QI initiative: Acute Kidney Injury (AKI) Care in Acute Oncology

The Christie NHS Foundation Trust

Patient First: Preventing Harm Improving care - Quality Improvement Theatre

Clinicians and QI staff - creating effective partnerships

Quality Improvement Initiative: Acute Kidney Injury (AKI) Care in Acute Oncology

Dr Tamer Al-Sayed MB ChB FRCP (London) MRCP (Nephrology) SCE (Acute Medicine) PGCE (PG Medical Education) GC (Medical Physiology & CV/Advanced Renal Specialisation)

Consultant in Acute & Renal Medicine Acute Kidney Injury Clinical Lead & Sepsis Co-Chair

Honorary Senior Lecturer, Department of Health & Medical Sciences, The University of Manchester

&Joanne Woolley, Clinical audit manager


22-23 Nov 2016, London


The partnership• Multiple National drivers: need for compliance with

best practice• Local clinical concerns: priority for improvement and

innovation• Clinical audit / QI team support for:

• Development of working group with Executive lead

• Use of AKI alert data collected for national purposes

• Data collection to support patient safety and quality monitoring

• Raising awareness, communicating progress

• Transfer to the electronic patient record and AKI dashboard

• Ongoing review and development


Acute Kidney Injury (AKI) at The Christie

• The Christie NHS FT - comprehensive cancer centre• largest single site cancer centre in

Europe treating more than 44,000 patients a year

• 18 months ago, new Acute medicine role appointed“As a Consultant treating acutely unwell patients, I have worked with an expert team to develop guidelines for staff and patients in the treatment of acute kidney injury (AKI)” Dr Al-Sayed



The Culture of Audit

• Feeds into clinical effectiveness and research committee

• Common goal – striving for excellence• One big team• Bidirectional interactions • Strong clinical governance leadership• Clinical audit a pivotal aspect of quality assurance• Proactive • Co-dependent


The Christie Experience • Collaboration with UHSM & AKI working party • Clinical guidelines developed• Hotline triage tool • Audit tool • New fluid balance forms on OAU • Patient information leaflet• NHS Think Kidneys – Showcased work • Local teaching • Regional posters and presentations• NPSA award nomination• RCP Excellence in patient care submission • Development of e-learning tool


NCEPOD & NICE

• For Better, for worse? – 2008 • Adding insult to injury – AKI 2009 • A time to intervene – 2012• Just say sepsis – 2015 • NICE AKI guidance 2012• NICE IV Fluid guidance 2013• NPSA June 2014 & August 2016


Key performance indicators – facets of a care bundle

• Urine output• Urinalysis • Fluid balance

• Critical perfusion pressure • Oxygenation

• Treatment of sepsis – door to needle times • Discontinuing toxic medications• Hand over • Data recording – audit & governance


Telephone triage for patients with suspected AKI

DIARRHOEA

Initial Assessment

Always review last U&E results in patient electronic notes

Questions:

• What chemotherapy is the patient on and when was the last treatment/tablet?• Are they receiving radiotherapy and when was their last treatment?• Number of recent episodes?

• How often do the bowels usually move? • How many stools a day is the patient passing or how much stoma output is there above normal amount? • Are stools/stoma output formed, loose or watery? Any faecal incontinence or urgency? Nocturnal movements?• Is there any abdominal pain e.g., cramping pains coming in waves?• For how many days has the patient had diarrhoea? Is it interfering with activities of daily living?• Are they able to eat and drink normally? Are they passing plenty of clear urine? • Do they have any other chemotherapy related toxicities, e.g. mouth ulcers, N/V, red hands/feet, stomatitis, mucositis?• Any recent antibiotics or recent hospital admissions?• Have they taken any laxatives or anti-sickness medication or any anti-diarrhoeal medication in the last 24 hours? What?

Advice:

If taking Capecitabine chemotherapy follow the Capecitabine management protocol

DRUGS - NB. Has the patient had a platinum based chemotherapy?Is the patient taking:

•NSAIDs e.g. Diclofenac, Ibuprofen•ACE inhibitors e.g. Ramipril, Lisinopril.

NB if patient taking any of the above drugs advise to omit until management plan agreed

Urgent review required or discuss with Acute Physician on MAU.


