Predict, prevent & manage AKI: A UK collaboration to detect a devastating condition AKI Case Study
Acute kidney injury (AKI) is a potentially devastating condition, thought to contribute to the deaths of tens of thousands of patients every year in the UK. But it is often preventable, write Professor Lui Forni, Dr Richard Venn and Dr Luke Hodgson, who detail how a new automated electronic alerting project at Western Sussex Hospitals NHS Foundation Trust aims to detect the risk of AKI early, promote intervention and save lives. A costly killer for the NHS As many as 100,000 deaths in secondary care are associated with acute kidney injury (AKI) each year, according to NHS England. 1 Many more patients go on to endure prolonged hospital admissions and to suffer from secondary chronic conditions. Now identified as one of two national clinical priorities for 2015-16, AKI is a chief concern for hospitals across the country. It affects as many as one in five emergency admissions to hospital and costs the NHS as much as 620m per year; more than breast cancer or skin and lung cancer combined. Often caused by stress on the kidneys due to other illnesses or infection, or the side effects of some drugs, more than a third of AKI cases occur after admission to hospital, with the elderly especially at risk. 2 It affects as many as one in five emergency admissions to hospital 3 and costs the NHS as much as 620m per year; more than breast cancer or skin and lung cancer combined. 4 National reports also indicate that the care of up 40 per cent of patients with AKI is inadequate, partly due to delayed recognition of the problem, and that as many as 20 per cent of post-admission AKI incidents are both predictable and avoidable. 5 1
Yet, despite a quality standard 6 being released by the National Institute for Health and Care Excellence (NICE), and NHS England s drive to significantly reduce premature mortality over the next five years, 7 electronic alerts that can warn doctors and nurses of the condition arising, have traditionally been studied for patients who already have AKI. Until recently little has been done in practice to predict which patients are at risk of developing the devastating condition. This is changing. Making prevention a reality A national motivation to tackle the problem is now being met with practical action. Specialist healthcare technology provider Patientrack, working with clinical input from Western Sussex Hospitals NHS Foundation Trust (WSHFT), has developed a successful clinical and ICT solution to systematically identify and flag those developing, or those with, AKI and subsequently promote a swift clinical response that until now has often been lacking. The solution, won national funding in May 2014 from the Department of Health and the Small Business Research Initiative (SBRI) so that it could be trialled at WSHFT and in March 2015 won a second round of funding with the aim of scaling the AKI alerting technology more widely across the NHS. Patientrack s early warning system has been widely used by doctors, nurses and other clinical staff at WSHFT since 2012 in order to capture bedside observations digitally, automatically calculate National Early Warning Scores (NEWS) and alert clinicians to deteriorating patients who require immediate medical intervention. The trust has now worked with Patientrack to embed a ground-breaking predictive scoring model, developed by its own specialist renal clinicians, into the early warning software platform so that an AKI risk score can be used to deliver real-time alerts to medical staff and advise on a best practice checklist that they must follow to care for patients appropriately and prevent conditions worsening. 2
The model, which is also combined with a national AKI staging algorithm, brings together various sources of data, including pathology results, to assess a patient s creatinine level and information including a patient s age, medical history and known co-morbidities, along with physiological information that is recorded at the bedside through Patientrack. These elements combine to generate a score which is then displayed on the patient s electronic chart and the hospital s Patientrack alerting system. Patients identified with AKI are issued with a red flag so that appropriate care can be given immediately. Those at risk of developing AKI are marked with an amber flag so that care packages can be delivered and patients who do not have the condition and are not judged to be at high risk are marked with a green flag. The result is an intelligent real-time technology designed to systemically improve the care of patients with or at risk of AKI. For the first time, clinicians can have complete visibility of the AKI status of every patient in the hospital and the system should allow healthcare professionals to identify every identifiable AKI, improve the management of people with AKI, and prevent the preventable. Wide ranging benefits Early intervention should help enable the prevention of morbidity and mortality associated with AKI, including secondary complications such as chronic kidney disease, but additional benefits are expected. Reduced lengths of stay, for example, will help to reduce further potential exposure to harm in the hospital environment and the technology could reduce the need for renal replacement therapies and escalation to intensive care. The result is an intelligent real-time technology designed to systemically improve the care of patients with or at risk of AKI. 3
