Acute Kidney Injury (AKI) Clinical Audit Tools 2011

Acute Kidney Injury (AKI) Clinical Audit Tools

September 2011

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Table of contents

Table of contents ............................................................................................. ii 1 Background............................................................................................... 1 2 Existing data collection for AKI ................................................................. 3 3 Relationship between audit methods ........................................................ 4 4 Patient reported outcome measures (PROM) ........................................... 5 5 Clinical pathways ...................................................................................... 5

5.1 ACUTE HOSPITAL ADMISSION ....................................................... 6 5.2 ELECTIVE VASCULAR SURGERY .................................................. 7 5.3 LABORATORY .................................................................................. 8 5.4 ADVERSE EVENT REVIEW ............................................................. 9 5.5 PRIMARY CARE ............................................................................. 10 5.6 RRT – Renal Unit or Critical Care .................................................... 11

6 Quality standards .................................................................................... 11 6.1 Acute Hospital Admission ................................................................ 12 6.2 Elective vascular surgery ................................................................. 13 6.3 Laboratory ....................................................................................... 13 6.4 Adverse event review ...................................................................... 13 6.5 Primary care .................................................................................... 14 6.6 RRT – Renal unit or critical care ...................................................... 14

7 Quality indicators .................................................................................... 15 7.1 Acute Hospital Admission ................................................................ 15 7.2 Elective vascular surgery ................................................................. 15 7.3 Laboratory ....................................................................................... 16 7.4 Adverse event review ...................................................................... 16 7.5 Primary care .................................................................................... 16 7.6 RRT – Renal unit or Critical Care .................................................... 16

8 Data items............................................................................................... 17 Core items for all data-sets ........................................................................ 18 8.1 Acute Hospital admission data items ............................................... 21 8.2 Elective vascular surgery data items ............................................... 29 8.3 Laboratory data items ...................................................................... 37 8.4 Adverse event review data items ..................................................... 38 8.5 Primary care data items ................................................................... 40 8.6 RRT – Renal unit or critical care ...................................................... 42 8.7 Complete Dataset as excel file ........................................................ 45

9 Possible methods of collection ................................................................ 46 9.1 Acute Hospital Admission ................................................................ 46 9.2 Elective vascular surgery ................................................................. 46 9.3 Laboratory ....................................................................................... 46 9.4 Adverse event review ...................................................................... 46 9.5 Primary care .................................................................................... 46 9.6 Critical care / Renal units ................................................................. 46

10 The future ............................................................................................ 47 Appendix 1 Existing Quality Standards and indicators ................................... 48

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Appendix 2 – Other considerations from scoping document .......................... 57 10.1 Attributes of items in an AKI dataset ................................................ 57 10.2 Other principles ............................................................................... 57 10.3 Data collection and return to a centre. ............................................. 58

Membership Acute Kidney Injury Delivery Board ........................................... 59 Membership Kidney Quality Information Partnership ..................................... 62 References .................................................................................................... 63

Acknowledgements This document was developed as part of the work of the Kidney Quality Information Partnership, and the Acute Kidney Injury Delivery Group. Members of both groups have actively participated in reviewing and refining the document between June 2010 and February 2011. In addition we are grateful to the comments of Dr Mark Thomas and Dr Charlie Tomson. Please direct any comments on this document to [email protected]

mailto:[email protected]

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Introduction

There is growing recognition that acute kidney injury (AKI) is a key quality and

safety challenge for the NHS. Around one in five people who are admitted to

hospital as an emergency will get AKI to some degree and it has a significant

impact on patient outcomes and NHS resources

AKI most commonly occurs as a consequence of other acute illnesses, such

as major infection or dehydration. Indeed, AKI outcomes can be seen as

being a marker for the quality of care of all acute illness. Auditing AKI

outcomes can therefore be a powerful tool for measuring the quality of many

aspects of acute care.

The monitoring of quality standards in AKI is at an early stage. Some centres

have attempted to adopt the previous and current illustrative CQUINs for AKI,

whilst others are choosing to monitor the quality of care through a range of

other means. In addition, some centres in the UK are pioneering work on the

identification and management of people in hospital with AKI through a variety

of innovative systems.

As work in this area gathers pace, there are significant gains to be had from

the development of a standardised set of metrics to measure patient

outcomes and care quality to compare the effectiveness of different processes

and interventions. The recent international agreement on a definition of AKI

and its stages, which has been adopted in the UK, marks a major step

towards achieving this goal.

This AKI clinical audit tools document aims to support clinicians and hospital

improvement teams who are working to improve the prevention, identification,

management and care for people who develop AKI. It identifies a series of

established markers which can be used to measure the quality of care for

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acutely unwell patients. It has been produced by the AKI Delivery Group and

the Kidney Quality Information Partnership.

The document describes the background to the problem and sets out the key

points in six common clinical pathways at which the quality of care for AKI can

be monitored. It brings together the existing quality standards for each

pathway, identifies indicators which could be considered for monitoring those

standards and details the data items which need to be collected to construct

these indicators.

However, the document is not expected to remain static; it will need to adapt

to the learnings and experiences of centres as they begin to develop and

implement AKI quality measures. It is possible that the patient pathways will

alter and highly likely that more refined standards will be developed (as part of

the NICE AKI guidance, for instance).

In the meantime, we hope that units will find the tools contained in this

document useful and will use them to carry out quality audits for AKI care.

Any comments on the tools are welcome and we would like to hear about the

experiences of individuals and units who have tried to implement them.

Please email [email protected].


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1 Background This paper proposes the development of a set of clinical audit tools and

observations (“data items”) important in monitoring the identification and

treatment of patients with Acute Kidney Injury (AKI). At present few nationally

agreed AKI measures exist, which makes comparison between different

services difficult or impossible. However, in order to improve quality of care

and outcomes in AKI it is crucial to be able to identify variation in outcomes

between areas, because in the causes of this variation are the keys to

improving outcomes in AKI for all.

AKI is an illness with a rapid reduction in kidney function over days or weeks

and has many causes but is most commonly associated with episodes of

acute illness, changes in medication or following diagnostic procedures. Care

pathways for patients with AKI are often not linear; they commonly span

different care sectors (primary and secondary) and different disciplines

(general practice, acute and elective secondary care medicine and surgery,

critical care, renal unit, and support disciplines such as chemical pathology

diagnostic imaging and pharmacy). The monitoring and improvement of care

in AKI will therefore require a dataset to effectively span these different areas.

AKI is common amongst acute admissions to hospital, with approximately 5-

20% of acutely admitted patients experiencing an episode of AKI during the

course of their illness1. Mortality from AKI varies between study, setting and

disease severity but is significant (over 50% in the setting of sepsis and multi-

organ failure)2. More recently it has become clear that even a small change in

serum creatinine in admitted patients is a marker for worse long-term

outcome, although the exact mechanism is unclear3,4,5. Currently the

prevalence of such changes in creatinine in a UK admitted or ambulatory

population is not known as the majority of studies have focused on more

severe (but less common) AKI.

The recent National Confidential Enquiry into Patient Outcome and Death

(NCEPOD) which reviewed care in patients who had died following AKI in

hospital concluded that AKI could have been avoided in 14% of the cases

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examined, and care was good in only 50%6. NCEPOD also criticised the poor

implementation of the NICE guidance on acute admission to hospital (CG50)7,

and poor patient / carer involvement in decision making regarding escalation

of care. This is disappointing because it is known that early application of

simple interventions such as screening for and treatment of sepsis and

assessment of volume status can potentially ameliorate and reverse AKI and

improve outcome8.

Monitoring outcomes in AKI therefore fulfils two of key outcomes in the recent

NHS white paper9 – namely improving patient safety and reducing

preventable deaths. In addition AKI is expensive as it associated with a

longer stay in an intensive care unit10, and a longer in-patient stay11. Length

of stay in intensive care is longer in patients with each increase in severity of

AKI based on the RIFLE criteria, with an average stay rising from six days in

patients without AKI, through eight, 10 and 16 days for AKI stages “risk”,

“injury” and “failure” respectively12. Patients who survive but continue to

require dialysis incur the on-going costs as well as burden of long-term

dialysis. The AKI dataset therefore needs to consider patient survival as the

major outcome following AKI, but should also cover other outcomes such as

effective re-enablement, development of CKD or an ongoing requirement on

dialysis.

