Scottish Patient Safety Programme Acute Kidney Injury

Scottish Patient Safety Programme Acute Kidney Injury Dr Laura Clark, Nephrologist and NHSG Clinical Lead, AKI @Nephron77 Louise Black, Quality Improvement Facilitator, NHS Grampian @louise_64spsp October 2018

ll of us 4

Pharmacy lead Labs Boss 5

Common and Bad The NHS campaign to improve the care of people at risk of, or with acute kidney injury

ind of what we re up to! 8

What worked for us Management support and buy in, in both Aberdeen Royal Infirmary and Dr Gray s Great leadership and a home grown team Lab Consultant support which is absolutely vital Pharmacy team enthusiasm in both ARI Renal and DGH Education sessions delivered to all multidisciplinary health professionals in pilot wards Staff willingness and enthusiasm to do the right thing ANP lead in ARI Trauma Orthopaedics AKI week pan Grampian which led to huge staff and public engagement 9

Healthy wee is 1 3 4-8 you MUST hydrate

Unless the Doctors or Nurses looking after tell you otherwise

mprovement 13

Burden of AKI in NHS Grampian Creatinine measurement AKI 1 alert AKI 2 alert AKI 3 alert Total = 634726 Total = 13723 Total = 4015 Total = 4082 Place of first AKI alert for an individual with AKI 0 20 40 60 80 100 percent General Practice Other in- and out-patients ARI in-patients

Potential average monthly AKI alerts in Grampian (and people) Average Month (28-day) Tests N (%) Persons getting a maximum AKI alert of 1,2 or 3 Creatinine tests done ~48,000 AKI 1 917-1165 (1.9-2.4) 357 AKI 2 249-358 (0.5-0.7) 90 AKI 3 224-429 (0.5-0.9) 66 Not applicable ~7,600 (15-17)

Where are the tests and the AKI in ARI? ITU / speciality block Place No AKI AKI 1 AKI 2 AKI 3 Not applicable Missing Total First AKI ARI 47,614 (32.2) 2,601 (63.1) 906 (75.4) 797 (75.2) 2,938 (9.3) 2,588 (40.3) 57,444 (29.8) (%) 201 821 (1.7) 100 (3.8) 72 (7.9) 68 (8.5) 12 (0.4) 542 (20.9) 1,615 (2.8) (3.2) 203 4 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (0.1) 0 (0.0) 8 (0.0) 204 678 (1.4) 48 (1.8) 5 (0.6) 3 (0.4) 9 (0.3) 19 (0.7) 762 (1.3) (1.2) 205 1,520 (3.2) 26 (1.0) 9 (1.0) 15 (1.9) 126 (4.3) 47 (1.8) 1,743 (3.0) (1.4) 206 156 (0.3) 4 (0.2) 0 (0.0) 0 (0.0) 2 (0.1) 1 (0.0) 163 (0.3) (0.1) 209 1,362 (2.9) 174 (6.7) 46 (5.1) 29 (3.6) 93 (3.2) 47 (1.8) 1,751 (3.0) (5.5) 210 479 (1.0) 5 (0.2) 3 (0.3) 1 (0.1) 87 (3.0) 50 (1.9) 625 (1.1) (0.3) 211 128 (0.3) 3 (0.1) 0 (0.0) 0 (0.0) 22 (0.7) 13 (0.5) 166 (0.3) (0.2) 212 981 (2.1) 50 (1.9) 14 (1.5) 0 (0.0) 64 (2.2) 35 (1.4) 1,144 (2.0) (2.4) 213 740 (1.6) 43 (1.7) 15 (1.7) 9 (1.1) 37 (1.3) 27 (1.0) 871 (1.5) (2.2) 214 453 (1.0) 8 (0.3) 5 (0.6) 4 (0.5) 44 (1.5) 11 (0.4) 525 (0.9) (0.7) 216 1,307 (2.7) 28 (1.1) 10 (1.1) 13 (1.6) 53 (1.8) 57 (2.2) 1,468 (2.6) (1.1) 217 409 (0.9) 22 (0.8) 16 (1.8) 3 (0.4) 1 (0.0) 17 (0.7) 468 (0.8) (0.5)

