www.england.nhs.uk

• Sarah Boul, Quality Improvement Lead and Rebecca Campbell, Quality Improvement Manager • sarah.boul@nhs.net and rebecca.campbell6@nhs.net • Twitter: @GoTeamRenal and @AKI_YorksHumber • October 2015

Yorkshire and the Humber Renal Network

AKIPCI Forum

9th October 2015

Hatfeild Hall, Aberford Road, Stanley, Wakefield, West Yorkshire, WF3 4JP

www.england.nhs.uk

AGENDA 1400 Welcome & Introduction

Dr John Stoves, Y&H Renal SCN Clinical Lead & Consultant Nephrologist, BTHFT

1410 AKI Alerting to Primary Care - Planning the Roll Out Dr Ian Stott, Consultant Nephrologist, Doncaster and Bassetlaw NHS Foundation Trust

1435 Prescribing and Acute Kidney Injury – Experiences in Primary Care Su Wood, Independent Prescriber, Prescribing Support Services & University of Leeds

1500 Identification and Management of Acute Kidney Injury in the Community Dr Alastair Bradley, GP, Tramways Medical Centre and Academic Training Fellow, University of Sheffield

1525 Tea and Coffee

1545

Tackling Acute Kidney Injury - Health Foundation Multi-Centre Quality Improvement Project Natalie Jackson, Academic Health Science Network

1600 Development of a Y&H Nurse Acute Kidney Injury Forum Andrea Fox, Lecturer, University of Sheffield and Louise Wild, AKI Nurse Educator, Sheffield Teaching Hospitals NHS Foundation Trust

1615 Acute Kidney Injury and Renal Developments at Calderdale and Huddersfield NHS Foundation Trust: Including the Challenges of Implementing the AKI CQUIN Dr Mansoor Ali, Consultant Renal Physician, Calderdale and Huddersfield NHS Foundation Trust

1640 Summary & Next Steps Dr John Stoves, Y&H Renal SCN Clinical Lead & Consultant Nephrologist, BTHFT & Dr Andy Lewington, Consultant Nephrologist, LTHT

1700 Close

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Yorkshire and the Humber AKIPCI Forum

Welcome & Introduction

Dr John Stoves, Y&H Renal SCN Clinical Lead &

Consultant Nephrologist, BTHFT

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Yorkshire and the Humber AKIPCI Forum

AKI Alerting to Primary Care - Planning

the Roll Out

Dr Ian Stott, Consultant Nephrologist, Doncaster and Bassetlaw NHS Foundation Trust

AKI alerting to Primary Care Planning the Roll-out

Dr Ian Stott Consultant Nephrologist

• Engagement and setting up the working group • Terms of reference • Estimating the impact • Developing guidance • Implementation

• Initial approach via CCG CQRG • NHS Doncaster agreed to fund a working

group • NHS Bassetlaw agreed a single group and set

of guidelines was appropriate

Engagement

Working group

• DBH staff: – Consultant Nephrologist – Consultant Acute physician – Senior biochemist

• GPs – CCG locality lead – Training lead – OOH GP

• Others: – Heart failure nurses – CCG IT lead – Admin support

Terms of Reference • GP guidelines including Out of Hours. • An implementation plan for General Practice

to include Education and Training. • An implementation plan for the Doncaster

Laboratory. • Patient information.

Workload (March 2015)

Number per month Per 10000 patients (Approx)

GP U&E samples 20964 524

AKI 1 76 2

AKI 2 8 0.2

AKI 3 6 0.15

Guidelines • Simple concise flowchart for ease of use • Separate flow chart for management of raised

potassium • More detailed guideline for reference –

adapted from Derby guidelines

• Following recent guidance from the Think Kidneys project agreed not to proceed with a formal plan for sick day rules

• Patient information for heart failure patients amended to include clear guidance on seeking advice from GP/HF nurse if unwell

Implementation

• Education sessions (TARGET, BEST) • Guidelines circulated to all practices • Alert comments with link to AKI guidelines • Date set for go live 1/10/15 • Review meeting with task group 19/11/15 • Further GP education session booked for the

new year (?Feb 2016)