In the future the monitoring of care outcomes will be through the development

of Indicators for Quality Improvement (IQI), and Nice Quality Standards (the

quality standard for CKD contains one standard for those with CKD acutely

unwell13). However, the development of IQI and quality standards in AKI is

currently hampered by different terminology, different coding practices, poor

understanding of AKI across healthcare teams, and not having either agreed

key data items or a consistent means of collecting national information on AKI

care or outcomes. The development and flow of an AKI dataset could be

directly linked to the refinement of such measures.

This data-set is designed to support the collection of current and likely quality

indicators including the Acute Services Illustrative CQUIN14, the UK Renal

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Association AKI module audit measures15, the shortly to be published KDIGO

quality standards16, and the vascular surgical society of Great Britain and

Ireland AKI audit (pilot in progress)17. The NICE guidance on AKI (currently

recruiting committee members) will inform further iterations of this work, but is

currently out of the scope of this document. This document makes explicit

areas where expert guidance is still required in order to define the operational

definitions of some of the clinical concepts.

2 Existing data collection for AKI Codes exist within ICD-10 (section N17 “Acute renal failure” and N19

“Unspecified renal failure”) which could allow collection of basic information on

the incidence of AKI within acute hospital settings in particular, and these are

available for national comparison via HES. However the codes are

insufficiently refined to allow investigation or monitoring of the appropriate

detection of AKI, the standard of care of those with AKI, or any outcome

except discharge alive from hospital. In addition it is very unlikely that a small

(but significant) change in serum creatinine would be clinically coded as AKI.

Renal units in the UK commonly provide renal replacement treatments for

patients both with end-stage renal disease (ESRD) and also AKI. Information

on those patients with ESRD is collected for national audit and quality

improvement by the UK Renal Registry (UKRR)18. At present the UKRR does

not collect information on patients treated in renal units for AKI and it is likely

that only a proportion of renal units collect sufficient electronic information

about the patients they treat with AKI to allow analysis.

The Intensive Care National Audit and Research Centre (ICNARC) co-

ordinates national collection of patient identifiable information about all

patients who are admitted to critical care units. In addition to APACHE II

physiological scores for the first 24hrs of admission, this dataset includes

subsequent care items in the daily critical care minimum dataset which would

allow for the identification of patients who receive RRT during the course of a

critical care stay and their outcome at critical care discharge. However this

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dataset does not contain information about care which could have prevented

AKI in the first place.

The Vascular Society of GB and Ireland is currently working with NHS kidney

Care to test the collection of items pertaining to AKI in patients undergoing

abdominal aortic surgery17. This work could also inform data collection in

other related areas such as cardio-thoracic or orthopaedic surgery. The

intelligence which refined these items, and the learning which will emerge

from their testing in practice, will be incorporated into the development of this

broad AKI dataset wherever applicable.

3 Relationship between audit methods At present it is postulated that there are six related, but different project

methods which either have been used previously, are currently involved in

pilot projects, or have active plans to pilot. Each method reflects a different

care pathway or part of the care pathway (and hence each merits its own

description). However, the pathways will also share some common concepts

which are best defined in common and shared than developed in isolation. It

is anticipated that the relationship between data items could look like figure 1.

Figure 1: Relationship between AKI audit group’s data items

COREPatient identifiers

Demographics EMERGENCYADMISSION

ELECTIVEVASCULARSURGERY

PRIMARYCARE

LABORATORY

PROM

PROM

ADVERSEEVENT

REVIEW(e.g. NCEPOD)

RRTCORE

Patient identifiersDemographics EMERGENCY

ADMISSION

ELECTIVEVASCULARSURGERY

PRIMARYCARE

LABORATORY

PROM

PROM

ADVERSEEVENT

REVIEW(e.g. NCEPOD)

RRT

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4 Patient reported outcome measures (PROM) No patient reported outcome measures have been validated or tested

amongst patients specifically with AKI. Such measures would need to be

tailored to fit with the different clinical contexts and varying clinical pathways

for those patients who develop AKI. It could be imagined that the patient

experience relating to the quality of information relating to AKI might be

considered a useful measure. In the current absence of an agreed AKI

PROM the current AKI dataset contains a placeholder in figure 1, but no

standards or items.

5 Clinical pathways In order to describe in informatics terms the quality standards, indicators and

data items, each audit method needs to start with an illustration of the

pathway being evaluated. Any step which is considered important to measure

must be present in the pathway. In this way it becomes clear which items

need to be collected, where they are in the pathway, and an indication of how

they might be collected. Any step which cannot be drawn in the pathway is

not (self evidently) possible to measure. The clinical pathways subject to

audit are drawn using unified mark-up language (UML) as this could be

understood by informatics professionals as well as clinicians. This could allow

early consideration to develop an AKI “dashboard” of key quality indicators.

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5.1 ACUTE HOSPITAL ADMISSION Acute admission to hospital and the subsequent days are a high risk period

for AKI. Standards of care in this pathway are listed in the Renal Association

Clinical Practice guidelines15, and the recommendations of the NCEPOD

report “Adding insult to injury”6. Audit of this care-pathway is currently being

piloted using the DH illustrative CQUIN in some UK regions. Operational

definitions need to be developed with relation to a definition of AKI, “recovery

to baseline”. Ultrasound indications are in section 6.1.5

[N][Y]

Presentation at hospital

Clinical Assessment

AKI Risk Assessment

Test serum creatinineand look up baseline value

Enact AKI care plan

AKI prevention care plan

[Fulfils definition AKI] [Does not fulfil definition AKI]

[High risk of AKI][Low risk of AKI]

US within 24hrsSenior review 12hrsRepeat creat within 24hrs

[AKI resolves] [requires RRT]

[Dies as IP] [Disch alive][Baseline eGFR]

Enact Standard Care

[AKI does not resolve][AKI resolves]

[Disch alive][Loss of eGFR]

[Dies as IP][RRT dependent]

[Discharged Alive][RRT dependent]

………

Medication review

Repeat creat 24hrsUS clinically indicated?*

* See text for definition

[N][Y]

Presentation at hospital

Clinical Assessment

AKI Risk AssessmentAKI Risk Assessment

Test serum creatinineand look up baseline value

Enact AKI care planEnact AKI care plan

AKI prevention care planAKI prevention care plan

[Fulfils definition AKI] [Does not fulfil definition AKI]

[High risk of AKI][Low risk of AKI]

US within 24hrsUS within 24hrsSenior review 12hrsRepeat creat within 24hrsRepeat creat within 24hrs

[AKI resolves] [requires RRT]

[Dies as IP] [Disch alive][Baseline eGFR]

Enact Standard Care

[AKI does not resolve][AKI resolves]

[Disch alive][Loss of eGFR]

[Dies as IP][RRT dependent]

[Discharged Alive][RRT dependent]

………

Medication reviewMedication review

Repeat creat 24hrsRepeat creat 24hrsUS clinically indicated?*US clinically indicated?*

* See text for definition

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5.2 ELECTIVE VASCULAR SURGERY This is based on the pilot study currently underway by the Vascular Society of

Great Britain and Ireland17

Pre-assessment by HCP

Test serum creatinine

Admission for procedure

Undergoes procedure

[Does not require RRT] [requires RRT]

[Dies as IP]

[AKI does not resolve][AKI resolves][Disch alive]

[Alive at 1 year]

Urine observations Serum biochemistryBlood pressure



[Dead at 1 year] [Dies as IP][RRT dependent]

[Dies as IP][Disch alive on RRT]

0-24hrs

24-48hrs

48-72hrs

Pre-assessment by HCP

Test serum creatinineTest serum creatinine

Admission for procedureAdmission for procedure

Undergoes procedure

[Does not require RRT] [requires RRT]

[Dies as IP]

[AKI does not resolve][AKI resolves][Disch alive]

[Alive at 1 year]




[Dead at 1 year] [Dies as IP][RRT dependent]

[Dies as IP][Disch alive on RRT]

0-24hrs0-24hrs

24-48hrs24-48hrs

48-72hrs48-72hrs

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5.3 LABORATORY The incidence of AKI between hospitals and regions in the UK is unknown.

The purpose of this dataset is to allow reliable, repeated interrogation of

pathology laboratories to compare the incidence of AKI and assess the impact

of any detection or prevention interventions in the future. It will also allow

international comparison and allow national identification of inequality.

Comparisons between results and centres may be limited until standardisation

of assays to an enzymatic method.

In addition to these proposed data items for audit these same data items

could be used to identify individuals with AKI locally and alert clinicians to this.

