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
Acute Kidney Injury (AKI) Key Facts
Mortality by Stage of AKI In a UK hospital-wide population with AKI: mortality 23.6% Selby NM et al CJASN 2012; 7(4): 533-40
AKI Risk put into perspective Data derived from: Hospital Episode Statistics Annual Report 2010, DoH VTE Prevention Programme 2010 and Selby et al 2012
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 >60 1.0 egfr 45-59.9 2.3 egfr 30-44.9 5.6 egfr 15-29.9 13 *non-proteinuric group shown; similar pattern seen across all levels of proteinuria James MT et al. Lancet 2010; 376: 2096-2103 Ishani A et al. JASN 2009; 20: 223 228
Public Knowledge regarding kidneys
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
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
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.
Automated Lab Alerts
Passive Alerts Please complete Trust AKI Bundle
Like diabetes AKI is everywhere! 7.5% of patients under nephrology
Where does the front line fit in our journey to improve AKI?
AKI Strategy the first step
Understanding our data STHK Prevalence Spells analysis Jul Aug Sep Total AKI 1 247 213 229 689 AKI 2 68 86 76 230 AKI 3 58 54 35 147 Total No of Spells with AKI 373 353 340 1,066 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
Community Vs Hospital Acquired Highest AKI level Acquired Total Spells % 1 2 3 Total Community 368 53% Hospital 321 47% Community 144 63% Hospital 86 37% Community 97 66% Hospital 50 34% Community 609 57% Hospital 457 43% All 1,066
Discharge Outcome Highest AKI level Home/ Temp Other NHS Provider Care Home Died Total Mortality rate (%) Transfer rate (%) 1 2 3 Grand Total C 304 10 22 32 368 9% 3% H 234 15 23 49 321 15% 5% C 102 5 11 26 144 18% 3% H 53 10 4 19 86 22% 12% C 58 9 8 22 97 23% 9% H 23 5 1 21 50 42% 10% C 464 24 41 80 609 13% 4% H 310 30 28 89 457 19% 7%
LOS Highest AKI level Home/ Temp Other NHS Provider Care Home Died Grand Total 1 2 3 Grand Total C 8.32 8.6 25.86 6.47 9.21 H 18.11 18.73 33.48 19.31 19.42 C 8.75 2.2 32.82 3.69 9.45 H 16.98 19 42.5 15.42 18.06 C 11.34 9.67 26.63 8.77 11.87 H 21.91 12.6 45.0 20.81 20.98 C 8.8 7.7 27.9 6.2 9.7 H 18.2 17.8 35.2 18.8 19.3 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.
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 1189. 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.
Deterioration Community Hospital Grand Total No deterioration Total 461 358 819 1 Level of deterioration Total 123 83 206 2 Levels of Deterioration Total 25 16 41 Grand Total 609 457 1066 24% 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
SLR Review AKI is everywhere! 1 2 3 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.
National CQUIN Acute Kidney Injury April 2015 May 2015 June 2015 Overall Q1 2015-16 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
% 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.
AKI Business Case
Active Alerts email/text r
Active Alerts Interruptive alert Kohle et al. PLoS ONE 2015
Active Alerts Form-linked alert Kohle et al. PLoS ONE 2015
AKI Management Bundle embed into proforma
Care Bundles The evidence in AKI
Care Bundles The evidence
Care Bundles The evidence
AKI Management Toolkit/Policy
Adverse Drug Events If not identified, AKI can result in a significant increase in drug related complications
Public Knowledge regarding kidneys & AKI
National CQUIN Discharge Info
AKI Education
AKI Education Grand rounds Audit Meetings Foundation and Core Trainee teaching CPPE pharmacists GP Collaborative events RCP Evening
AKI Apps
Other Initiatives with Fluids & Hydration
Fluids Chart
Fluids Prescription
Fluids Infomercial http://www.powtoon.com/m/f6fuk6xxwlk/1/
To help protect your privacy, PowerPoint has blocked automatic download of this picture. Hydration: Finding the Right Balance A Guide for Care Home Staff