• Access to ICE results reporting being rolled out for all GP surgeries

• ICE alerts developed to highlight patients with AKI and those at risk due to previous episodes of AKI

• Aim is to ensure that all primary care staff have access to historical result data to aid in interpretation of AKI alerts

ICE hazard warnings

Next steps • Review meeting following go-live • More detailed GP training session arranged for

Feb 2016 • AKI CQUIN and post-AKI management • Audit data to monitor frequency of AKI alerts

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Prescribing and Acute Kidney Injury –

Experiences in Primary Care

Su Wood, Independent Prescriber, Prescribing Support Services & University of Leeds

Prescribing and Acute Kidney Injury Experiences in primary care Su Wood

Introduction I am a pharmacist working in GP surgeries in Bradford Focus on prescribing for older people

AKI risk and prescribing Nephrotoxic drugs – increased risk to the kidney – ? part of cause All renally excreted drugs – higher blood levels increases risk of all adverse drug reactions Older people – reduced level of kidney function – reduced reserve – increased risk

Prescribing for older people with reduced kidney function – is there a problem? NICE CKD guidance in 2003 - raised awareness of kidney function - ‘review medicines’ - eGFR seemed to be giving different estimates to CrCL (Cockcroft & Gault) for older people

Prescribing for older people with reduced kidney function – is there a problem?

A retrospective study in Sweden by Helldén et al (2009) found that 14% of hospital admissions of elderly patients were primarily caused by ADRs and one-third were related to impaired kidney function, generally in very old women.

A French primary care study by Breton et al (2011) found that the prevalence of inappropriate drug use in reduced kidney function was independently related to higher all-cause mortality

Helldén, A et al. Adverse Drug Reactions and Impaired Renal Function in Elderly Patients Admitted to the Emergency

Department: A Retrospective Study. Drugs & Aging:2009; 26; 7; 595-606(12).

Breton G, Froissart M, Janus N et al. Inappropriate drug use and mortality in community-dwelling elderly with impaired kidney function – the Three-City population-based study. Nephrol Dial Transplant 2011;26:2852-9

PhD thesis Are recommendations for prescribing applied for older people with reduced kidney function in primary care? A mixed methods study to explore and improve implementation.

PhD thesis Currently writing up Will be going to publication next year Today I will share with you some findings

Is there a problem? A case note review in 5 GP practices 594 people aged 65yrs and older with eGFR<60ml/min/1.73m2 reviewed. 25% were on one or more drugs which recommendations suggest should be discontinued or the dose reduced because of the low level of kidney function. 70 different drugs implicated.

Case note review in 5 GP practices The choice of KF equation made a big difference to whether prescribing needed to be altered 29% had a creatinine clearance (Cockcroft & Gault) (CrClCG) of 30ml/min or lower, but only 7% with eGFR (as calculated by the Modification of Diet in Renal Disease equation) < 30ml/min/1.73m2 Wood, S, Petty, D., Glidewell, L., Raynor, T. Are we over-dosing our elderly patients with renally excreted drugs in primary care? IJPP 2011;19 (suppl. 2):38.

PCT-wide prescribing data survey S Wood pre-publication

70,900 people aged 65yrs and older 8 drugs/ drug classes investigated 84.6% of those on the investigation drugs had a kidney function test on the record in the previous 15mths

S Wood pre-publication

Drugs investigated S Wood pre-publication

Avoid below a defined level of kidney function

Alendronic acid Metformin

Reduce dose below a defined level of kidney function

Simvastatin Gabapentin/ pregablain

Ineffective below a defined level of kidney function

Thiazides Nitrofurantoin

Risk to kidney NSAIDs ACEI/ ARBs

% people aged ≥65yrs on the drugs S Wood pre-publication

% found with a kidney function too low for the drug prescribed – 85yrs and older S Wood pre-publication

eGFR vs CrClCG for drug dosing

Helou’s literature review (2010) - when they looked at articles looking specifically at the older patient, they concluded that CG remains the most accurate formula.