Finally, if linked either locally or centrally to HES it would be possible to report

AKI in hospitalised and non-hospitalised patients, and audit the recommended

repeat creatinine check within 24hrs. Linkage to the NRD would allow the

exclusion of patients on RRT which is generally not possible within local

pathology or PAS systems.

Serum creatiinine assayed

Compared to previous result

[No previous results]

[Report result][No other action]

Warning “poss AKI” on report


[Does not fulfil definition AKI]

[Fulfils definition AKI]

Serum creatiinine assayed

Compared to previous result

[No previous results]


Warning “poss AKI” on report


[Does not fulfil definition AKI]

[Fulfils definition AKI]

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5.4 ADVERSE EVENT REVIEW This approach to audit of care of patients with AKI was adopted in the

NCEPOD “adding insult to injury report”6.

Patient dies as IP with ICD-10 code for ARF

[Does not fulfil definition AKI][Fulfils definition AKI]

Review of notes by responsible consultant

Independent expertNotes review totemplate

Organisational questionnaireTo host acute NHS Trust

[Good care] [AKI avoidable][Some omissions]

Recognition of AKI

Overall assessment

[Within 48hrs] [> 48hrs]

Patient dies as IP with ICD-10 code for ARF

[Does not fulfil definition AKI][Fulfils definition AKI]

Review of notes by responsible consultant

Independent expertNotes review totemplate

Organisational questionnaireTo host acute NHS Trust

[Good care] [AKI avoidable][Some omissions]

Recognition of AKIRecognition of AKI

Overall assessmentOverall assessment

[Within 48hrs] [> 48hrs]

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5.5 PRIMARY CARE The prevalence of AKI in a population managed by primary care in the UK is

not known.

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Patient admitted to renal unit or critical care

[Yes][No]

Does patient has ESRF on dialysis requiring RRT ?

Collect information on;Max no. organ failuresPre-existing CKDHosp / community aquired AKI

Insertion of vascular catheter for RRT

[Died][Alive on RRT][Alive off RRT]

[Exit]

Patient requires RRT for removal of metabolicwaste, water or correction of metabolic acidosis

[No][Yes]

[Exit]

MSSA or MRSA Bacteraemia whilst has vascular catheter?

[No][Yes]

Discharged from renal unit or critical care

Discharged from hospital

[Died]

[Alive off RRT]

[Alive on RRT]

Agreed transfer to renal unit or critical carePatient referred to renal unit or critical care

Patient admitted to renal unit or critical care

[Yes][No]

Does patient has ESRF on dialysis requiring RRT ?

Collect information on;Max no. organ failuresPre-existing CKDHosp / community aquired AKI

Insertion of vascular catheter for RRT

[Died][Alive on RRT][Alive off RRT]

[Exit]

Patient requires RRT for removal of metabolicwaste, water or correction of metabolic acidosis

[No][Yes]

[Exit]

MSSA or MRSA Bacteraemia whilst has vascular catheter?

[No][Yes]

Discharged from renal unit or critical care

Discharged from hospital

[Died]

[Alive off RRT]

[Alive on RRT]

Agreed transfer to renal unit or critical carePatient referred to renal unit or critical care

5.6 RRT – Renal Unit or Critical Care

6 Quality standards Within each patient pathway there are key quality standards which are

expected in the care pathway. Examples of quality standards for other

disease areas such as dementia, venous thrombo-embolism and the CKD

standards13 are available for comparison on the NICE website. A plethora of

different standards are confusing, can result in barriers to implementation, and

represent an undue burden of collection to the NHS. Where-ever possible

therefore existing quality standards have been adopted before considering

new standards.

In some instances the quality standards could be the same in several different

pathways, with the difference being the method of audit rather than the

standard (for instance between 5.1 and 5.5). As this constrains the overall

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number of different standards this approach is to be encouraged. Examples

of draft standards for discussion are listed under each heading.

6.1 Acute Hospital Admission Adapted from NCEPOD6, RA AKI guidelines15, and NICE CKD quality

standard13.

6.1.1 All patients admitted as an emergency, regardless of specialty, should have their electrolytes and creatinine checked routinely on admission and appropriately thereafter. Exception will need to be made for patients admitted for end-of-life care.

6.1.2 For those in-patients who develop AKI there should be both a robust assessment of contributory risk factors, identification of reversible and treatable causes and appropriate examination and investigations for the possible complications that may arise.

6.1.3 All acute admissions should receive adequate senior reviews (with a consultant review within 12 hours of admission)

6.1.4 All non-anuric patients who have AKI should have multistix reagent strip urinalysis performed and recorded in the care-plan.*

* A care-plan in this context is a clinical record of patient care (medical, nursing or shared) which includes a record of observations, but also an appropriate clinical plan based on that observation. This should include frequency of repeating observations, and a threshold which would trigger further assessment.

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6.1.5 People presenting with acute kidney injury have their medication reviewed, an assessment of volume status, and an ultrasound scan for renal morphology and the presence or absence of obstruction if the later is clinically indicated. Indications for an renal tract ultrasound include; • Patients with unexplained AKI

• Patients whose renal function has failed to improve after correction

of initial presumed cause (eg after fluid replacement and removal of

nephrotoxins)

• Patients with a history of urinary tract pathology eg bladder tumour

• Patients with a single kidney

• Patients with evidence of previously un-investigated CKD

• Patients with unexplained haematuria

6.2 Elective vascular surgery These are currently engineered from the Vascular Society GB and Ireland

data items17, and the quality requirements of the renal NSF19.

6.2.1 All patients undergoing elective surgery where there is a risk of peri-operative AKI should have their creatinine checked as part of a pre-surgery assessment. Threshold for degree of risk and the named procedures will need to be developed.

6.2.2 Patients undergoing AAA repair are to receive regular physiological monitoring over the at-risk period following their operation. This will require further operational definition of “regular” and the “at risk period”, and might include a protocolised early warning system (EWS).

6.3 Laboratory

6.3.1 All laboratories measuring serum creatinine will work towards adopting an alert system based on changes in serum creatinine to warn the requester of the possibility of acute kidney injury.

6.4 Adverse event review As section 6.1 plus

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6.4.1 Predictable and avoidable AKI should never occur. This standard requires an operational definition to allow comparisons between audits, but could include a failure to identify the patient at risk, the risk of any procedure, and an appropriate management plan.

6.4.2 AKI should be recognised within 48hrs (RA audit draft measure 4)

6.5 Primary care Based on the NICE guidance on the detection and treatment of CKD20.

6.5.1 All patients who have a serum creatinine checked in which no previous result is available will have the result rechecked within 2 weeks to differentiate between AKI and CKD.

6.6 RRT – Renal unit or critical care

6.6.1 Transfer to the renal unit or critical care should occur within 24 hours of the transfer being agreed as clinically indicated.

6.6.2 Vascular access should be placed by experienced or appropriately supervised staff. Real-time ultrasound guidance should be used to aid placement of upper body access. Incidence of vascular access bacteraemia should be reduced to a minimum, and should work towards a zero incidence of MRSA bacteraemia.

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7 Quality indicators Quality indicators are the specific questions which measure whether each

quality standard is being achieved. Nationally the NHS Information centre for

health and social care (NHSIC) is defining such Indicators for Quality

Improvement (IQI) in other areas of care which are expected to match with the

NICE defined quality standards wherever possible. Therefore, when defining

AKI care IQI for each pathway wherever possible existing quality indicators

have been adopted which have already been endorsed. Examples of draft

indicators are listed under each heading. These must be carefully considered

to ensure they are collectable and represent an acceptable burden on the

NHS.

7.1 Acute Hospital Admission These are based on the illustrative CQUIN for AKI 2011-12 (appendix 1).

7.1.1 Percentage of emergency admissions to have

• Physiological scoring performed to identify patients at high risk of clinical deterioration (e.g. MEWS Score)

• Consultant review within 12 hours of admission

7.1.2 Percentage of emergency admissions with a major risk factor for AKI to have:

• Medication review

• Serum creatinine rechecked within 24 hours of admission

7.2 Elective vascular surgery

7.2.1 Percentage of patients undergoing elective surgery where there is a risk of peri-operative AKI (requires operations definition) who have their creatinine checked as part of a pre-surgery assessment.

7.2.2 Percentage of patients undergoing AAA repair who receive the following interventions over the first 72 hours post-operatively (a) daily re-measurement of serum creatinine

(b) continuous monitoring of urine volume

(c) regular (minimum 4 hourly) physiological measurements including

blood pressure.