VOMITING

Initial Assessment

Always review last U&E results in patient electronic notes

Questions:

•Frequency (number of episodes in last 24/48 hours) and nature of nausea with or without vomiting? •Assess bowel movements; Any symptoms that suggest constipation? Any diarrhoea?•What food and fluids have you been taking over last few days? •Any signs of dehydration e.g. decreased urine output, fever, thirst, dry mucous membranes etc.•What is the underlying cancer diagnosis? •What is the extent of the disease? – e.g. known metastases to brain, bone, liver etc.•What medication is the patient taking i.e. antiemetics and has there been any recent changes?•Increasing abdominal pain?

Advice:

If taking Capecitabine chemotherapy follow the Capecitabine management protocol

DRUGS - NB. Has the patient had a platinum based chemotherapy?Is the patient taking:

•NSAIDs eg Diclofenac, Ibuprofen•ACE inhibitors eg Ramipril, Lisinopril.NB if patient taking any of the above drugs advise to omit until management plan agreed

Review prescribed antiemetic medication;

Assess patient compliance

Phone / review the patient in 24 hours

As for grade 1

Advise to get GP review consider changing antiemetic including route of admin.

Phone / review the patient in 24 hours

If symptoms worsen or are associated with other toxicities consider admission.

Urgent review required or discuss with Acute Physician on MAU.


Time Oral Intake Running Total

IV 1 IV 2/ Other Running Total

Total

Intake

07: 00

08: 00

09: 00

10: 00

11: 00

12: 00

13: 00

14: 00

15: 00

16: 00

17: 00

18: 00

19: 00

20: 00

21: 00

22: 00

23: 00

24: 00

01: 00

02: 00

03: 00

04: 00

05: 00

06: 00

TOTAL

INTAKE

Urine Running Total

Other Other Running Total

Total

Output

TOTAL

OUTPUT

Balance from

previous day:

Cumulative

balance:

Weight:

Balance from

previous day:

Cumulative

balance:

Weight:

BALANCE

Developed by Katerina Pearson, OAU Sister


AKI alert and guidance on blood result


Change in biochemical assay


AKI alerts post change in algorithm• Initial audit identified need for change in algorithm to

improve accurate classification of AKI stage• Increased numbers identified; level 3 maintained


AKI alerts: quality monitoring and improvement

• Adherence to care bundle and root cause analysis• Policy, guidance, education, awareness raising


Assessing risk factors on admission


Monitoring compliance with care bundle• Early increased compliance since pilot, eg.:

• Ultrasound KUB <24hours: up from 51% to 60%• Stop nephrotoxic medications: up from 54% to 63%• Urine dipstick and analysis: up from 54% to 67%


Strong Leadership • Focus within The Christie:• Governance – clinical audit leadership and

steering • Clinical specialist leadership • Executive board membership• Embedding data collection into clinical

systems • Empowering staff to collect data• Assigning trainees with current projects •


Sharing & Promoting Best Practice • Executive dissemination • Education – Presentations

• Non-medical prescribers

• Acute Oncology Masterclass for NW AON

• Morbidity & Mortality Grand Round

• Representation at the GM, Lancashire & South Cumbria Strategic Clinical Network

• National patient safety presentations• GP correspondence • Link with sepsis and IV fluid groups


Practical Solutions – Real Problems

• Clinical audit will assure delivery and quality of this entire project through robust long term data collection & analysis

• AKI Dashboards – safety thermometer • EPR – AKI documentation• e-prescribing – medicines optimization • e-learning tools • AKI discharge summaries for GP & patients


Simple is Effective Maximising the utility of clinical audit

A fully integrated team

Pioneering in Cancer Care in the UK Innovative & Expert real time cross disciplinary team

working beyond historical barriers

The power of a culture shift A new tradition

Medicines optimization Proactivity at the front door

Maximising patient outcomes


References & Resources

• AKI toolkit 12 – RCP Oct 2015• AKI APP – RCPE • NICE AKI Guidance 2012• NCEPOD – Adding Insult to Injury 2009• NHS ‘Think Kidneys’ programme• Academy of Medical Royal Colleges • Royal College of Radiology – Contrast Nephropathy• Society of Intensive Care Medicine • Society for Acute Medicine • Royal College of Nursing • Royal Society of Medicine – Nephrology section • Renal Association/British Renal Society website

Healthcare

QI initiative: Acute Kidney Injury (AKI) Care in Acute Oncology