Spruill (2008) concluded that, although MDRD may be useful for estimating GFR, CG should still be used for drug adjustments; the decline in kidney function with age is expressed linearly with CG and exponentially with MDRD

Hellou R. Should We Continue to Use the Cockcroft-Gault Formula? Nephron Clin Pract 2010;116:c172-c186

Spruill W, Wade W, Cobb H. Comparison of Estimated Glomerular Filtration Rate with Estimated Creatinine Clearance in the Dosing of Drugs Requiring Adjustments in Elderly Patients with Declining Renal Function. Am. J. Ger Pharmacol 2008;6;3:153-160

Kidney function equations – effect of age (S. Wood)

Difference between eGFR and CrCl S Wood

Difference between eGFR and CrCl S Wood

srcr

age 70 75 80 85 90 95 100

22 26 31 36 41 45 5016 20 23 27 31 36 4012 15 18 22 25 29 329 12 15 18 21 24 277 10 12 15 18 20 236 8 10 13 15 18 204 7 9 11 13 15 184 5 7 10 12 14 16

90100110120

80

506070

Roberts et al (2009) used gentamicin drug levels to look at equation effect in older people

◦MDRD (eGFR) overestimated kidney function as age increased (29% and up to 69%) and

◦ C&G underestimated kidney function, though this was of a smaller magnitude (10%), consistent across age, and thus better suited for dose calculation, especially in the elderly;

◦ age significantly influenced MDRD overestimation in their population (P = 0.037).

Roberts GW, Ibsen PM, Schioler CT. Modified diet in renal disease method overestimates renal function in selected elderly patients. Age & Ageing 2009 38(6):698-703.

Outcome-based comparison Higher doses and higher rates of major bleeds when doses of eptifibatide, tirofibran or enoxaparin were determined by MDRD compared to those using CrClCG (Melloni et al, 2008)

Melloni C., Peterson E et al. Importance of Glomerular Filtration Rate Formula for Classification of Chronic

Kidney Disease in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J. Am. Coll. Cardiol 2008;51;10:992-6

Baltimore Longitudinal study on Aging

Measured creatinine clearance ‘gold standard’ in pharmacokinetic studies during drug development.

Compared measured creatinine clearance with CrClCG, MDRD and CKD-EPI

Found MDRD and CKD-EPI equations significantly overestimated creatinine clearance in older people leading to dose calculation errors for many drugs, particularly for those with severe impairment.

CrClCG slightly underestimated. Dowling T, Wang E, Ferrucci L et al. Glomerular filtration rate equations overestimate creatinine clearance in older individuals enrolled in the Baltimore Longitudinal Study on Aging: impact on renal Drug Dosing. Pharmacotherapy 2013; 33(9):912-19

Example -Female age 85yrs, LBW 45Kg, creatinine 90

CrCl (C&G) = 1 x (140-85) x 45 = 27.5ml/min 90 eGFR = 52ml/min/1.732

NOAC – eGFR normal dosing - CrClCG – reduce dose of rivaroxaban/ apixaban

European Heart Rhythm Association guidelines on NOAC treatment (2013), ‘CrCl is best assessed by the Cockcroft method’

Enalapril – CrClCG – 8x dose effect

GP interviews S Wood pre-publication

15 GPs interviewed across Bradford to understand their experience of prescribing for older patients with reduced kidney function. Analysis of their responses used to suggest what needs to change

Key theme 1: in primary care there is a lack of awareness, knowledge, and understanding about prescribing in the reduced kidney function of older people.

“I suspect for some clinicians, and I include myself in that, there may be a knowledge gap” (P1)

“it’s probably one of those areas where there is a bit of a blind side” (P4)

“I wasn’t aware. This is terrible because I use a lot of gabapentin and pregabalin, obviously, in neurology” (P6)

Key theme 2: kidney function testing is required and needs assessment when prescribing

we often check the bloods …..but I don’t often drill, ever is probably the right word, drill down to the eGFR to see whether any of the medications that they’re on tally with the GFR (P9)

we are very good at knowing when to re-check the U & Es, but are we actually correlating that with what people are on? (P7)

Key theme 3: the application of kidney function level to prescribing decisions is needed at both drug initiation and at medication review.

With the medication review you’ve just got a list of the drugs in front of you – So you’ve got to have that knowledge.. well it’s got to be in your head (P11)

once they are on the repeats it doesn’t then, doesn’t then flag it up again [warnings]. (P4)

“when you are continuing something that somebody else has started, this is wrong probably, but you feel less a responsible decision to continue something. That’s wrong I admit” (P7)

renal function isn’t one of the things that we benchmark against when we review medications, (P12)

Key theme 4: there is difficulty in remembering to apply the recommendations for use, and dosing, of drugs in reduced kidney function.

it’s remembering which medications you need to be careful with, those are the pitfalls. (P12)

I think it’s so QOF orientated now, you know we are focused on perhaps the wrong stuff in medication reviews. (P7)

the reality is that the world we live in in general practice is there are lots of boxes to tick – have you checked the blood pressure, have you done the BMI, code this, code that, do that, (P1)

Qualitative GP interview study S Wood pre-publication

Prescribing safety was a primary motivation for the GPs, and raising awareness and education would be welcomed and seen as important.

Patient and drug specific warnings and prompts to highlight a low kidney function, and when to apply recommendations, are needed at both initiation and review.

Kidney function needs to be assessed and applied when prescribing and reviewing medications

Conclusion Older people are being harmed because their kidney function is not accounted for when they are prescribed medications.

Increased risk of AKI

Increased risk from drugs in AKI

AKI - Reducing risk from prescribing

Sick day rules and alerts Patients with risk factors should be warned of the possibility of developing AKI if they become acutely ill, especially with diarrhoea and vomiting.

They should be advised to increase their fluid intake and avoid any nephrotoxic medication while ill.

Empowering patients to take charge of their own healthcare could prevent a number of cases of AKI that develop in the community

AKI - Reducing risk from prescribing ‘Think kidneys’ NHS England medicines optimisation in AKI

tool

AKI - Reducing risk from prescribing

Resource repository – e.g. charts NOACs Antidiabetic drugs Antibiotics NSAIDs & opiates Gabapentin & pregabalin

AKI - Reducing risk from prescribing

Renal advice, E-consultation Communication to primary care - post-discharge and out-patient

- clear advice on drugs, sick day rules, monitoring etc

Future intervention and research - increase awareness and knowledge,

- improve decision support

- patient and drug specific warnings and prompts at drug initiation AND medication review,

- clarify prescribing resources

The ageing population is going to make it bigger! We’re just prescribing more and more stuff aren’t we? (P13)

Thank you for your attention

SusanI.Wood@bradford.

nhs.uk

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Yorkshire and the Humber AKIPCI Forum

Identification and Management of

Acute Kidney Injury in the Community

Dr Alastair Bradley, GP, Tramways Medical Centre and Academic Training Fellow, University of Sheffield

Identification and management of Acute Kidney Injury in Primary Care ALASTAIR BRADLEY TRAMWAYS MEDICAL CENTRE SHEFFIELD

Role of Primary Care

Early identification

Prevention

Early follow-up after discharge

Continued monitoring and vigilance

Education Patients

Staff

Peers

Evidence and guidance

Research

NICE Clinical Guidance 169 Acute Kidney Injury

Clinical Guidance 182 Chronic Kidney Disease

Quality Standard 76 Acute Kidney Injury

Commissioning for Quality and Innovation (CQUIN) 2015/16

Who is at risk of developing AKI?

chronic kidney disease

heart failure

liver disease

history of acute kidney injury

oliguria (urine output less than 0.5 ml/kg/hour)

young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer

hypovolaemia

use of drugs with nephrotoxic potential (such as NSAIDs, aminoglycosides, ACE inhibitors, ARBs and diuretics) within the past week, especially if hypovolaemic

symptoms or history of urological obstruction, or conditions that may lead to obstruction

sepsis

a deteriorating paediatric early warning score

severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)

symptoms or signs of nephritis (such as oedema or haematuria)

haematological malignancy

hypotension.

Preventing CKD progression

AKI affects over 20% of acute admissions and is associated with approximately 50% of preventable hospital deaths.

Acute kidney injury and mortality in hospitalized patients.Wang HE, Muntner P, Chertow GM, Warnock DG Am J Nephrol. 2012; 35(4):349-55

CKD is reported to be the most consistent pre-existing condition Through the QOF system in primary care there is a ready register

of patients with CKD 3-5. Hypovolaemia, including exposure to sepsis and nephrotoxic

drugs is the most modifiable risk factor All patients on this register should have NSAID review and

cessation if possible Consider the effectiveness of ACE inhibitors and ARBs in non-

diabetic patients

Defining progression

1.3.3 Define accelerated progression of CKD as:

a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or

a sustained decrease in GFR of 15 ml/min/1.73 m2 per year

These people are at greater risk of progression to end-stage kidney disease.

1.3.4 Take the following steps to identify the rate of progression of CKD:

Obtain a minimum of 3 GFR estimations over a period of not less than 90 days.

In people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR

Be Vigilant!

Acute kidney injury and CKD

1.3.9 Monitor people for the development or 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.

What the NICE QS says.

13-18% of admissions are affected £1.02b (1% of NHS budget) “…patients died before discharge in approximately 28%

of admissions where acute kidney injury was recorded.” Up to 30% of cases of acute kidney injury may be

preventable, and risk assessment and prevention, early recognition and management are key factors in preventing deaths and reducing complications

Acute kidney injury is increasingly being seen in primary care, and so it is important to raise awareness of the condition among healthcare professionals working in primary care

Statement 1. People who are at risk of acute kidney injury are made aware of the potential causes.

Statement 2. People who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for this condition.

Statement 3. People in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored.

Statement 4. People have a urine dipstick test performed as soon as acute kidney injury is suspected or detected.

Statement 5. People with acute kidney injury have the management of their condition discussed with a nephrologist as soon as possible, and within 24 hours of detection, if they are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant.

Statement 6. People with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist.

Take Home messages for Primary Care

Assessing Risk of AKI

Preventing AKI

Detecting AKI

Identifying the causes of AKI

NICE CG169 (August 2013)

Preventing AKI

CG169 says very little for primary care prevention except: Seek advice from a pharmacist Consider temporarily stopping ACE inhibitors ARBs in patients

with vomiting, diarrhoea and sepsis

Awareness Who is at risk When they are more at risk Increase monitoring Stopping or managing nephrotoxic medications AKI as a consequence of systemic illness eg vasculitis or

paraneoplastic syndrome

Detecting AKI

Use creatinine rather than eGFR

Increased frequency of monitoring in those at risk with concurrent illness

a rise in serum creatinine of 26 micromol/litre or greater within 48 hours

a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days

a 25% or greater fall in eGFR in children and young people within the past 7 days

Identifying the cause of AKI

Dipstick urine as soon as possible, particularly for haematuria

Urgent ultrasound for obstructive causes -Secondary care

Early discussion with Renal Physicians after removing potential causes.

AKI CQUIN What does it mean for General Practice

The percentage of patients with AKI treated in an acute hospital whose discharge summary includes each of four key items:

1. Stage of AKI (a key aspect of AKI diagnosis); 2. Evidence of medicines review having been undertaken

(a key aspect of AKI treatment) 3. Type of blood tests required on discharge; for

monitoring (a key aspect of post discharge care); 4. Frequency of blood tests required on discharge for

monitoring

Auditing AKI discharge summaries

An opportunity for GPs to review AKI admissions through their Significant Event Analysis (SEA)

Learning points from AKI admission

Actioning these to reduce AKI admissions

Auditing future AKI events within the practice

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AKIPCI Forum Time for a break?

20 minutes only please!

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Tackling Acute Kidney Injury - Health

Foundation Multi-Centre Quality Improvement Project

Natalie Jackson, Health Informatics Senior Project Manager,

Academic Health Science Network

Part of the Yorkshire & Humber AHSN

e: academy@yhahsn.nhs.uk/ t: 01274 383926

www.improvementacademy.org

Or visit our Academy Office: Bradford Institute for Health Research Temple Bank House / Duckworth Lane / Bradford / BD9 6RJ

Tackling Acute Kidney Injury - Health

Foundation Multi-Centre Quality Improvement Project

Natalie Jackson October 2015

The aim of the study

…the introduction of a package of interventions for AKI will improve both basic standards of patient care and patient outcomes…