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7.3 Laboratory

7.3.1 Percentage of serum creatinine checks which fulfil the criteria for AKI (requires operational definition including the presence or absence of any previous creatinine value, the time-frame since last measurement, and the absolute or percentage change in creatinine required).

7.3.2 Refinement of 7.3.1 to include stage of AKI.

7.3.3 Percentage of the reports of those fulfilling the criteria which include and alert to the possibility of AKI.

7.4 Adverse event review As 7.2 plus;

7.4.1 Percentage of cases in where AKI was considered to be predictable and avoidable. An operational definition of this is required.

7.5 Primary care

7.5.1 Percentage of patients who have a serum creatinine checked in which no previous result in that patients primary care record who have a second measurement of GFR within 2 weeks of the first.

7.6 RRT – Renal unit or Critical Care

7.6.1 Number of people and percentage of total acute hospital admissions who require RRT for AKI during their admission to hospital. This should be separated by setting between critical care and renal unit where one exists.

7.6.2 Number of people and percentage of people who require RRT for AKI who are alive at discharge from a renal unit / critical care and discharge from hospital.

7.6.3 Number of people and percentage of people who undergo RRT for AKI who have independent kidney function on hospital discharge or still require ongoing RRT.

7.6.4 Proportion of patients who were transferred to a critical care or renal unit setting > 24hrs after it was agreed to be clinically appropriate to transfer as a proportion of all renal unit or critical care admissions.

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8 Data items This section defines the items which are required to be collected in order to

construct the IQI. An example set of data items which could be used to drive

the existing audits are attached below, and sub divided by AKI audit

methodology. Wherever possible the same data item is used in several

different pathways. There are examples of where a data item is present

within a care-pathway but does not directly drive a current quality standard or

quality indicator. These are currently retained because they are present in

on-going audits (for example the current 2010/11 illustrative CQUIN) and their

collectability and utility as a measure of quality is still under assessment.

Please interpret these currently “aspirational” items with care; they are

retained because they represent likely future care quality markers. However

until electronic and/or clinical assessment tools to collect them are developed,

they are unlikely to be collectable without undue burden.

To help with the assessment of data items these will be scored by the two

domains:

A: importance to quality

0 – No utility for monitoring quality

1 – Some value in monitoring quality

2 – Good measure of quality

3 – Essential quality measure

B: ease of collection

0 – Impossible to collect now or in foreseeable future

1 – Could be collected in the future using tools currently under development

2 – Could be collected now with modest impact on burden.

3 – Routine collected already

It could be anticipated that items which score 3:3 would be taken forward

without delay, those 0:0 rejected, and those in between retained for future

development.

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Core items for all data-sets

Row Section Item no Description Definition Purpose Importance Collection

2 EpisodeCare 2 Date fulfilled definition of AKI

Date that the patient fulfilled the KDIGO / RA definition for AKI 3 1

5 EpisodeCare 5 End of care episode date

Discharge date from hospital if inpatient, or date routine monitoring of kidney function re-established if in primary care

Calculation of Length of stay as marker of additional resources consumed 2 2

EpisodeCare 6 Site where audit is being undertaken

The site and setting where the audit is taking place

To allow comparison between care sites and settings. 2 2

19 Demographics 1 Traced NHSnumber Patient NHSnumber

Allows linkage to ONS caused of death, and HES episodes to compare associated diagnoses and procedures 2 3

20 Demographics 2 Surname Patient Surname

Allows linkage to ONS caused of death, and HES episodes to compare associated diagnoses and procedures 2 3

21 Demographics 3 Date of birth Patient Date of Birth Allows calculation of stage of CKD and eGFR to 2 3

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differentiate AKI and CKD

22 Demographics 4 Sex Patient Sex

Allows calculation of stage of CKD and eGFR to differentiate AKI and CKD 2 3

23 Demographics 5 Ethnic Group Patient self reported ethnic group

Allows calculation of stage of CKD and eGFR to differentiate AKI and CKD. Reassurance of equity of access to high quality treatment and outcome 2 3

24 Demographics 6 Postcode

Patient postcode at normal place of residence

Reassurance of equity of access to high quality treatment and outcome 2 3

25 Demographics 7 GP practice identifier

Identifier of GP practice with whom the patient is registered for long-term care.

Reassurance of equity of access to high quality treatment and outcome 2 3

62 Organisation 1 Denominator

Number of individuals from whom the patient was drawn

To allow calculation of prevalence 3 3

63 Organisation 2 Denominator Description

Text description of the definition of the denominator population

For example; "all patients referred to renal services", "all acute medical admission" 3 3

64 Organisation 3 Date of first day of audit period

Date of the first day of the period audited 3 3

65 Organisation 4 Date of last day of audit period

Date of the last day of the period audited 3 3

20

66 Organisation 5 Sampling percentage

If patient is part of a sample from the population with AKI rather than then entire population with AKI what proportion was sampled.

To allow calculation of prevalence 3 3

21

8.1 Acute Hospital admission data items


1 EpisodeCare 1 Date of start episode of care

Admission date if emergency admission to hospital. 1st Consultation where kidney function assessed during this illness if in primary care. Date of intervention or procedure if elective admission or daycase attendance 2 3

3 EpisodeCare 3

OPCS code of procedure if elective admission

OPCS code of primary procedure for which the patient was admitted

Identification of procedures as examples of high and poor quality AKI care 2 3

4 EpisodeCare 4 Admission date

Date of inpatient admission if different to EC1

Separation of community and hospital acquired AKI 2 3

6 DefinitionAKI 1

Observation of patient serum creatinine value at baseline

Closest Serum Creatinine >30days and <365days to EC1

Differentiating AKI from Acute on Chronic Kidney disease 2 2

7 DefinitionAKI 2

Date of observation of patient serum creatinine value at

Date of closest serum creatinine >30days and <365days to EC1 2 2

22

baseline

8 DefinitionAKI 3

Observation of patient closest prior serum creatinine value

Serum creatinine checked immediately prior to this episode of care

See definition of AKI; 1.5x increase in creatinine over 7days, or 26umol/L increase over 2 days 3 2

9 DefinitionAKI 4

Date of observation of patient closest prior serum creatinine value

Date of serum creatinine measured immediately prior to this episode of care 3 2

10 DefinitionAKI 5

Observation of patient first serum creatinine value

First serum creatinine checked this episode of care Defines episode of AKI 3 2

11 DefinitionAKI 6

Date of observation of patient first serum creatinine value

Date of First serum creatinine checked this episode of care 3 2

12 DefinitionAKI 7

Observation of patient second serum creatinine value

Second serum creatinine checked this episode of care

Marker of quality (standard to re-check serum creatinine within 24hrs of abnormal). Measure of success of initial care 3 2

13 DefinitionAKI 8

Date of observation of patient second serum creatinine value

Date of Second serum creatinine checked this episode of care 2 2

14 DefinitionAKI 9

Observation of patient highest serum creatinine value

Highest serum creatinine value during this episode of care

Stage of AKI (see AKIN definition) 2 2

15 DefinitionAKI 10

Date of observation of patient highest serum creatinine value

Date of highest serum creatinine value during this episode of care 3 2

23

16 DefinitionAKI 11 Urine volume measured first 24hrs

Is there sufficient information available to establised urine volume for 6 consecutive hours during the first 24 hours of episode of care?

Marker of quality (standard is to monitor input and output in any patient with or at risk of AKI) 2 1

17 DefinitionAKI 12

Urine volume passed during 6hrs of first 24hrs

Volume of urine passed during the first consecutive 6hour period measured during the first 24 hours

See definition of AKI; small urine volume or no urine volume 2 1

18 DefinitionAKI 13 Renal Replacement therapy required

Renal replacement therapy (HD, CRRT, PD) required for the purpose of removal of fluid or electrolytes.


