Embed Size (px)
Citation preview
Improving the prevention, recognition and management of AKI: the ‘Think Kidneys’ initiativeCharlie Tomson - @CharlieTomson; [email protected], Intervention Workstream, NHS England ‘Think Kidneys’
RCPSG meeting 18.03.2016; 1335-1410
No conflicts of interest to declare
2
Think Kidneys: programme objectives
The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. It will aim to do this by ensuring that:A variety of tools and interventions are developed and implemented to support the prevention, early detection, treatment and enhanced recovery of patients with AKIPatients who develop AKI are appropriately managed to reduce further deterioration, long term disability and deathAppropriate education and training programmes are developed for all health professionals based on best available evidence.
| 3
| 4
Hydration Theme
ExpertReference Group
AlgorithmSub-Group
NHS England PatientSafety Steering Group
UK Renal Registry
Riskworkstream
Educationworkstream
Detectionworkstream
Intervention workstream
Implementationworkstream
Measurementworkstream
Acute Kidney InjuryNational Programme Board
Workstreams
Risk: identify patients at riskEducation: develop educational resources for public, patients, professionalsDetection: automated laboratory generation of AKI warning stage test resultsMeasurement: national AKI registry linked to UKRR/HES/ONS, supporting local regional and national QIIntervention: appropriate clinical management of AKI (1o and 2o care)Implementation: using commissioning and other quality leversHydration
RISK: Communities at risk of AKI
Secondary care:Any acute illness; frail, elderly; CKD; heart failure; liver disease; diabetes mellitus (esp if albuminuric); neurological or cognitive impairmentPrimary care: Diabetes mellitus; CKD; dementia; heart failure; frail, elderly; psychiatric disease; children with CKD; patients with cancer
https://www.thinkkidneys.nhs.uk/wp-content/uploads/2015/07/Communities-at-risk-of-developing-AKI-Think-Kidneys-010715.pdf
RISK: Example: adults having surgery
Non-modifiable risk factors:Age>=65y; eGFR<60; kidney transplant; Diabetes mellitus; Heart failure; Liver diseasePrevious episode of AKIEmergency surgeryIntraperitoneal surgeryModifiable risk factors:Use of drugs that could be harmful to kidney function eg NSAIDs
EDUCATION
InfographicGP educational resources (with RCGP)Undergraduate curriculumProposal for public education campaign (unfunded)Patient educational resources (with BKPA)Care homes guidanceCentre for Postgraduate Pharmacy Education campaignDevelopment of an app
DETECTION: the AKI algorithm
| 9
| 10
Answer: at least as well as any other algorithm; any ‘improvements’ would increase false + rate
UK Renal Registry
Patient
Renal Units LABSLABS
LABS
The UKRR: AKI direct from labsFrom renal IT systemsCKD4/5, D-AKI and ESRD
HES, ONS etc
Direct from labsAKI in 1y and 2y care
AKI data specification
https://www.thinkkidneys.nhs.uk/resources/
1. The Warning Grade Test Result• Patient Identifiers• The index creatinine and eGFR
2. Retrospective & Prospective Lab Data• All creatinine & eGFR data from
preceding 15 months• All creatinine & eGFR data from
next 15 months
Data submissions from lab to UKRR
https://www.thinkkidneys.nhs.uk/aki/aki-data/
INTERVENTION
Medicines management toolkit• Audit measuresDietetic managementMinimum content for secondary care bundle• Audit measuresMinimum AKI-related content for discharge summariesAdvice on re-starting drugs stopped during AKI admissionsAgreeement with RCPath on communication of warning stage test resultsPrimary care: guide to responding to AKI warning stage test results• Audit measures
SECONDARY CARE ‘BUNDLE’ components
| 15
SECONDARY CARE audit measures (TBC…)
Denominator: inpatients with an AKI 1,2,or 3 warning stage test result• Exclude ‘false positives’ e.g. progression of CKD, completion of pregnancy, TrimethoprimNumerators: % of patients with• Evidence of an ABCDE assessment • Evidence of a decision on whether patient has sepsis• Evidence in the medical notes of a decision on whether the patient is
