Acute Kidney Injury: The Wessex Experience Mark Uniacke Consultant in Renal and Transplantation Wessex Kidney Centre Chair Wessex AKI Clinical Forum Wessex

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Acute Kidney Injury An Overview

Acute Kidney Injury:The Wessex ExperienceMark UniackeConsultant in Renal and TransplantationWessex Kidney CentreChairWessex AKI Clinical ForumWessex Strategic Clinical Network

The challengeOutlineAKI is everyones business.The Challenge.The Wessex AKI Clinical Forum.The impact.The Future.

1. To help highlight why we have structured our forum as we have it is everyones business3AKI is everyones businessDistribution of AKI episodes across acute specialties, stratified by AKI stage.

Selby N M et al. CJASN 2012;7:533-540Distribution of AKI episodes across acute specialties, stratified by AKI stage. Relatively few patients were directly cared for by a nephrologist, although there was a higher proportion of stage 3 AKI in that group. Eventhough nephrology have been taking the lead .. No specialty is immune AKI for the most part should be viewed is everyones problem we need to make people think about the kidneysCommunityHospitalCommunity -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 admissionOther condition requiring hospital admission - no AKI on admissionHospital dischargePredisposing factorse.g. CKD, cardiac surgeryProtective factorse.g. good fluid balance Precipitating factors Pre-renal: e.g. hypovolaemia, sepsisRenal: e.g. nephrotoxic drugs, contrastPost-renal: e.g. obstructionHospital -acquired AKI

Community - acquired AKI in hospitalEmergency hospital admission

ConsequencesLonger length of stayRenal replacement therapyDeathCostsConsequencesNew or worse CKDChronic renal replacement therapyMedication changeRehab/Nursing HomeDeathCosts

Risk of recurrent AKITotal AKI in hospitalFor the uninitiated I I want to here outline a conceptual model of the AKI pathway to illustrate the multiple stages at which intervention is possible. 8The Whole PathwayGuidelinesNephrologyReferralCare BundlesResearchEducationeAlertsBiomarkersPreventionSick Day Rules Follow up after dischargeThe PatientThe whole pathway no point in implementing eALerts unless alone as a recent paper in the lancet demonstrated without additional interventions such as education. 9Physicians are people who pour medicine, of which they know very little, into people of whom they know lessVoltaire 18th CenturyWhat does it take to be good at something in which failure can be so easy, so effortless?Atul Gawande 2007 Back to basics!. which has formed the backbone of our philosophy in Wessex

The message is one of good clinical medicine. AKI management is not rocket science. Spend time with the patient and understand their management. Back to basics.Use example of my patient on Monday and possibly as SHO. NB NHS England Think Kidneys it is not about bad doctors and nurses AKI is a patient safety issue and it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable intervention. Make point that systems etc. are well and good e.g. eAlerts but people need to do the blood tests in the first place10AKI is not about bad doctors and nursesAKI is a patient safety issue but it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventionsAcute Kidney Injury National Programme Risk analysis rarely stops at the individual 112.8 million population

7 Acute Trusts

9 CCGs

3 Community Trusts

Two regional renal units

The challenge in Wessex like the South West SCN we are spread out over a broad geographical area12Wessex AKI Clinical ForumAn example of regional AKI management not the bee all and end all but a template for what needs to be done13The ForumNephrologists

NHS England SCN manager

Trust AKI leads currently 6

CCG representatives

Public Health ConsultantLaboratory Lead

Nurse specialist

University of Southampton Wessex CLARCH and HHR

AHSN representative

Acute Medicine/Renal TraineesConstantly expanding divided into subgroups depending on need eAlert, education, primary care, and next a Nurse led subgroup regular meetings supported by the SCN 15Founding principlesharmonizing 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 resourcesa network provides a stronger platform to lobby for resourcescollaborative research/audita point of accountability

Give examples collaboration, accountability 16 Wessex AKI Clinical Forum2014/15 Work streamsAcute hospital careE-alert subgroupAKI Care PathwayAKI hospital education coursePrimary careAKI education workshopsAKI Care Pathway for Primary CareStakeholder engagementAKI Awareness and Education Launch Event 15/4/15AKI Outreach

Impact

Keep it simple message complimentary pathways for hospital and primary care19

Education steps in WessexHospitalStructured AKI Educational Programme targeting foundation and core trainees based on the ALS model using practical scenarios -Local leadsPrimary Care CCG Target events- AKI workshops run by local nephrologist and GPTo date has been ad hoc grand rounds etc.

Example Amongst others21LAEDILocal awareness and early diagnosis scheme

McMillan GPsNow supporting one GP to provide peer to peer AKI education in the community

Impact , evidence and how are we going to manage it?22AKI OutreachBournemouth Hospital 2014-2015One specialist nurse (5 half days per week)QA Portsmouth Appointed AKI specialist nurse August 2015University Hospital SouthamptonAppointed AKI specialist nurse August 2015Results of interventionData provided by Martin Southgate Clinical audit RBHPaul Broom Biochemistry PGHJulia Knott Diabetes Secretary RBH

BLIntervention2014June-AugSept-Dec

New AKI flags N=188148( n = 96 seen by ST)RIP23 (14%) 8 (5%)Readmission(in 28 days)45 (27%)14 (9%)

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

CreatinineBLX163AdmissionX275DischargeX192

Nephrologist referralsUnknown29 (30% of those seen)

Stage 2 & 3 Wessex AKI Clinical Forum2015/16 Work streamsAcute hospital carePrimary careCommunityStakeholder engagementAKI CQUIN guidance for commissionersNurse EducationExpand OutreachUndergraduate AKI medical educationImplement new AKI core medical teaching moduleLocal Awareness & Early Detection Initiative (LAEDI)Develop AKI topic for GP TraineesLMC engagement & educationGP Train the Trainers moduleOut of hours GP engagement Set up community trust subgroupSet up community pharmacy subgroupSet up commissioners AKI meetingDevelop AKI Network website Patient and family education. To FinishAKI 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. Opportunity to revolutionise the care of ill comorbid patientsTreat AKI well = treat sick patient well and visa versa27