26 Demographics 7 Observation of patient weight

Measure of patient weight within 30days of episode of care and the first 48hrs of episode of care

Allows calculation of urine volume per kg body weight, and BSA for the adjustment of eGFR 2 2

27 Demographics 8 Observation of patient height

Any measure of adult height within the last 10years measured or reported by person

Calculation of BSA for the adjustment of eGFR 1 1

28 Comorbidity 1 Diabetes Mellitus

Does the patient have a pre-existing diagnosis of type 1 or type 2 diabetes

Differentiation of outcomes in those with and without pre-existing conditions likely to directly affect risk 2 2

24

of AKI and outcome

29 Severity 1 Number organ failures

Maximum concurrent number of organs which have "failed" during this episode of care (not including kidney failure)

Differentiation of outcomes in those with different severity of illness 2 3

30 Severity 2 Highest Level of care received

Highest level of care (as defined by Critical Care "bed levels 1-3"

Marker of quality of care. Marker of appropriate use of resources 2 3

31 AKIcause 1 Contrast media prior to episode

Patient administered contrast media during the 7 days prior to EC1

Marker of quality as this should be a largely preventable cause of AKI 2 1

33 AKIcause 3

Observation of the reagent stick urinalysis for blood

Urinalysis for blood recorded on patient urine sample produced during first 24hrs of care episode

Differentiation of those with intrinsic renal disease (different likelihood of recovery) 1 1

34 AKIcause 4

Observation of the reagent stick urinalysis for protein

Urinalysis for protein recorded on patient urine sample produced during first 24hrs of care episode

Differentiation of those with intrinsic renal disease (different likelihood of recovery) 1 1

25

35 AKIcause 5 Urinary tract obstruction

Ultrasound scan / bladder scan shows obstruction of urinary tract (uni or bilateral hydro-ureter, bladder outflow obstruction), or evidence of relieved obstruction (resolving hydro-ureter)

Differentiation of those with obstructive renal disease (different likelihood of recovery) 3 2

36 AKIcause 6

Observation of the patients fluid balance assessment

Was the patient considered to be hypovolaemic, euvolaemic or hypervolaemic at there first fluid balance assessment within 24hours of EC1 Marker of care quality 3 2

37 CareQuality 1 U&E checked on admission

Was a sample of blood measured for concentrations of urea, creatinine, sodium and potassium ("U&E") on admission Marker of care quality 3 2

38 CareQuality 2 U&E rechecked within 24hrs

Was a second sample of blood measured for concentrations of urea, creatinine, sodium and potassium ("U&E") within the first 24 hours Marker of care quality 3 2

26

39 CareQuality 3 Urinalysis performed

Was a sample of urine produced during the first 24hours of care episode tested with a reagent stick for blood and protein and the result recorded. Marker of care quality 2 1

40 CareQuality 4 Senior Review occurred

Was the patient reviewed by a senior doctor within 12 hours of the beginning of this episode of care Marker of care quality 3 2

41 CareQuality 5 Ultrasound performed

Did the patient undergo an ultrasound scan within 24hous of EC1 Marker of care quality 2 2

42 CareQuality 6 Fluid balance assessment performed

Was an assessment made and a conclusion recorded as the patient fluid status within 24 hours of EC1 Marker of care quality 3 2

43 CareQuality 7 AKI Risk assessment

Was an AKI risk assessment undertaken within 24 hours of EC1 Marker of care quality 3 2

44 CareQuality 8 Physiological scoring performed

Was physiological scoring performed to identify patients at high risk of clinical deterioration (e.g. Marker of care quality 3 2

27

MEWS Score)

45 CareQuality 9 Presence of "major risk factor for AKI"

Is the patient assessed using items CQ-7 and CQ-8 found to have a major risk factor for AKI

Marker of care quality. Required to identify denominator at risk group for items CQ-2 and CQ-10 when used in the 2011-12 CQUIN 2 2

46 CareQuality 10 Review of medication Was the patients medication reviewed Marker of care quality 2 2

47 CareQuality 11 Care plan

Was the result of a AKI risk assessment used to create a care plan which included the stated intention to re-check Creatinine within 24hrs, and to monitor fluid balance Marker of care quality 2 2

51 Outcome 1 Patient alive at discharge

Was the patient discharged from hospital alive if an inpatient Measure of care outcome 3 3

52 Outcome 2 Dialysis at discharge

Was the patient discharged from hospital without independent kidney function (Did the patient either have plans for ongoing dialysis or

Measure of care outcome - non recovery of AKI 3 2

28

dialysis withdrawn for palliative care)

53 Outcome 3

Observation of patient serum creatinine at discharge from hospital

Last serum creatinine measurement prior to hospital discharge if hospital inpatient, and patient not planned for ongoing dialysis treatment

Measure of care outcome - persistent kidney damage 2 2

54 Outcome 4 Patient alive at day 90 Was the patient alive at 90days following EC1 Measure of care outcome 2 2

55 Outcome 5 Dialysis at day 90

Did the patient not have independent kidney function at day 90 (Did the patient either have plans for ongoing dialysis or dialysis withdrawn for palliative care)


56 Outcome 6

Observation of patient serum creatinine at day 90

Last serum creatinine measurement prior to day 90 in patient not planned for ongoing dialysis treatment


29

8.2 Elective vascular surgery data items


1 EpisodeCare 1 Date of start episode of care

Admission date if emergency admission to hospital. 1st Consultation where kidney function assessed during this illness if in primary care. Date of intervention or procedure if elective admission or daycase attendance 2 3

3 EpisodeCare 3 OPCS code of procedure if elective admission






8 DefinitionAKI 3




30

9 DefinitionAKI 4



10 DefinitionAKI 5



11 DefinitionAKI 6









32 AKIcause 2 Contrast media following episode

Patient administered contrast media during the 3 days following to EC1

Risk factor for non-recovery of AKI 2 1



31


Was the patient discharged from hospital without independent kidney function (Did the patient either have plans for ongoing dialysis or dialysis withdrawn for palliative care)


67 Definition AKI 14

Highest serum potassium (9-15 months pre EC1) 1 1


Highest serum potassium (3-9 months pre EC1) 1 1

69 Severity 3 Highest serum potassium (0-24hrs post EC1) 1 1




Highest serum urea (9-15 months pre EC1) 1 1


Highest serum urea (3-9 months pre EC1) 1 1

74 Severity 6 Highest serum urea (0-24hrs post EC1) 1 1


32



Highest serum creatine (9-15 months pre EC1) 2 2


Highest serum creatinine (3-9 months pre EC1) 2 2

79 Severity 9 Highest serum creatinine (0-24hrs post EC1) 2 2



82 Severity 12 Lowest haemoglobin (0-24hrs post EC1) 1 1




Total urine volume during surgery 2 1


Total urine volume (0-24rs post EC1) 2 1


Total urine volume (24-48hrs post EC1) 2 1


Total urine volume (48-72rs post EC1) 2 1


Lowest 6hr urine volume (0-24hrs post EC1) 1 1

33





92 AKIriskfactor 3 SBP pre-EC1

Pre-assessment SBP value if available, otherwise closest prior to EC1 2 2

93 AKIriskfactor 4 DBP pre-EC1

Pre-assessment DBP value if available, otherwise closest prior to EC1 2 2

94 Severity 15 Lowest recorded SBP (0-24hrs post EC1) 1 1



97 Severity 18

Patient on inotrope/vasopressor infusion at any time (0-24hrs post EC1) 1 2

98 Severity 19

Patient on inotrope/vasopressor infusion at any time (24-48hrs post EC1) 1 2

99 Severity 20

Patient on inotrope/vasopressor infusion at any time (48- 1 2

34

72hrs post EC1)

100 Outcome 7 Alive at one year post EC1 2 1

101 AKIriskfactor 5 Aspirin/Dipyridamole

Patient taking aspirin and/or dipyridamole during the week prior to EC1 1 1

102 AKIriskfactor 6 Clopidogrel

Patient taking clopidogrel during the week prior to EC1 1 1

103 AKIriskfactor 7 Beta blocker

Patient taking beta blocker during the week prior to EC1 1 1

104 AKIriskfactor 8 Statin

Patient taking statin during the week prior to EC1 1 1

105 AKIriskfactor 9 ACE inhibitor

Patient taking ACE inhibitor during the week prior to EC1 1 1

106 AKIriskfactor 10 ARB

Patient taking ARB during the week prior to EC1 1 1

107 AKIriskfactor 11 Loop diuretic

Patient taking loop diuretic during the week prior to EC1 1 1

108 AKIriskfactor 12 NSAID

Patient taking NSAID during the week prior to EC1 1 1

35

109 AKIriskfactor 13 Top clamp position 1 1

110 AKIriskfactor 14 Clamp duration (minutes) 1 1

111 AKIriskfactor 15 Left Renal Vein ligated / divided

Was the left renal vein ligated or divided? 1 1

112 AKIriskfactor 16 Renal Artery Occlusion If EVAR was there a Renal Artery Occlusion 1 1

113 AKIriskfactor 17

Volume 0.9% saline infused during operation (ml) 1 1


Volume Hartmans / Ringers infused during operation (ml) 1 1

115 AKIriskfactor 19 Volume colloid infused during operation (ml) 1 1


Volume bank blood infused during operation (ml) 1 1


Volume bank FFP infused during operation (ml) 1 1


Volume salvaged blood infused during operation (ml) 1 1

119 AKIriskfactor 23 Did the patient develop intestinal ischemia? 1 1


Did the patient require surgery for intestinal ischemia? 1 1

36


Did the patient need laparotomy for other cause? 1 1

37

8.3 Laboratory data items


8 DefinitionAKI 3




9 DefinitionAKI 4



10 DefinitionAKI 5



11 DefinitionAKI 6



38

8.4 Adverse event review data items


8 DefinitionAKI 3




9 DefinitionAKI 4



10 DefinitionAKI 5



11 DefinitionAKI 6



17 DefinitionAKI 12 Urine volume passed during 6hrs of first 24hrs

Volume of urine passed during the first consecutive 6hour period measured during the first 24 hours

