Acute kidney injury Keeping kidneys healthy: The AKI programme board. Dr Richard Fluck, National Clinical Director (Renal) NHS England

Transcription

1 Acute kidney injury Keeping kidneys healthy: The AKI programme board Dr Richard Fluck, National Clinical Director (Renal) NHS England

2 NHS Outcomes Framework

3 NHS Five Year Forward View A vision for the future of the NHS. Developed by the partner organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority The purpose: to articulate why change is needed, what that change might look like and how we can achieve it

4 Think Kidneys

5 What is acute kidney injury? Acute kidney injury (AKI) is a rapid deterioration of renal function, resulting in inability to maintain fluid, electrolyte and acid-base balance. It normally occurs in the context of other serious illness (e.g. sepsis) on a background of risk.

6 Who is most at risk? Two patients are admitted via accident and emergency on a Friday night. George, an 86 year old man has crushing chest pain and ECG changes consistent with a large heart attack. Julia, a slim 56 year old, with long standing diabetes, has not been feeling right - the GP did a blood test and her serum creatinine is 456 umol/l. Who should we most be worried about?

7 Why is it important? Associated with other serious illness Force multiplier for poor outcomes Potential to improve care Reduce avoidable harm - death and morbidity Reduce cost Important marker of illness

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9 One in five emergency admissions to hospital will have AKI "AKI is 100 times more deadly than MRSA infection Around 20 per cent of AKI cases are preventable costs of AKI to the NHS are m pa

10 reducing avoidable death, long-term disability and chronic ill health VTE prevention: estimate 25,000 deaths pa Data derived from: Hospital Episode Statistics Annual Report 2010, DoH VTE Prevention Programme 2010 and Selby et al 2012

11 The pathway and commissioning levers Risk assessment CQUIN in test in SDH Improved diagnosis Safety alert NHS England Treatment NICE guidance Care bundles Recovery Proposed national CQUIN Primary care Secondary care

12 Strategy Who is at risk? When do people sustain AKI? How should patients with AKI be managed? What do people need to know? The NHS campaign to improve the care of people at risk of or with, acute kidney injury 12

13 Who Who is at risk? Determining the vulnerable population Pre existing comorbidities

14 When When do people sustain AKI? How is early diagnosis supported? 60% of AKI arises in the community A trigger event e.g. infection, sickness, cardiac event

15 How How should AKI be managed? How does that look in primary and secondary care? Prevention Treatment Recovery

16 What What do people need to know? Education for the public Education for patients and carers Education for professionals

17 Who is at greatest risk? For George, his risk of death is 32.2% For Julia, her risk of death is 53.1% Data adapted from Chawla et al Clin J Am Soc Nephrol 2013

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19 Think Kidneys objectives Develop and implement tools and interventions for prevention, detection, treatment and enhanced recovery Promote effective management of AKI Provide evidence-based education and training programmes Highlight importance of AKI to commissioners, health care professionals and managers The NHS campaign to improve the care of people at risk of or with, acute kidney injury 19

20 Think Kidneys AKI Programme The NHS campaign to improve the care of people at risk of or with, acute kidney injury 20

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22 What are NHS patient safety alerts? Method by which NHS can rapidly alert the healthcare system to patient safety risks, or to provide guidance on preventing harm Level 3: Directive: requires specific action(s) within timeframe Level 2: Specific resource and information sharing Level 1: Warning of emerging risk The NHS campaign to improve the care of people at risk of or with, acute kidney injury 22

23 National groups ACB scientific committee Met July 2013 Biochemists, nephrologists and software providers Algorithm and minutes available online Renal Association guidelines committee Met October 2013 Nephrologists, biochemists, acute physicians, ICU, patients Ratified algorithm Guidelines to be produced ogramme/aki-algorithm/ British Association Paediatric Nephrologists Met Sept 2013 Paediatric nephrologists, biochemists Ratified algorithm with one adaptation for paeds

24 Specification of the algorithm Based on KDIGO as closely as possible Two stage approach to determining reference creatinine: Uses lowest creatinine within last 48hrs (for 27µmol/l rise) or within last 7 days (for 50% rise or greater) If no recent creatinine, uses median creatinine value from last 12 months Generates a numerical test result (stage 1, 2 or 3) that can then be sent to patient management systems If no reference value within 12 months: advice message (to repeat creatinine) but no AKI stage The NHS campaign to improve the care of people at risk of or with, acute kidney injury 2

25 Comparisons with existing systems AKI incidence 6.9% 4.5% for stage 1 1.4% for stage 2 1.0% for stage 3 RLH algorithm Number of alerts in patients with baseline creatinine available AKI stage AKI stage AKI stage NHS England algorithm Number of patients with AKI 30 day mortality AKI 1 AKI 2 AKI 3 Trevor Hine, Shahed Ahmed: personal communication

26 Electronic alerts improve VTE prophylaxis and reduce thrombosis events Kucher N et al. N Engl J Med 2005;352:

27 Terminology e-alerts Detection Alerting 27

28 Care bundles and response

29 Specific actions: Work with LIMS provider to integrate NHSE AKI detection algorithm into Laboratory Information Management System (LIMS) Ensure test results are sent: To hospital patient management systems Into a data message for transmission to a central point (UK Renal Registry) Educate primary care physicians as to the use of AKI detection The NHS campaign to improve the care of people at risk of or with, acute kidney injury 29

30 Anticipated outcomes Improve detection of AKI in secondary care setting Standardisation Universal access Sustainability Laboratory quality assurance Evidence generation and algorithm review Mechanism for sending test results to primary care IT systems Allow ongoing innovation in alerting systems Measurement: data transfer to UKRR The NHS campaign to improve the care of people at risk of or with, acute kidney injury 30

31 Measurement can drive improvement Message Regional, National Master patient index Research Patient management system LIMS level result AKI Registry QI Local systems Other data systems Alert Response The NHS campaign to improve the care of people at risk of or with, acute kidney injury 31

32 Section 251 exemption

33 The revised Caldicott recommendations: 6.7 Exceptional disclosure in the public interest (section 251 of the NHS Act 2006) Sometimes researchers require specific information about individuals that cannot be anonymised or pseudonymised in a safe haven, and gaining explicit consent may be highly impractical. Legislation is in place that allows personal confidential data to be processed for medical purposes such as research. Regulations under section 251 of the NHS Act62, often referred to simply as section 251, allows the common law duty of confidence to be set aside under specific circumstances. Applicants must demonstrate that the aim of the processing is in the public interest, that anonymised information could not be used to achieve the required results, and that it would be impractical, both in terms of feasibility and appropriateness, to seek specific consent from each individual affected. For research the approval of a Research Ethics Committee is also needed. The key test is one of necessity, not convenience.

34 The Governments response to the revised recommendations: Principle 7. The duty to share information can be as important as the duty to protect patient confidentiality Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies. page 25: There will be occasions when it is not possible to use services like CPRD and it can be demonstrated that obtaining consent is not practicable. For these circumstances the Health Research Authority has the power to approve research applications for access to patient information without consent taking into consideration advice provided by the Confidentiality Advisory Group. page 26: For example, to achieve authorisation, NHS England has included a requirement for CCGs to have a research strategy, and the criteria for Academic Health Science Networks include a requirement for plans to ensure that the network, including NHS providers, shares data (usually anonymised data but also identifiable data where there is a legal basis) to support research and promote participation in both commercial and non-commercial trials.

35 AKI National Programme NHS England Patient Safety Steering Group AKI National Programme Board Risk Education Detection Intervention Implementation Measurement Advisory Group Algorithm Sub- Group Software Implementation Sub-Group Best Practice in E- alert Group Hydration Sub- Group Expert Reference Group

36 meta data Renal Units LABS LABS LABS RPV Patient UK RR SRR HES, RGOS etc UK Renal Data Collaboration RaDaR BAPN Primary care prescribing etc NHSBT Research and Audit

37 Renal Units meta data AKI data Primary and secondary care Direct from labs LABS LABS LABS RPV UK RR SRR Patient HES, RGOS etc UK Renal Data Collaboration RaDaR BAPN Primary care prescribing etc NHSBT Research and Audit

38 National algorithm and mandate to report

39 System levers Safety collaboratives: AHSN/SCN Sign up for safety Health Foundation Forward view: into action 2015/16 NHS England is proposing to introduce new national CQUIN indicators to tackle sepsis and acute kidney injury; and a new quality premium indicator to tackle resistance to antibiotics. 08/04/2015

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41 The challenge Understanding of the kidneys IPSOS Mori poll 2014 general population 51% knew kidneys make urine 8% thought the kidneys pumped blood 12% were aware of role on medicines processing The NHS campaign to improve the care of people at risk of or with, acute kidney injury

42 The challenge Understanding of the kidneys (2) Risks to the kidney 68% alcohol 53% dehydration 22% medications 1% smoking The NHS campaign to improve the care of people at risk of or with, acute kidney injury

43 The challenge Understanding of the kidneys (3) What is acute kidney injury? 15% had heard of it 16% might of heard of it 69% had never heard of it Physical injury identified as principle reason Only 1 in 5 guessed correct causes The NHS campaign to improve the care of people at risk of or with, acute kidney injury

44 Summary Acute Kidney Injury is important The national supporting infrastructure is coming into play Next steps are develop improvement strategies across the NHS The NHS campaign to improve the care of people at risk of or with, acute kidney injury

45 Acknowledgements Joan Russell Head of Patient Safety NHS England Ron Cullen Director UK Renal Registry Karen Thomas Think Kidneys Programme Manager UK Renal Registry Teresa Wallace Think Kidneys Programme Coordinator UK Renal Registry The chairs and co-chairs of all the workstreams in Think Kidneys The NHS campaign to improve the care of people at risk of or with, acute kidney injury 45