How the frontline can make an impact on AKI outcomes

Transcription

1 How the frontline can make an impact on AKI outcomes 22 nd October 2015 Cheshire & Mersey Strategic Clinical Networks AKI Workshop Dr Ragit Varia Consultant Acute Medicine

2 Acute Kidney Injury (AKI) Key Facts

3 Mortality by Stage of AKI In a UK hospital-wide population with AKI: mortality 23.6% Selby NM et al CJASN 2012; 7(4):

4 AKI Risk put into perspective Data derived from: Hospital Episode Statistics Annual Report 2010, DoH VTE Prevention Programme 2010 and Selby et al 2012

5 Bi-directional relationship of AKI and CKD 1 million patients with baseline assessments of serum creatinine and proteinuria CKD and proteinuria increase risk of AKI 233,803 hospitalised patients in 2000 aged over 67 AKI increased risk of ESRD by 13 fold Baseline renal function Rate ratio for hospital admission with AKI* egfr > egfr egfr egfr *non-proteinuric group shown; similar pattern seen across all levels of proteinuria James MT et al. Lancet 2010; 376: Ishani A et al. JASN 2009; 20:

6 Public Knowledge regarding kidneys

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10 National CQUIN The CQUIN focusses on the recovery and follow up elements of the pathway which are both important elements given over 50% of AKI is currently occurring in primary care. Improving the provision of information to GPs at the time of discharge will start to develop the knowledge base of GPs on AKI and will also positively impact on readmission rates for patients with AKI. Requirements in discharge summary are: 1. Stage of AKI 2. Evidence of medicines review having been undertaken 3. Type of blood tests required on discharge for monitoring 4. Frequency of blood tests required on discharge for monitoring

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12 AKI Definition A recent survey revealed the use of at least 35 definitions in the literature. ARF AKD ERF ESKD ESRD AKI is defined by KDIGO/NICE as any of the following: a rise in serum creatinine of 26 micromol/litre or greater within 48 hours a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours

13 Staging of AKI AKI STAGE Serum creatinine criteria 1 Increase in serum creatinine of 26 micromol/litre or more within 48 hours OR 1.5 to 2-fold increase from baseline 2 Increase in serum creatinine to more than 2 to 3-fold from baseline 3 Increase in serum creatinine to more than 3-fold from baseline OR Serum creatinine more than 354 micromol/litre with an acute increase of at least 44 micromol/ litre Urine output criteria Less than 0.5 ml/kg/hour for more than 6 hours* Less than 0.5 ml/kg/hour for more than 12 hours Less than 0.3 ml/kg/hour for 24 hours or anuria for 12 hours Staging of AKI is appropriate because, with increased stage of AKI, the risk for death and need for RRT increases. Furthermore, there is now accumulating evidence of long-term risk of subsequent development of cardiovascular disease or CKD and mortality, even after apparent resolution of AKI.

14 Automated Lab Alerts

15 Passive Alerts Please complete Trust AKI Bundle

16 Like diabetes AKI is everywhere! 7.5% of patients under nephrology

17 Where does the front line fit in our journey to improve AKI?

18 AKI Strategy the first step

19 Understanding our data STHK Prevalence Spells analysis Jul Aug Sep Total AKI AKI AKI Total No of Spells with AKI ,066 Total Emergency spells* 3,643 3,390 3,512 10,545 AKI Prevalence 10.2% 10.4% 9.7% 10.1% Stage 3 AKI Prevalence 1.6% 1.6% 1.0% 1.4% *Admission Method 21-28, excluding Obstetrics and Paediatrics

20 Community Vs Hospital Acquired Highest AKI level Acquired Total Spells % Total Community % Hospital % Community % Hospital 86 37% Community 97 66% Hospital 50 34% Community % Hospital % All 1,066

21 Discharge Outcome Highest AKI level Home/ Temp Other NHS Provider Care Home Died Total Mortality rate (%) Transfer rate (%) Grand Total C % 3% H % 5% C % 3% H % 12% C % 9% H % 10% C % 4% H % 7%

22 LOS Highest AKI level Home/ Temp Other NHS Provider Care Home Died Grand Total Grand Total C H C H C H C H The NCEPOD report estimates that 20-30% of AKI is avoidable. NICE Costing guidance suggests that for AKI patients, length of stay is 4.7 days longer than those where AKI was avoided. Our aim is to deliver a 4.7 length of stay reduction to 25% of the hospital acquired AKI population.