See definition of AKI; small urine volume or no urine volume 2 1

57 Outcome 7 Date of death Date that patient died

Identification of in-hospital mortality for adverse event review inclusion 3 3

58 Outcome 8 Coded within hospital episode statistics as

Clinical coding of episode includes ICD-

Identification of those who could have had AKI for 2 3

39

having had AKI during this episode of care

10 code consistent with AKI

adverse event review inclusion

59 Outcome 9 AKI predictable

NCEPOD assessment criteria: Predictable, unpredictable or unknown

Retrospective assessment of predictability of the AKI 2 1

60 Outcome 10 AKI avoidable

NCEPOD assessment criteria: Avoidable or un-avoidable

Retrospective assessment of avoidance of AKI 2 1

61 Outcome 11 AKI quality of care

NCEPOD assessment criteria: Good practice, Room for improvement - clinical care, Room for improvement - Organisational care, Room for improvement Clinical and Organisational care, Less than satisfactory care, Insufficient data

Retrospective assessment of care quality in AKI 2 1

40

8.5 Primary care data items


8 DefinitionAKI 3




9 DefinitionAKI 4



10 DefinitionAKI 5



11 DefinitionAKI 6



28 Comorbidity 1 Diabetes Mellitus

Does the patient have a pre-existing diagnosis of type 1 or type 2 diabetes

Differentiation of outcomes in those with and without pre-existing conditions likely to directly affect risk of AKI and outcome 2 2

39 CareQuality 3 Urinalysis performed

Was a sample of urine produced during the first 24hours of care episode tested with a reagent stick for blood Marker of care quality 2 1

41

and protein and the result recorded.

47 CareQuality 11 Care plan

Was the result of a AKI risk assessment used to create a care plan which included the stated intention to re-check Creatinine within 24hrs, and to monitor fluid balance Marker of care quality 2 2

42

8.6 RRT – Renal unit or critical care


3 EpisodeCare 3

OPCS code of procedure if elective admission









29 Severity 1 Number organ failures

Maximum concurrent number of organs which have "failed" during this episode of care (not including kidney failure)

Differentiation of outcomes in those with different severity of illness 2 3

30 Severity 2 Highest Level of care received

Highest level of care (as defined by Critical Care "bed levels 1-3"

Marker of quality of care. Marker of appropriate use of resources 2 3




43

48 CareQuality 12

Ultrasound used to place vascular access catheter for RRT

Was real time ultrasound guidance used to insert vascular access catheter for RRT Marker of care quality 2 1

49 CareQuality 13 Date or MRSA or MSSA bacteraemia

Date of an MRSA or MSSA bacteraemia whilst patient has vascular catheter in-situ for purposes of RRT

Marker of care quality. Major patient safety marker 3 2

50 CareQuality 14 MRSA or MSSA Organism causing bacteraemia

Marker of care quality. Major patient safety marker 2 2




Was the patient discharged from hospital without independent kidney function (Did the patient either have plans for ongoing dialysis or dialysis withdrawn for palliative care)


53 Outcome 3

Observation of patient serum creatinine at discharge from hospital

Last serum creatinine measurement prior to hospital discharge if hospital inpatient, and patient not planned for


44

ongoing dialysis treatment

54 Outcome 4 Patient alive at day 90 Was the patient alive at 90days following EC1 Measure of care outcome 2 2

55 Outcome 5 Dialysis at day 90

Did the patient not have independent kidney function at day 90 (Did the patient either have plans for ongoing dialysis or dialysis withdrawn for palliative care)


45

8.7 Complete Dataset as excel file

Contact [email protected] for a copy of the complete dataset

as an excel file


46

9 Possible methods of collection This document does not define exactly how that data items would be collected

for each audit as in some cases pilots are underway, or would be required to

establish the most practicable methods.

9.1 Acute Hospital Admission The 2010/11 illustrative CQUIN is being piloted in the East Midlands

Specialised commissioning group. It is anticipated that this audit would be

performed as a snap-shot of all emergency admissions over a fixed period.

9.2 Elective vascular surgery This audit is currently ongoing and uses data entry by vascular surgeons

using a secure on-line data-entry tool.

9.3 Laboratory Local units are currently piloting different methods to extract and analyse this

data. In units where the data is “warehoused” it is anticipated that it would be

a relatively straightforward task to collect this basic data-set on the prevalence

of a change in serum creatinine.

9.4 Adverse event review The detailed methodology of the NCEPOD audit methodology including the

assessment forms is available from the NCEPOD website6.

9.5 Primary care Pilots would be required to demonstrate that this data could be collected from

primary care, although the shortly to be operational GPES would appear to

make such an audit technically possible.

9.6 Critical care / Renal units The ICNARC initial assessment on presentation to critical care (incorporating

APACHE2 physiology score) does not include sufficient information to allow

collection of the incidence of RRT in patients admitted to critical care.

However the Critical Care Minimum Data Set (CCMDS) does establish the

need for RRT on a daily basis during a critical care episode.

47

Most UK renal units collect information on outpatient haemodialysis treatment

sessions, but many units do not routinely collect this for inpatients or those

with acute rather than chronic kidney disease. However, if units could be

enabled to collect this information it is likely collectable via existing routes to

the UKRR for comparison of outcomes for those who receive RRT for AKI

between units. Linkage to HES would be required in order to establish the

proportion of admitted patients who underwent RRT for AKI, and possibly to

establish outcome.

10 The future This document represents a first step in defining tools to audit AKI. Over the

next 6-12 months it is hoped that other groups will take parts of this work and

establish whether it can be used as a framework to drive local quality

improvement. Current pilot projects will also report during this time (such as

the National Vascular Society and also groups who implemented the first

illustrative CQUIN) which will further guide the practicality of this data

collection. It is highly likely that these audit tools will need to be revised in the

light of these developments.

In the future it will be increasingly important that items for quality monitoring

and improvement are firmly grounded in items which would be routinely

collected during high quality AKI care (either directly or derived from them).

This might also necessitate changes to the items or their collection method.

Provided at least some of these audit tools have proved practicable and useful

then consideration should be given in the future to further refine and minimise

to the dataset to enable monitoring of standards with the minimum of burden.

48

Appendix 1 Existing Quality Standards and indicators

National Service framework (part 2)19 The NSF part 2 identifies “Acute Renal Failure” (AKI) as one of the four quality

requirements. The current nationally mandated national renal dataset does

not include the measurement of outcomes in AKI. The AKI dataset would

need to enable the monitoring of the following markers of good practice;

1. Timely identification and referral to renal and critical care services for

specialist, culturally appropriate advice and assessment. (Level 3)

2. Appropriate pre-operative testing and interventions, in accordance with

the NICE guideline on pre-operative testing.

3. Involvement of local critical care networks in planning, commissioning

and monitoring the delivery of critical care services to acutely ill renal

patients. (Level 4)

4. Liaison with specialist renal services to facilitate optimal management

of people with ARF in the most clinically appropriate setting. (Level 4)

For children and young people

5. Treatment and care in accordance with Getting the right start: National

Service Framework for Children, Young People and Maternity Services.

49

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)6 The NCEPOD highlighted the poor care received by some patients who died

in hospital following AKI. The AKI dataset would need to enable the

monitoring of the key recommendations;

1. All patients admitted as an emergency, regardless of specialty, should

have their electrolytes checked routinely on admission and

appropriately thereafter. This will prevent the insidious and

unrecognised onset of AKI.