hypovolaemic/normovolaemic/hypervolaemic (within x of test result)• Evidence in the medical notes of the results of dipstick urinalysis (within x h of test result)• Evidence of a review of drug treatment in the light of AKI• Evidence of request for renal ultrasound (when indicated –operational definition
required)• Completion of minimum AKI-related dataset in discharge summary
Minimum AKI-related content for discharge summary
Community-acquired or hospital-acquired?Highest AKI stageSerum creatinine at discharge• Increasing, stable, or falling?ITU admission yes/noRRT given yes/no Cause of AKI (?? hypovolaemia/hypotension/sepsis/intrinsic renal/post-renal)Drugs stopped during admission• Restarted prior to discharge?• Considered contraindicated in future?Requirement and arrangements (1o or 2o care) for follow-up of renal function
MANAGEMENT OF AKI IN PRIMARY CARE
60-70% of all AKI is community-acquiredAKI warning stage test results to be released to primary care April 2016• Likely frequency = 1 per FTE GP every 1-2 months• 70% AKI stage 1Many GP tests on sick patients taken on lunchtime visits: results dealt with OOHExpected response requires careful calibrationRAND Consensus process: 2 clinical pathologists, 2 acute physicians, 2 nephrologists, 4 GPS (including rural, urban, out of hours, anti-over-medicalisation) – 2-stage voting on appropriate lab and GP response to ~700 scenarios
Acute Kidney InjuryBest practice guidance: Responding to AKI Warning Stage Test Results for Adults in Primary Care
Publication date April 2016
21
Proposed primary care audit measures: structure
Practice systems to ensure that AKI warning stage test results are seen and responded to by the appropriate clinician, including response to critical test resultsEstablish an AKI register and ‘alerts’ to identify and support management of patients who have had a history of AKI
Proposed primary care audit measures: prevention
Use of NSAIDs amongst patients with CKD (NICE CG182)• ? Restrict to high-risk subset e.g. those on , or bothCommunicate and code risk of AKI (NICE QS76) in patients with• Previous history of AKI• CKD3 (eGFR<60 over >=3/12)• Neurological or cognitive impairment
Carer status clarified and codedUp to date with immunisationAvoid combination of ACEI and ARB in patients with CKD (NICE CG182)
Proposed primary care audit measures: post-AKI care
Denominator: patients with a discharge diagnosis of AKINumerators: proportions with• Coded AKI diagnosis• Coded AKI stage• Coded Cause • Given information about AKI and risk of CKD and coded ‘at risk’ of AKI• Medication review within ??4/52 of discharge• Previously coded as hypertensive who have had BP rechecked within ?? 4/52 of
discharge• Repeat serum creatinine/eGFR within 3/12 of discharge• Urine albumin:creatinine within 3/12 of discharge• Repeat eGFR/UACR at 1,2 and 3 years post discharge
Position statement on ‘sick day guidance’
https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2015/07/Think-Kidneys-Sick-Day-Guidance-v8-131115.pdf
Summary
Ambitious national programme to reduce harm associated with AKI(once labs get their LIMS sorted) ‘Free’ measurement system for incidence and outcomesAHSN Patient Safety Collaborative to drive implementationEvidence base for proposed interventions: largely expert opinionDirection of causality unclear• IF AKI is just a very good marker of severity of underlying illness, mortality will be driven
largely by the underlying illness rather than specific management of AKI• If AKI is just a very good marker of ‘susceptible kidneys’, then better management of AKI
will not necessarily prevent future CKD/ESKDNo (current) plan for formal evaluation of the impact of the programme
How to find out moreKaren ThomasThink Kidneys Programme ManagerUK Renal [email protected]
Teresa WallaceThink Kidneys Programme CoordinatorUK Renal [email protected]
| 28
Contact Think Kidneys
Richard FluckNational Clinical Director for RenalNHS [email protected]
Joan RussellHead of Patient SafetyNHS [email protected]
Ron CullenDirectorUK Renal [email protected]
www.linkedin.com/company/think-kidneys
www.twitter.com/ThinkKidneys
www.facebook.com/thinkkidneys
www.youtube.com/user/thinkkidneys
www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk
