Download - AKI - Secondary care considerations
![Page 1: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/1.jpg)
Dr Richard Fluck National Clinical Director (Renal)
Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury
Secondary care considerations
![Page 2: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/2.jpg)
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 2
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.
![Page 3: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/3.jpg)
KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney International Supplement 2012; 2(1): 1-138
How is AKI defined?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 3
![Page 4: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/4.jpg)
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 4
![Page 5: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/5.jpg)
Who is most at risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 5
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?
![Page 6: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/6.jpg)
| 6
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
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 7: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/7.jpg)
| 7
Mortality with AKI stage
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 8: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/8.jpg)
| 8
NCEPOD report published in 2009
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Poor assessment of risk factors for AKI and acute illness
Delays in recognising AKI
Most patients with AKI are not cared for by nephrologists
Most patients with AKI are not cared for by nephrologist
‘Good’ care in <50% cases
![Page 9: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/9.jpg)
| 9
Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
For George, his risk of death is 32.2%
For Julia, her risk of death is 53.1%
![Page 10: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/10.jpg)
| 10
Who is at greatest risk?
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 11: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/11.jpg)
Our shared purpose: reduce harm related to AKI
Who is at risk?
When do people sustain AKI?
How should patients with AKI be
managed?
What do people need to know?
| 11The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 12: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/12.jpg)
Understanding RiskVulnerability
A fixed set of characteristics – e.g. age, comorbidities including CKDs, diabetes, drugs
TriggerAn event that might precipitate AKI, e.g. surgery, sepsis
ResponseMitigating the risk e.g. sick days rules, monitoring
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 12
![Page 13: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/13.jpg)
The vulnerable populationFixed factors
The elderly
The frail
Existing comorbidities
Chronic kidney disease
Previous history of acute kidney injury
Modifiable risk factors
Drugs
NSAID – auto-regulation
Diuretics – volume status
ACEi/ARB and other BP targeted medications – BP and auto-regulation
Metformin – side effects enhanced
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 13
![Page 14: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/14.jpg)
Reducing risk: Sick day guidance (a.k.a rules)
Previous history of acute kidney injury
Bristol CLAHRC undertaking formal evidence review
Plan to use this to build consensus with other stakeholders e.g. British Hypertension Society, British Society for Heart Failure
Interim position statement prepared for Think Kidneys website - bit.ly/TK-Sick-Day-Rules
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 14
![Page 15: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/15.jpg)
Improving diagnosis: using changes in serum creatinine
Laboratory definition and standardisation
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 15
![Page 16: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/16.jpg)
National Algorithm
Based in LIMS
Compares serial creatinine measures
| 16The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 17: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/17.jpg)
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
17
![Page 18: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/18.jpg)
Is it enough to do a test?
| 18The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
In conclusion, this randomised, controlled study did not show a meaningful benefit of an electronic alert system for acute kidney injury in patients in hospital.
![Page 19: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/19.jpg)
| 19
Detect Alert
Lets talk about ‘alerts’
Respond
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 20: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/20.jpg)
| 20
Care bundles and response
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
![Page 21: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/21.jpg)
STOP-AKI Aintree University Hospital, Liverpool
| 21The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Change package
Automated test-alert
Care bundle
Education package
Results
Mortality reduced from 26% to 19%
Length of stay reduced by 2.7 days
Chong et al ASN November 2015
Abstract presentation
![Page 22: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/22.jpg)
The national CQUIN and recovery
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 22
Year 1
Discharge communication
Communication of AKI
Need for follow up
Medications
Why?
High readmission rates
Primary care knowledge
Future risk
Medicines management
![Page 23: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/23.jpg)
The impact of AKI on people with diabetes
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 23
Clin J Am Soc Nephrol. 2011 Nov;6(11):2567-72. doi: 10.2215/CJN.01120211. CV1, Christianson A, Himmelfarb J, Leonard AC.
![Page 24: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/24.jpg)
‘AKI warning stage’
Patient management
system
Alert Response
Local systems
MessageMaster patient index
Other data systems
AKI Registry
RegionalNational Research
QI
System Measurement
24
![Page 25: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/25.jpg)
SummaryAKI is:
Common1 in 5 of all emergency
admissions2/3 starts in the community
CostlyIt increases the risk of death and harmIt costs resources
TreatableEducationEarly detectionBetter intervention
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 25
![Page 26: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/26.jpg)
www.linkedin.com/company/think-kidneys
www.twitter.com/ThinkKidneys
www.facebook.com/thinkkidneys
www.youtube.com/user/thinkkidneys
www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk
Acknowledgements
| 26The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations
Joan RussellHead of Patient SafetyNHS [email protected]
Ron CullenDirectorUK Renal [email protected]
Karen ThomasThink Kidneys Programme ManagerUK Renal [email protected]
Annie TaylorCommunications Consultant to the Acute Kidney Injury National [email protected]
The chairs, co-chairs and teams of all the workstreams in ‘Think Kidneys’
![Page 27: AKI - Secondary care considerations](https://reader035.vdocument.in/reader035/viewer/2022070517/58d0ccfc1a28ab866c8b6707/html5/thumbnails/27.jpg)
The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 27