2. Predictable and avoidable AKI should never occur. For those in-

patients who develop AKI there should be both a robust assessment of

contributory risk factors and an awareness of the possible

complications that may arise.

3. All acute admissions should receive adequate senior reviews (with a

consultant review within 12 hours of admission as previously

recommended by NCEPOD3).

4. NCEPOD recommends that the guidance for recognising the acutely ill

patient (NICE CG 50) is disseminated and implemented. In particular

all acute patients should have admission physiological observations

performed and a written physiological monitoring plan made, taking into

account the degree of illness and risk of deterioration.

5. There should be sufficient critical care and renal beds to allow rapid

step up in care if appropriate.

6. All level 3 units should have the ability to deliver renal replacement

therapy; and where appropriate these patients should receive clinical

input from a nephrologist.

7. All acute admitting hospitals should have access to either onsite

nephrologists or a dedicated nephrology service within reasonable

distance of the admitting hospital.

8. All acute admitting hospitals should have access to a renal ultrasound

scanning service 24 hours a day including the weekends and the ability

to provide emergency relief of renal obstruction.

50

Renal Association current AKI Audit Measures15 1. Incidence of acute admissions/patients undergoing major surgery who

had

• the risk of AKI assessed on admission/pre-surgery

• electrolytes checked on admission/pre-surgery and rechecked

within 24 hours

2. Incidence and outcomes of patients diagnosed with

• community-acquired AKI

• hospital acquired AKI

3. Incidence and outcomes of patients with different causes of AKI

4. Proportion of patients where there has been a delay of >48 hours in

recognising the diagnosis of AKI

6. Proportion of patients with or at risk of AKI who are prescribed

intravenous fluids without an assessment of volume status

7. Proportion of patients with AKI who did not have the appropriate

adjustment of medication doses

8. Proportion of patients with or at risk of AKI who receive nephrotoxic

medications

9. Proportion of patients who had a urinalysis performed within 24 hours

of the diagnosis of AKI unless anuric

10. Proportion of patients developing AKI secondary to obstruction who

had a renal ultrasound examination < 24 hrs after a diagnosis of AKI

established.

11. Proportion of patients at high risk of contrast induced AKI (CI-AKI) who

developed AKI and did not

• receive pre-procedure volume assessment

• receive appropriate volume expansion

• have appropriate adjustments to medications

12. Incidence of delays of transfer of patients with AKI >24 hours following

referral to renal services due to a lack of resources on renal unit

13. Incidence of patients with single organ AKI admitted to ICU for RRT

due to a lack of resources on the renal unit

51

14. Number of AKI inpatient transfers requiring escalation of care within 24

hours of arrival on renal unit

15. Proportion of AKI survivors with residual chronic kidney disease with

post discharge CKD planning

16. Incidence of dialysis catheter-related bacteraemia and sepsis in

patients with AKI

17. Incidence of heparin induced thrombocytopenia

18. Proportion of critically ill patients with AKI treated with alternate day

haemodialysis who receive Kt/V ≥ 1.2 per session

19. Proportion of critically ill patients with AKI treated with continuous renal

replacement therapy who receive > 25 mls/kg/hr post dilution

ultrafiltration

20. Proportion of patients with AKI receiving renal replacement therapy

reviewed by dietician within 24 hours

21. Proportion of patients with AKI receiving renal replacement therapy

prescribed the recommended nutritional support

22. Proportion of patients with AKI who recover kidney function within 90

days of episode as defined by return of serum creatinine to within 20%

of baseline value (most recent value within 3 months but accepting

value up to one year)

• dialysis independence (if previously requiring dialysis)

23. Outcome measures for patients developing AKI should include

• length of hospital stay

• hospital mortality

• 90 day mortality

• one year mortality

52

Previous Department of Health Commissioning for Quality (CQUIN) 14

53

54

2011-12 Department of Health Commissioning for Quality (CQUIN)

Description of goal Improving the prevention, detection and management of Acute Kidney Injury (AKI) in patients admitted as an emergency to hospital

Rationale for Inclusion Acute Kidney Injury (AKI) is a common consequence of acute illness, affecting up to 20% of emergency hospital admissions. It is associated with significant excess morbidity and mortality, and the NCEPOD report

published in June 2009

documented widespread substandard care of people with AKI. Up to 30% of cases of AKI are estimated to be avoidable through better medical management of acutely unwell patients and NICE Clinical Guideline 50 has endorsed the importance of physiological monitoring and scoring to identify patients at risk of clinical deterioration. Improving the recognition of acute illness and AKI risk has the potential to significantly improve the quality of care for patients with acute illness and lead to significant productivity improvements. Recent local audits have shown that the recording and documentation of physiological observations is not being performed for all patients and that many cases of avoidable AKI are still occurring. This has been linked locally to above average lengths of stay at the Trust and therefore this indicator is a key driver of improved productivity as well as quality. The final indicator values and rules for partial achievement have been agreed by the Trust clinical reference group as realistic and clinically appropriate.

Description of indicator This is a composite indicator (C1 and C2) incorporating metrics relating to the recognition of acute illness in emergency admissions and to the prevention and detection of AKI

Numerator C1. % of emergency admissions to have:

• Physiological scoring performed to identify patients at high risk of clinical deterioration (e.g. MEWS Score)

• Consultant review within 12 hours of admission

C2. % of emergency admissions with a major risk

55

factor for AKI to have: • Medication review • Serum creatinine rechecked within 24 hours

of admission

Denominator Total number of adult emergency admissions Data source and frequency of collection

C1 and C2. Local audit of case records and interrogation of laboratory results relating to all adult emergency admissions for two days each quarter in 2010/2011 (dates to be specified retrospectively by commissioner).

Organisation responsible for data collection

Provider

Frequency of reporting to commissioner

Quarterly

56

Other quality indicators In addition there are published guidelines from the international KDIGO

group16 which are reflected in the final version of the update of the UK Renal

Association AKI guidance (2011).

57

Appendix 2 – Other considerations from scoping document

10.1 Attributes of items in an AKI dataset

10.1.1 Specific and Defined unambiguously in clinical and in informatics terms.

10.1.2 Measurable

10.1.3 Agreed to be useful to share

10.1.4 Agreed to be a key determinant of either patient outcome in AKI, or a surrogate for quality of care in AKI care pathway.

10.1.5 Realistic means of getting the data into a central (or regional) place to allow comparison between settings or centres.

10.1.6 Timely – could be done repeatedly without undue burden to demonstrate improvement in quality with time.

10.2 Other principles

10.2.1 Where-ever possible items in the dataset should be capable of fulfilling both primary uses (i.e. to directly facilitate patient care) and also be useful to measure outcome (secondary uses).

10.2.2 Ideally the dataset should be setting independent even if it is initially only deployed and collected in a sub-set of all the possible settings

10.2.3 Ideally the dataset would cover quality in all the aspects of the AKI pathway (Prevention, Detection, Referral, Initial Management, Ongoing management, dealing with sequelae.)

10.2.4 The dataset should be a small as possible to be effective thereby simplifying the task of its deployment and maintenance and the minimising burden of collection to the NHS.

10.2.5 The data-set should almost exclusively use items previously validated by the work of national and international guideline groups and from clinical and epidemiological research. Exceptions might include data on administrative boundaries or care structures unique to the NHS but thought to important in AKI outcome. An exceptional item might be considered if of a speculative nature but with consensus of professional assurance of its value versus the burden of collection to the NHS.

10.2.6 There would need to be a tight definition of who to include in the first place (“the denominator”) in order for the data-set to accurately cover the subsequent entire care pathway of such people.

10.2.7 The data in the dataset should be patient-identifiable to allow linkage with other data-sets unless the benefit of so-doing is considered insufficient to justify this by NIGB.

58

10.3 Data collection and return to a centre.

10.3.1 Items relating to hospital admission, discharge, procedures, associated diagnosis and in hospital death are routinely collected in hospital PAS and returned to the SUS to generate HES. As discussed above this data is insufficient alone to allow quality improvement.

10.3.2 Information relating to AKI in primary care could be available electronically in the future (2012) via services such as the GPES.

10.3.3 Information relating to an ongoing dialysis requirement is collected electronically through renal unit computer systems. This information is contained in the existing NRD with established flows to the UK renal registry and proposed flow to the IC. Information on the acute requirement for dialysis within renal units could be collected in this way with several renal units recording all dialysis sessions delivered already.