What is the mortality of those with AKI? 3% immediate mortality 13% 7 day mortality 24% 30 day mortality

NHS Grampian Wide interventions New AKI Guidance on Intranet Departmental education sessions Going live with AKI e-alerts to coincide with AKI Awareness week March 2018 AKI Awareness week Testing checklists in vascular, Dr Grays, General Medicine

AKI Trakcare E-alerts

Trauma Ortho Work Part of SQSF Fellowship Aim of reducing harm by focusing on risk assessment and fluid assessment and considering stopping medications? Reduction of AKI 1&2 by 20% Process measure- completion of checklists Outcome measures-number of AKI alerts, LOS, RRT, Mortality Balancing measures- readmissions with heart failure 22

Process changes Risk Assessment sticker- now embedded in clerking STOP Checklist Presentation to orthopaedic and anaesthetic colleagues Education with pre- and post education questionnaire Switch on AKI e-alerts January 2018 prior to widespread rollout Patient information leaflets and AKI board

Risk Assessment Sticker If any 1 RISK + any 1 EVENT = START AKI Prevention BUNDLE

(If any 1 RISK + 1 EVENT) = Initiate STOP AKI prevention bundle Sepsis = SEPSIS 6, screen and treat promptly Toxins = Alternative/withold nephrotoxics (NSAIDs, ACEi/ARB, CCB/alpha-blockers, Diuretics, Gent/vanc, Contrast procedures). Optimise BP/volume status = avoid/correct hypovolaemia (IV fluids), optimise BP/Volume status(review need of anti-hypertensive meds) Obstructive symptoms catheter/bladderscan? Prevent harm = Daily U+E until U+E normalise, Fluid balance Input/ Output charts and Daily Weights. Review medications.

STOP AKI Prevention Bundle If Persistent 1) Daily bloods (inc. bicarb, K+) 2) Urinalysis (blood/ protein, leucocytes) +/- renal USS. 3) Drug dosing adjustment. 4) D/W seniors/ Renal physician 5) Ensure F/U plan (e.g. discharge when U+E normal/ recheck U+Es, when to restart BP/ACEi meds)

Trauma Orthopaedics - ARI You have made my life easier as drugs are stopped before I get there! Orthogeriatrician

I am confident at recognising and managing a patient at RISK of AKI Strongly Disagree Disagree Neither agree/disagree Agree Strongly Agree 0 10 20 30 40 50 60 70 Percentage of responses Pre-Education Post-Education 33

I am confident at recognising and managing a patient with AKI Strongly Disagree Disagree Pre-Education Post-Education Neither agree/disagree Agree Strongly agree 0 10 20 30 40 50 60 70 80 Percentage of responses 34

I am confident at making a diagnosis of AKI most of the time Strongly Disagree Disagree Neither agree/disagree Pre-Education Post-Education Agree Strongly agree 0 10 20 30 40 50 60 70 80 Percentage of responses 35

Dr Gray s Hospital, Elgin 36

Nov 17 Nov 17 Nov 17 Nov 17 Dec 17 Dec 17 Dec 17 Dec 17 Dec 17 Jan 18 Jan 18 Jan 18 Jan 18 Feb 18 Feb 18 Feb 18 Feb 18 Mar 18 Mar 18 Mar 18 Mar 18 Apr 18 Apr 18 Apr 18 Apr 18 Apr 18 May 18 May 18 May 18 May 18 Jun 18 Jun 18 Jun 18 Jun 18 Jul 18 Jul 18 Jul 18 Jul 18 Jul 18 Aug 18 Aug 18 Aug 18 Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Count AKI ealert notifications Ward 5 DGH 16 14 12 10 8 ealerts switched on 6 4 2 New Sticker introduced New Dr's AKI Teaching session 0 38