Package of interventions

Electronic detection

Care bundle Education programme

Selby NM et al. Clin J Am Soc Nephrol. 2012 Selby NM. Curr Opin Nephrol Hypertension 2013 Xu G et al. BMJ Open 2014 Kolhe et al. submitted PLoS ONE 2014

Stepped wedge design

Frimley Park Bradford Teaching Hospitals

Ashford & St Peters Leeds General infirmary

St James Hospital, Leeds

Baseline Data collection

Intervention Data collection

Intervention Data collection

Intervention Data collection

Intervention Data collection

Intervention Data collection

Data collection

Sharing the learning

Peer Assist

Peer Review

Bradford's plans

Rationale: Test on one unit, adapt, achieve reliability then spread Acute admission areas as a starting point Why MAU?

• Good clinical leadership • High number of Alerts • 40 beds and 70 staff • Rotational staff

Challenges • Large ward, fast turnover making case finding difficult • Rotational nature of staff makes it hard to ensure all trained • Around 20-30 cases per month – will take time to test robustly

Care Bundle

Education

Alert

Quality Improvement Methods

• Data to monitor compliance • Bundle Testing (PDSA cycles) • Co-design • Weekly updates to the ward • Continued management support • Hit rates for guidance and care bundle

How is it going so far?

0

2

4

6

8

10

week 1 week 2 week 3 week 4

number of care bundles commenced

number of alerts number of bundles commenced

Using coloured boarder – possibly orange

How is it going so far?

Nursing team felt Junior Drs need more training

Nurses do 8am handover & mention AKI - Drs to do the

same?

Bundle looks a bit complicated - Something about points absolutely essential, and those for consideration?

AKI N/A annoying and risk that the alert may become ignored.

Stickers are best Prefer sheets rather than

labels – easier to read

Do we need the prompts re Nephrotoxic drugs on actual bundle, asked if perhaps we could include some definitions of the stages instead?

Next steps

• Finalise spread plans at Bradford Teaching Hospitals Foundation Trust.

• Prepare for the next knowledge sharing event

(Peer Review) • Going live at Leeds General Infirmary in March

2016

Contact Details

www.improvementacademy.org

@Improve_Academy @TacklingAKI

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Yorkshire and the Humber AKIPCI Forum

Development of a Y&H Nurse Acute

Kidney Injury Forum

Andrea Fox, Lecturer, University of Sheffield and Louise Wild, AKI Nurse Educator, Sheffield Teaching Hospitals NHS

Foundation Trust

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https://www.youtube.com/watch?v=UmcJc2gobcI&rel=0

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Acute Kidney Injury and Renal

Developments at Calderdale and Huddersfield NHS Foundation Trust:

Including the Challenges of Implementing the AKI CQUIN

Dr Mansoor Ali, Consultant Renal Physician, Calderdale and

Huddersfield NHS Foundation Trust

Acute Kidney Injury and Renal Developments at Calderdale and Huddersfield NHS Foundation Trust (CHFT): Including the Challenges of Implementing the AKI CQUIN

Dr M N Ali Renal Consultant

• Renal input was from Leeds • x2 visits per week • Referrals and OP • Satellite Units x2 • No dedicated In-patient renal services • Delay in reviews and sometimes unnecessary transfer • Long distance travel for patients • Increased mortality from AKI

History

• AKI in reach • Providing dedicated in patient renal specialist opinion • OP clinics • Transplant clinic - Leeds • General Medicine/Renal on-call (weekdays/weekend on

call 1:5)

Job Plan (54 weeks)

• Who receives it? - Secretaries @ CRH/HRI - Urgent via switchboard • Mostly throughout the week (no particular pattern for the week – Friday and

Tuesday busiest) • What is being referred? - AKI - AKI on CKD - CKD - Dialysis patients r/v - Transplant - Nephrotic/Nephritic - Pregnancy complications - Electrolyte abnormalities - Anaemia - Urology/Stones

Referrals

Total No. Referrals

•Known vs New

HRI 35% K

65% NK

CRH 27% K

73% NK

• 72% referrals from CRH were seen on the same day • 75% from HRI seen on the same day • 46% patients seen and discharged early to be followed up in the

clinic and further investigated • 7% (HRI) / 6% (CRH) transferred to SJUH • 4 transferred to LGI under a different specialty- F/U OP • 2 transferred to BRI under a different speciality • 1 Transferred to STH • PD/HDx/Transplant patients have been reviewed and managed

within CHFT • Special arrangements for patient’s treatment carried out ~ e.g.

calciphylaxis, relapsing vasculitis, Iron etc.