10.3.4 Intensive Care National Audit and Research Centre (ICNARC)21 collect information central on outcomes in patients admitted to intensive care unit.

10.3.5 Items relating to the identification of cases of AKI, and clinical management in hospitals are currently not recorded electronically. This is likely to represent the greatest burden of collection to the NHS and will likely need the establishment of an electronic data-collection tool to enable electronic central returns using existing connections to the IC.

59

Membership Acute Kidney Injury Delivery Group

Title Mr, Dr, Prof etc

Name Organisation (s) Position (s) held e.g. Please list here relevant positions in other organisations

Dr Ian Barnes Department of Health National Clinical Director for Pathology

Dr

Gifford Batstone

NHS Connecting for Health

National Clinical Lead for Pathology, Office of the Chief Clinical Officer

Dr Benjamin Bray NHS Kidney Care Clinical Advisor to NHS Kidney Care

Ms Anne Casey Royal College of Nursing

Advisor on Information Standards

Dr

Mike Cheshire NHS North West Medical Director

Dr Erika Denton Norwich Radiology Academy

Consultant Radiologist Medical Director PACS Programme, Connecting for Health National Clinical Lead for Diagnostic Imaging, Department of Health

Dr Donal O’Donoghue (Chair)

Department of Health National Clinical Director for Kidney Care

Ms Lesley Durham North of England Critical Care Network (NoECCN)

Chair NOrF Network Director

Dr

Sian Finlay Dumfries and Galloway Royal Infirmary

Acute Medicine Consultant, Member of Society for Acute Medicine Member of Renal Association Member of AKI Competencies Group (led by Andrew Lewington)

Dr

Paul Glynne UCLH Medical Director

Dr

Tim Gould Intensive Care Society Consultant ICM Bristol Royal Infirmary

Consultant ICM Examiner DICM Regional Education Adviser ICM

60



Previous Clinical Director

Mr Tom Gray NHS East Midlands Royal Derby Hospital

Pharmacy Lead Chief Pharmacist

Dr Mike C Jones Royal Infirmary of Edinburgh The Royal College of Physicians The Academy of Royal Medical Colleges

Consultant Physician

Ms Monica Jones NHS Information Centre

Head of Architecture and Standards

Dr Andrew Lewington

Renal Association Consultant Renal Physician/Honorary Senior Lecturer Leeds Teaching Hospitals

Ms Beverley Matthews

NHS Kidney Care Director

Ms Jane McDonald British Renal Association (BRS) Salford Royal NHS Trust

President BRS Lead Nurse Salford Royal NHS Trust

Dr Rajib Pal Royal College of General Practitioners

General Practitioner Clinical Director (Cardiac/Stroke/Renal) South Birmingham PCT GP Trainer

Ms Joanne Pope London Specialised Commissioning Group London Kidney Care Network

Network Managers Forum Network Manager

Mr John Sedgewick

Royal College of Nursing Nephrology Nursing Forum

Executive Committee Member RCN Nephrology Forum Chair – Education & Research Board, European Dialysis & Transplant Nurses Association/ European Renal Care Association Programmes Director & Principal Lecturer

61



(Nephrology Nursing) Dr Paul

Stevens

Royal College of Physicians

BRS immediate past President

Dr Duncan Watson

University Hospitals Coventry and Warwickshire NHS Trust Critical Care Networks

Consultant in Critical Care Medicine Chair of Critical Care Clinical Leads Forum

62

Membership Kidney Quality Information Partnership


Name Organisation (s)

Dr Donal O’Donoghue National Clinical Director, DH Ms Beverley Matthews NHS Kidney Care Ms Cherry Bartlett Dr Paul Roderick Renal Advisory Group Dr Mark Davies NHS Information Centre Ms Jane Pearson Moore Dr Damian Fogarty Renal Association (UKRR) Dr Dave Collett NHS Blood and Transplant Ms Rachel Johnson Professor John Feehally Renal Information Exchange Group Dr Grant Kelly Primary Care Dr Rick Jones Pathology IT Dr David Meechan East Midlands Public Health

Observatory James Hollinshead Mr Mike Catchpole Health Protection Agency Ms Catherine Turner Specialised Commissioners Forum Mr Peter Knight Research CapabilityNetworks Mr Andrew Jackson Programme Budgeting Ms Dawn Mankin Mr David Mitchell National Vascular Society Dr James Medcalf Clinical Lead KQIP

63

References

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MacLeod A. Incidence and Outcomes in Acute Kidney Injury: A

Comprehensive Population-Based Study. JASN Apr 1, 2007 18: 1292-

1298. 2 Liano F, Junco E, Pascual J, Madero R, Verde E. The spectrum of

acute renal failure in the intensive care unit compared with that seen in

other settings. The Madrid Acute Renal Failure Study Group. Kidney

International 1998; 53:S16-24 3 Lassus JPE, Nieminen MS, Peuhkurinen K, Pulkki K, Siirilä-Wairs K,

Sund R, Harjola V-P for FINN-AKVA study group. Markers of renal

function and acute kidney injury in acute heart failure: definitions and

impact on outcomes of the cardiorenal syndrome. European Heart

Journal doi:10.1093/euroheart/ehq293. 4 Levy et al. The Effect of Acute Renal Failure on Mortality: A Cohort

Analysis. JAMA 1996;275:1489-1494 5 Lassnigg et al. Minimal Changes of Serum Creatinine Predict

Prognosis in Patients After Cardiothoracic Surgery: A Prospective

Cohort Study. J Am Soc Nephrol 2004;15:1597-1605 6 Adding Insult to injury. A review of the care of patients who died in

hospital with a primary diagnosis of acute kidney injury (acute renal

failure). A report by the National Confidential Enquiry into Patient

Outcome and Death (2009). www.ncepod.org.uk 7 Acutely Ill Patients in hospital. NICE guidance CG50.

http://guidance.nice.org.uk/CG50/Guidance/pdf/English 8 Gunal AI, Celiker H, Dogukan A, Ozalp G, Kirciman E, Simsekli H, et

al. Early and Vigorous Fluid Resuscitation Prevents Acute Renal

Failure in the Crush Victims of Catastrophic Earthquakes. J Am Soc

Nephrol 2004 15: 1862-1867. 9 Liberating the NHS. Transparency in Outcomes (2010).

www.dh.gov.uk

http://www.ncepod.org.uk/

http://guidance.nice.org.uk/CG50/Guidance/pdf/English

http://www.dh.gov.uk/

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10 Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A,

Herskowitz A, Mangano DT. Renal dysfunction after myocardial

revascularisation: risk factors, adverse outcomes, and hospital

resource utilization. Ann Intern Med 1998; 128(3): 194-203 11 Durmaz I, Buket S, Atay Y, Yagdi T, Ozbaran M, Boga M, et al.

Cardiac surgery with cardiopulmonary bypass in patients with chronic

renal failure. J Thorac Cardiovasc Surg 1999; 118(2): 306-15 12 Hoste EAJ, Clermont G, Kersten A, Venkataraman R, Angus DC,

De Bacquer D and Kellum JA. RIFLE criteria for acute kidney injury

are associated with hospital mortality in critically ill patients: a cohort

analysis. Critical Care 2006; 10: R73 13 NICE quality standard for Chronic Kidney disease.

http://www.nice.org.uk/guidance/qualitystandards/chronickidneydisease

/ckdqualitystandard.jsp 14 Commissioning for Quality (CQUIN) Acute Services Illustrative

example. www.dh.gov.uk 15 Clinical Practice Guidelines. Acute Kidney Injury. 5th Edition (2011)

UK Renal Association.

http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx 16 Kidney Disease Global Outcomes Collaborative. www.kdigo.org 17 The Vascular Society of Great Britain and Ireland.

www.vascularsociety.org.uk/ 18 UK Renal Registry. www.renalreg.com 19 The National Service Framework for Renal Services. Part 2: Chronic

Kidney Disease, Acute Renal Failure and End of Life Care (2005). 20 Chronic kidney disease. National clinical guideline for early

identification and management in adults in primary and secondary care.

www.NICE.org.uk/ 21 Intensive Care National Audit and Research Centre.

https://www.icnarc.org

http://www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp

http://www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp

http://www.dh.gov.uk/

http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx

http://www.kdigo.org/

http://www.vascularsociety.org.uk/

http://www.renalreg.com/

http://www.nice.org.uk/

https://www.icnarc.org/

Health & Medicine

Acute Kidney Injury (AKI) Clinical Audit Tools 2011