23 Critical Care 13% (134) of the AKI patients from our population spent an average 6 days in Critical Care. (range is large: 0-71 and distribution weighted towards 0-3 days) Any reduction in the burden placed on Critical Care would contribute to improved patient experience and reduce the bed burden on the Trust. An ITU bed day cost for a patient with AKI is on average An AKI team would intervene earlier in the patient s clinical deterioration thus affecting transfer to RLUBHT hub for care. Re-admissions 30% of the patients identified were readmitted to the Trust within 30 days It is anticipated that by informing the GP of the blood tests that need to be carried out post-admission and enabling better monitoring of AKI in primary care, readmission rates would decrease. Evidence from Nottingham University Hospitals showed that post introduction of a specialist AKI nursing team 30 day readmission rates for AKI Levels 2 and 3 reduced from 16% to 12% 1. Whilst a 4% reduction in readmissions may appear small, it is known these readmissions usually have an extended LOS.

24 Deterioration Community Hospital Grand Total No deterioration Total Level of deterioration Total Levels of Deterioration Total Grand Total % 21% 23% Apart from aiming to have an impact on hospital acquired AKI, there will also be the ability to have an impact on hospital based deterioration in community acquired AKI

25 SLR Review AKI is everywhere! All AEOBS 28.01% 24.35% 19.05% 25.98% W1C 17.71% 20.87% 24.49% 19.32% W1BGP 15.67% 13.04% 19.05% 15.57% W1B 6.39% 9.13% 8.84% 7.32% W4BS 4.79% 6.09% 8.84% 5.63% W4BN 3.92% 2.61% 4.08% 3.66% W1E 3.19% 3.91% 0.68% 3.00% W4E 2.18% 3.04% 5.44% 2.81% DELS2 1.74% 2.17% 2.04% 1.88% W5CAS 2.03% 1.30% 0.00% 1.59% W3ALP 2.18% 0.87% 0.00% 1.59% W3C 0.87% 1.74% 0.68% 1.03% W3F 1.16% 1.30% 0.00% 1.03% Other 10.16% 9.57% 6.80% 9.57% AKI cuts across all specialties an 80/20 split between Medical Care Group and Surgical Care Group, with 70% in General Medicine/A&E and 15% in General Surgery/Urology/Trauma & Orthopaedics. The Length of Stay for Surgical Care Group patients with AKI is 2 days longer than those with AKI within the Medical Care Group (15.4 against 13.4) strongly suggesting that there may be opportunities for increased length of stay savings within Surgical Care.

26 National CQUIN Acute Kidney Injury April 2015 May 2015 June 2015 Overall Q The percentage of key items included in the reviewed AKI discharge summaries 6% 12% 21% 13.0% Requirements in discharge summary are: 1. Stage of AKI Target required by Q4 is >90% 2. Evidence of medicines review having been undertaken 3. Type of blood tests required on discharge for monitoring 4. Frequency of blood tests required on discharge for monitoring

27 % Missin g Data AQ AKI (target Pop <5%) Target Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD ACS Pop Rank REM Aintree C 0% 50.0% 37.5% 37.5% 24 1 RJR Countess C 0% 50.0% 0.0% 0.0% 20 6 RXR E Lancashire C 10% 50.0% 19.4% 19.4% 31 2 RXN Lancs Teaching C NoData 50.0% - RBT Mid Cheshire C 40% 50.0% 0.0% 0.0% 11 6 RTX Morecambe Bay C 20% 50.0% 11.1% 11.1% 9 5 Performance RW6 Pennine Acute C 2% 50.0% 0.0% 0.0% 80 6 Target starts RQ6 Royal Liverpool C 37% 50.0% 0.0% 0.0% 20 6 July 2015 RVY Southport C 2% 50.0% 12.5% 12.5% 8 4 RBN St Helen's C 0% 50.0% 16.7% 16.7% 12 3 RWJ Stockport SP 4% 50.0% - RMP Tameside SP 3% 50.0% - RWW Warrington SP NoData 50.0% - RBL Wirral C 3% 50.0% 0.0% 0.0% 44 6 Apr-15 May-15 Jun-15 All the process measure that AQ has identified to achieve improved outcomes need to be achieved for each patient (Appropriate Care Score) This needs to be achieved with 50% of the trust AKI Stage 3 population.

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29 AKI Business Case

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31 Active Alerts /text r

32 Active Alerts Interruptive alert Kohle et al. PLoS ONE 2015

33 Active Alerts Form-linked alert Kohle et al. PLoS ONE 2015

34 AKI Management Bundle embed into proforma

35 Care Bundles The evidence in AKI

36 Care Bundles The evidence

37 Care Bundles The evidence

38 AKI Management Toolkit/Policy

39 Adverse Drug Events If not identified, AKI can result in a significant increase in drug related complications

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41 Public Knowledge regarding kidneys & AKI

42 National CQUIN Discharge Info

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44 AKI Education

45 AKI Education Grand rounds Audit Meetings Foundation and Core Trainee teaching CPPE pharmacists GP Collaborative events RCP Evening

46 AKI Apps

47 Other Initiatives with Fluids & Hydration

48 Fluids Chart

49 Fluids Prescription

50 Fluids Infomercial

51 To help protect your privacy, PowerPoint has blocked automatic download of this picture. Hydration: Finding the Right Balance A Guide for Care Home Staff

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