Outcomes

Improvements to Hospital Bed LOS • Discharge F/up in the OP clinics meant shortening LOS in the

hospital by 0.2 days

Improvements to ICU LOS • At ICU HRI - 18% of the total referrals and 70% of the referred patients

were seen and dealt with, at HRI without the need for transfer to Leeds • At CRH - 11% of the referrals were from ICU and 60% of those referrals

were seen and managed at CHFT • Overall, ICU LOS has reduced by 138 bed days over the year, reducing the

pressure on ICU beds across the trust

Financial Calculation

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

• ISN global initiative • CRH/HRI

AKI 0 by 25

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

• Public awareness • Educational materials and information • Patient engagement and

empowerment • Interest and enthusiasm from Clinical

Governance, Pharmacy, Acute Medicine and Kidney Research UK

• March 2016

AKI awareness within CHFT

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

•

Adherence to AKI Bundles and stopping the nephrotoxic Aisha Sadiq, Fardose Anjum, Mansoor N Ali (Poster Presentation BRS July 2015)

• AKI bundle use was not 100% compliant • In 92% of the patients with AKI - drugs with nephrotoxic potential

were stopped and in 75% of the patients, this was done in <24 hrs • There is certainly an important role played by the ward pharmacist in prompting stopping and adjusting dosing as per GFR • Restarting and communication with the primary care was poor • Management of the medications with nephrotoxic potential was

better when AKI bundle was initiated

•

AKI Quality Standards- Urine Dip Audit Thamarai Muthusamy & Mansoor N Ali Sept 2015 (unpublished) •Urine dipstick - informative and non-invasive diagnostic tool - readily accessible - tests for urine sample for blood, protein, leucocytes, nitrites and glucose - NICE states “the test should be done as soon as possible after AKI is suspected or detected and within 6 hours at most.” [NICE quality standard (QS76, 2014)]

•

AKI Quality Standards- Urine Dip Audit Thamarai Muthusamy & Mansoor N Ali Sept 2015 (unpublished) • A prospective audit assessing dipstick and nephrotoxic medications • 66 case notes across HRI and CRH • Time period - July and August 2015 • Data collectors- myself and Dr Muthusamy • Only 20 patients (30%) have urine dip performed Limitations for urine dip:

- Lack of awareness on the importance/education - Incontinent patients - Anuric patients

.

URI

NE

DIP

Baseline 58% Sep-13 44% Oct-13 40% Nov-13 0% Dec-13 78% Jan-14 70% Feb-14 70% Mar-14 50% Apr-14 80% May-14 67% Jun-14 38% Jul-14 75%

Service Delivery; Quality Improvement Projects

Aug-14 Sep-14 Oct-14

11/13-10/14 Jan-15

75% 40% 38% 57% 41%

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

• 50 staff members • 24/50 able to define AKI • Not all were aware of the symptoms • Common answers given “ reduction in urine

output” and “dehydration” • All answered yes to monitoring Urine OP • Not all able to check bloods on the system • 20/50 knew what nephrotoxic are and would

regularly check bloods

AKI Survey CHFT 2015 Mansoor N ALI (ASN 2015)

Training Needs: • better understanding of AKI • online learning modules • educational nursing sessions • management of AKI from a nursing perspective? • What to inform patients and relatives of their condition? • What medications to look out for? • How to accurately measure fluid balance? • What investigations are required to diagnose AKI? • What do abnormal blood results mean/what should I tell patients and relatives? • Why is there an emergency need to treat high K? what does high K do/mean?

AKI Survey CHFT 2015 Mansoor N ALI (ASN 2015)

• CHFT AKI project aimed at nurses and HCA’s • Teaching sessions • Simulation • Educational package for nurses and the healthcare

colleagues on induction • Grand round and teaching sessions on AKI/renal

presentations for trainees • General Practitioners

AKI - Education and training

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

• National CQUIN scheme – 0.25% • Monthly data collection • Reported quarterly to commissioners • Associated with payment • Diagnosis and treatment in hospital and

the plan of care to monitor kidney function after discharge

• Evidence from discharge summaries

AKI CQUIN 2015

Numerator

1. Stage of AKI (a key aspect of AKI diagnosis) 2. Evidence of medicines review having been

undertaken (a key aspect of AKI treatment) 3. Type of blood tests required on discharge for

monitoring (a key aspect of post discharge care) 4. Frequency of blood tests required on discharge

for monitoring (a key aspect of post discharge care).

Each item counts separately towards the total i.e. review of four items in each of 25 discharge summaries creates a monthly numerator total of up to 100.

AKI CQUIN 2015

Denominator

25 or fewer patient records have AKI detected and who have survived to discharge in each monthly sample Denominator is N x 4 (where N equals all patient records meeting that criteria) i.e. review of four items in each of N discharge summaries If more than 25 patient records meet these criteria, a random sample of 25 sets of patient records should be reviewed, and the denominator will equal 100 i.e. review of four items in each of 25 discharge summaries

AKI CQUIN 2015

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Apr-15 22 1 16 5 4 26 May-15 25 1 18 1 1 21 Jun-15 24 1 11 2 4 18

Q1 21% Baseline Jul-15 25 1 23 3 3 30

Aug-15 25 0 22 4 4 30 Sep-15 25 3 22 6 6 37

Q2 32% Target 21% Oct-15

Nov-15 Dec-15

Q3 Target 50% Jan-16 Feb-16

Mar-16 Q4 Target 90%

AKI Bundle- Recognition and Initial Management of Acute Kidney Injury (AKI 6) (Proposed version)

RECOGNITION Stage Serum creatinine (SCr) Urine output (UO)

1 Rise>1.5x baseline or >26µmol/L in 48hr <0.5mL/kg/hr >6 hrs

2 Rise ≥2x baseline SCr <0.5 mL/kg/hr >12 hrs

3 Rise ≥3× baseline or >354µmol/L or on RRT <0.3mL/kg/hr >24 hrs/ anuria 12 hrs

IMMEDIATE INTERVENTION: To be completed on initial assessment Target Time completed Initial when done

1 Document urine dip result 4hr

2 Document U&E’s, calcium, HCO3 4hr

3 Review fluid status and start fluid balance chart- target UO<0.5ml/kg/hr

4hr

4 Stop all nephrotoxic drugs and review other anti-hypertensives

4hr

5 Alter doses of medication based on eGFR 4hr

6 Bladder scan 6hr

Version 15 – 2/10/15

• AKI 0 by 25 • AKI awareness day in the trust (March 2016) • AKI Audit activities • AKI Teaching • AKI primary care • AKI CQUINS • CKD patient involvement and education (audit survey) • Compliance with NICE AKI/CKD guidelines • Dietetics- Watch the space! • Renal Referrals Criteria • Renal Biopsy intervention • Joint Rheum/Renal clinic for Lupus/Vasculitis • Vascular collaboration • Haematology/Geriatric/Urology collaboration • R+D

Service Delivery; Quality Improvement Projects

• Proposal for another consultant post • Acute dialysis team (Renal Support

team) • Community Clinics (Todmorden and

Holmfirth) • Specialist transplant clinics

Aspirations and Possibilities….

CHFT AKI Collaborative Group ~ Dr Andy Hardy/Dr Suneeta Teckchandani/Dr Karen Mitchell CQUIN improvement Group Clinical Governance Group Special Thanks: Sanisah Aman, Aisha Sadiq Fardose Anjum, Dr Thamarai Muthusamy

Acknowledgements:

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Questions/Feedback/Thoughts/Suggestions

www.england.nhs.uk

Yorkshire and the Humber AKIPCI Forum

Closing Remarks & Next Steps

Dr John Stoves, Y&H Renal SCN Clinical Lead & Consultant

Nephrologist, BTHFT & Dr Andy Lewington, Consultant Nephrologist, LTHT

Please return completed evaluation forms!

www.england.nhs.uk

Yorkshire and the Humber AKIPCI Forum

Thank you for Attending!