolaemia, sepsisRenal: e.g. nephrotoxic drugs, contrastPost-renal: e.g. obstruction

Hospital -acquired AKI

Community - acquired AKI in hospital

Emergency hospital admission

ConsequencesLonger length of stayRenal replacement therapyDeathCosts

ConsequencesNew or worse CKDChronic renal replacement therapyMedication changeRehab/Nursing HomeDeathCosts

Risk of recurrent AKI Total AKI in hospital

The Whole Pathway

Guidelines

NephrologyReferral

Care Bundles

Research

Education

eAlertsBiomarkers

Prevention

Sick Day Rules

Follow up after discharge

The Patient

“Physicians are people who pour medicine, of which they know very little, into people of whom they know less”

Voltaire 18th Century

‘What does it take to be good at something in which failure can be so easy, so effortless?’

Atul Gawande 2007

AKI is not about bad doctors and nurses

AKI is a patient safety issue but it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions

Acute Kidney Injury National Programme

2.8 million population

7 Acute Trusts

9 CCGs

3 Community Trusts

Two regional renal units

Wessex AKI Clinical Forum

AKI Network Forum

• Wessex SCN

Regional AKI Leads

• Local Renal Units• Wessex/Dorset

Local Trust Leads

• Renal• ITU• MAU

The Forum

• Nephrologists

• NHS England SCN manager

• Trust AKI leads – currently 6

• CCG representatives

• Public Health Consultant

• Laboratory Lead

• Nurse specialist

• University of Southampton – Wessex CLARCH and HHR

• AHSN representative

• Acute Medicine/Renal Trainees

Founding principles

harmonizing the AKI pathway based on evidence and national guidelines will embed best practice

improve advice/guidance and referral practices sharing of expertise, manpower and other resources

a network provides a stronger platform to lobby for resources

collaborative research/audit

a point of accountability

Wessex AKI Clinical Forum2

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Acute hospital care

E-alert subgroup

AKI Care Pathway

AKI hospital education

course

Primary care

AKI education workshops

AKI Care Pathway for Primary Care

Stakeholder engagement

AKI Awareness

and Education

Launch Event 15/4/15

AKI Outreach

Impact

Education steps in WessexHospital

Structured AKI Educational Programme targeting foundation and core trainees – based on the ALS model using practical scenarios

-Local leads

Primary Care

CCG Target events

- AKI workshops run by local nephrologist and GP

LAEDILocal awareness and early diagnosis scheme

McMillan GPs

Now supporting one GP to provide peer to peer AKI education in the community

AKI OutreachBournemouth Hospital 2014-2015

One specialist nurse (5 half days per week)

QA Portsmouth

Appointed AKI specialist nurse August 2015

University Hospital Southampton

Appointed AKI specialist nurse August 2015

Results of interventionData provided by Martin Southgate Clinical audit RBH

Paul Broom Biochemistry PGHJulia Knott Diabetes Secretary RBH

BL Intervention2014 June-Aug Sept-Dec

New AKI flags N= 188 148 ( n = 96 seen by ST)RIP 23 (14%) 8 (5%)Readmission(in 28 days) 45 (27%) 14 (9%)

LOS (Mean /St Dev) 15 days (19) 9 days (9) (*p=0.002)

CreatinineBL X 163Admission X 275Discharge X 192

Nephrologist referrals Unknown 29 (30% of those seen)

Stage 2 & 3

The Future

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Acute hospital care Primary care Community

Stakeholder engagement

AKI CQUIN guidance for

commissioners

Nurse EducationExpand Outreach

Undergraduate AKI medical education

Implement new AKI core medical teaching module

Local Awareness & Early Detection Initiative (LAEDI)

Develop AKI topic for GP Trainees

LMC engagement & education

GP ‘Train the Trainers’ module

Out of hours GP engagement

Set up community trust subgroup

Set up community pharmacy subgroup

Set up commissioners’

AKI meeting

Develop AKI Network website

Patient and family education.

To Finish

AKI appears to be a proxy indicator of a vulnerable subpopulation with high comorbidity who are at risk of future hospital admissions, recurrent AKI episodes, progressive decline in renal function and death.