Ward 5 Alerts v's no of patients 35 30 30 31 New doctor rotation 25 20 21 21 22 FY teaching session AKI 20 15 16 14 10 14 13 10 12 5 0 April May June July August September Total AKI's 39 Total no of pt's

Nov 17 Nov 17 Nov 17 Nov 17 Dec 17 Dec 17 Dec 17 Dec 17 Dec 17 Jan 18 Jan 18 Jan 18 Jan 18 Feb 18 Feb 18 Feb 18 Feb 18 Mar 18 Mar 18 Mar 18 Mar 18 Apr 18 Apr 18 Apr 18 Apr 18 Apr 18 May 18 May 18 May 18 May 18 Jun 18 Jun 18 Jun 18 Jun 18 Jul 18 Jul 18 Jul 18 Jul 18 Jul 18 Aug 18 Aug 18 Aug 18 Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Count AKI ealert notifications Ward 6 DGH 16 14 12 10 8 6 ealerts switched on 4 2 New Sticker introduced New Dr's 0 AKI Teaching session 40

25 23 Ward 6 Alerts v's no of patients 21 22 20 FY Teaching session AKI 15 13 10 10 New doctor rotation 5 7 8 9 8 6 7 5 0 April May June July August September Total AKI's 41 Total no of pt's

Apr 18 Apr 18 Apr 18 Apr 18 Apr 18 May 18 May 18 May 18 May 18 Jun 18 Jun 18 Jun 18 Jun 18 Jul 18 Jul 18 Jul 18 Jul 18 Jul 18 Aug 18 Aug 18 Aug 18 Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Sep 18 Count AKI ealert notifications Ward 7 DGH 16 14 12 10 New sticker introduced 8 New dr rotation FY teaching session AKI 6 4 2 0 42

I like the ealerts that we now have on TRAKCare these are really helpful as they flag an abnormal result on my patients Ward Pharmacist I now feel I have a better understanding of AKI and can safely advise my patients about the importance of being hydrated and also about accurately recording fluid intake and output HCSW Ward 6, DGH The lanyards cards are really helpful for new medical staff thank you. They work well with the management guidance on the intranet FY1 Ward 5/6, DGH Our fluid balance charts are orange at the moment and we have moved them either to the front of the patient folder at the bottom of the bed or onto a clipboard at the bottom of the bed this is much easier for staff to see and find: Ward Manager, Ward 6 Love these posters they are so easy to understand for all of us: Domestic Support Ward 5 We are working together for the benefit of our patients this information will help us as a professional team Ward Pharmacists, Ward 6, DGH 44

NHS Grampian AKI week incorporated World Kidney Day (March 2018) Our Mobile Information bus was stationed at Tesco carparks in Forres, Buckie and Elgin during the AKI awareness week. A huge amount of resources were available for members of the public and again great interest generated Staff in Elgin were reminded to keep hydrated and free bottles of water were donated by ASDA, Elgin for this event 46 Dr Laura Clark, Consultant Nephrologist appeared on STV news to promote kidney health!

Dr Gray s Hydration Hero 48

Continue to test sticker in Dr Gray s Hospital and in the wider setting across NHS Grampian Revisit Trauma Orthopaedics in ARI and work with ENP and junior doctors Showcase our work at the international quality event in Glasgow in March 2019 Showcase our work at NHS Grampian annual quality event in May 51 2019

Plan another AKI week!!!! 52

What have we learned? POSITIVES Raising awareness is a good thing for everyone! Education is a good thing! Good communication and Teamwork make it easy! CHALLENGES It is hard to measure avoidable harm from AKI. It may be difficult to reduce harm from AKI as AKI is usually a surrogate marker of severity of other illnesses It may be even more difficult to show evidence of reduction in harm with these interventions. Resource intensive work 53

Further steps! Integrate AKI work with the deteriorating patient work stream Primary Care work particularly follow -up/discharge plans Look at mortality, RRT & LOS outcome data 54