Financial benefits for hospitals are also expected and not only as a result of reduced lengths of stay. The solution can help to achieve commissioning for quality and innovation (CQUIN) targets around AKI, an incentive to reward good care of patients with the condition, which contribute to payments worth up to 2.5 per cent of a provider s annual contract value. And ultimately, the project is providing doctors and nurses with a more intelligent picture and a rapid, accurate assimilation of various sources of data in order to immediately highlight which patients need intervention to prevent the serious consequences of AKI. Developing the solution The system will be developed as time goes on, feeding in new data, such as pharmacy and medication information. And, although at present the trust is using the national AKI staging algorithm 8 and its own AKI predictive scoring model, the technology can be applied to any early warning score developed in the future. This technology should be of significant interest to NHS hospitals. Early intervention should help to prevent morbidity and mortality, including secondary complications such as chronic kidney disease. Even more can be achieved, including reduced lengths of stay and the potential for a reduction in renal replacement therapies and escalation to intensive care. Dr Richard Venn, consultant in anaesthesia and intensive care at Western Sussex Hospitals NHS Foundation Trust 4
As more patients are cared for using the system, potentially beyond Western Sussex, the AKI scoring model could also be refined based on richer data from larger samples, as well as potentially being adapted for different circumstances and demographics. Scaling the solution across the NHS With such an emphasis now being placed on reducing deaths associated with AKI, the project embarked on in Western Sussex is highly relevant to many hospitals, something that a second round of Department of Health funding has reinforced. Several hospitals have already expressed a strong interest to add the AKI application into their own early warning system software through the Patientrack Research User Group and, in addition, a standalone solution is now being made available for hospitals not using Patientrack. Patientrack gives clinicians the ability to flag up which patients are at risk of acute kidney injury almost from the moment they walk through the door, so that they can see which patients are at risk from the first set of observations. Effectively it is an intelligent real-time technology that should systemically improve the care of patients. It will prevent and it will help to improve the management of people who come in with AKI. Professor Lui Forni, consultant in intensive care and renal medicine and chair of the AKI section of the European Society of Intensive Care Medicine 5
Significant interest is anticipated from the NHS. Large capital investments have not been needed in Western Sussex, and cost effective deployment could easily be achieved elsewhere. With such an urgency being placed on tackling AKI, any project that reveals a strategy to prevent the condition and improve management of patients with AKI could have an impact across the NHS and beyond. Award winning Patientrack AKI, working in partnership with WSHFT, is a winner of the UK government s Small Business Research Initiative (SBRI) and National Institute for Health Research Healthcare Technology Co-operative Devices for Dignity (D4D) competition for innovative ideas from industry to develop cutting-edge technology solutions to help kidney patients. Professor Lui Forni is a consultant in intensive care and renal medicine and chair of the AKI section of the European Society of Intensive Care Medicine (ESICM) Dr Richard Venn is a consultant in anaesthesia and intensive care at Western Sussex Hospitals NHS Foundation Trust Dr Luke Hodgson is an intensive care research registrar at Western Sussex Hospitals NHS Foundation Trust 1 NHS England Acute Kidney Injury Programme http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/ 2 http://www.england.nhs.uk/wp-content/uploads/2014/03/bg-present-keep-kidneys.pdf 3 Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients. 4 CG169 Acute kidney injury: NICE Guidance https://www.nice.org.uk/guidance/cg169 5 Stewart J, Findlay G, Smith N et al. Adding Insult to Injury. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure). National Confidential Enquiry into Patient Outcome and Death. London: NCEPOD, 2009;1-100. 6 NICE quality standards [QS76] http://www.nice.org.uk/guidance/qs76 7 NHS England, The Forward View Into Action: Planning for 2015/16 http://www.england.nhs.uk/wp-content/ uploads/2014/12/forward-view-plning.pdf 8 See for example, NHS England Acute Kidney Injury (AKI) Algorithm, http://www.england.nhs.uk/ourwork/patientsafety/ akiprogramme/aki-algorithm/ 6
About Patientrack Patientrack is an award winning, always-on, active safety and communication system that has been proven to help improve safety and reduce harm. We provide healthcare professionals with fast, real-time access to: Accurate vital signs capture and electronic charts Reliable information for early identification of deteriorating patients Effective alerting to enable appropriate involvement in care planning An easy to use system that fits in with existing ward processes and clinical pathways Visibility of national or local early warning scores (EWS) Valuable reports that deliver powerful information from ward to board By enabling the capture and integration of key clinical information, Patientrack is designed to meet national patient safety targets and objectives to reduce avoidable harm. Web: www.patientrack.com Email: info@patientrack.com Tel: +44 1749 685 238