involving care homes in think kidneys
TRANSCRIPT
Programme for the day10:00 Welcome, housekeeping and plan for the day
10:10 Understanding the care home environment and setting the scene for change
10:40 The only way is Essex!
11:00 Think Kidneys National Programme – about acute kidney injury
11:30 Qs & As
11:55 Coffee break
12:05 How working with care homes could change the status quo – risk, prevention & care
12:15 Group work 1 – Learning about the care home environment – challenges and influences
13:00 Lunch
13:45 Getting it right for Nellie
14:15 Group work 2 – Resources, engagement and what’s needed
15:00 Qs & As and comments
15:15 Summary of the day and an action plan
Promoting Quality of Life in Care Homes
My Home Life
www.myhomelife.org.uk
Professor Julienne Meyer CBE
Promoting Quality of Life in Care Homes
So...what do we think about care
homes?
•Scandals?
•Poor quality?
•Money-grabbing?
•Undesirable?
•Less relevant?
•In decline?
Promoting Quality of Life in Care Homes
Older people in care homes • 17, 678 care homes in UK
• 78% privately owned
• 405,000 older people (>65yr)
• Average age 85 years
• 80% cognitive impairment
• 40% depression
• 75% severely disabled
• Going into care later, sicker and more frail
• Median period (admission to death) is 15
months
Age UK (2015)
Promoting Quality of Life in Care Homes
Workforce• ½ million employed in care
homes
• Care-assistants less than
living wage
• Lack of funding for training
• Paid less than those looking
after our rubbish
• 66% NVQ2 (4 or 5 GCSEs)
• 39% feel unappreciated by
public
Promoting Quality of Life in Care Homes
“Islands of the old”
• Unsupported, isolated, mistrusted
• Feeding the system rather than
feeding residents!
• High levels of personal stress
Promoting Quality of Life in Care Homes
Understand context, Value & respect• >3x number of care home beds, compared with NHS beds
• Caring for some of the most vulnerable citizens in society
• Making a significant contribution to care of frail older
people in our society. Projected to increase, not decrease.
• Care homes not paid the fair rate for care by LAs and
most care home staff on minimum wage (undervalued)
• <25% registered for nursing (mainly social care workforce)
• Residents going in later with more health problems
• Workforce needs healthcare training and/or better access
to health expertise
Promoting Quality of Life in Care Homes
Common conditions(BUPA/CPA 2011)
• Neuro condition or mental disorder (75%)
– Dementia (44%),
– Stroke (20%),
– Depression (20%),
– Epilepsy (6%)
– Parkinson’s disease (5%)
• Heart disease (21%),
• Arthritis (18%),
• Diabetes (14%),
• Fractures (12%),
• Osteoporosis (9%),
• Lung or chest disease (8%)
• Cancer (7%).
Promoting Quality of Life in Care Homes
Need for Formative Care
“For many residents, the optimum approach is that of end of life care, not conventional long-term
condition management.” BGS (2011)
• Dependent ‘dwindling’ older people not well served by the existing medical approaches.
• ‘Social watersheds’ may provide triggers for Formative Care
• Optimising of quality of life and experience (prime purpose)
• Target population (trajectory and social transitions)
• Little evidence at present (more research)
• Implementation of electronic care records and standardised assessment processes (helpful)
Bowman and Meyer, J (2014)
Promoting Quality of Life in Care Homes
Examining Renal Patients’ Death Trajectories without Dialysis
• Trajectories for stage-5 CKD
– Predictable uraemic death
– Predictable death from other causes
– Unpredictable death
• Issues of concern
• Difficulties in managing the unknown
• Number of healthcare professionals involved
• Heavy symptom burden
• Lack of professional knowledge (hard for family)
• Pressures brought to bear on families caring
Noble et al (2010)
Promoting Quality of Life in Care Homes
Quest for Quality• A health service suitable for the
specific needs of this population.
• The residents and their relatives
must be at the centre of decisions
about care.
• A multi-disciplinary approach.
• A partnership approach with care
homes and social care
professionals.
Promoting Quality of Life in Care Homes
Explaining the barriers to and tensions in delivering effective
healthcare in UK care homes
• Older people are very complicated
• Trajectories are difficult to predict
• Don’t have the training
• Resources are tight
• Regulation is always present
• Roles and responsibilities aren’t clear
• Communication is a problem
Robbins et al (2013)
Promoting Quality of Life in Care Homes
Provision of NHS generalist and specialist services to care homes in
England: review of surveys
• GP:Care Home ratio varies between 30:1 and 1:1
• Some GPs do weekly clinics, while others visited only on request
• Up to 8 different types of nurses provide in-reach services
• 25% of trusts report unequal access to physiotherapy and occupational
therapy
• 35% report unequal access to district nursing
Iliffe et al (2015)
Promoting Quality of Life in Care Homes
Relationships, Expertise, Incentives, and Governance:
Supporting Care Home Residents’ Access to Health
Care: An Interview Study from England
Solutions have focused around:
– Remuneration – carrot
– Regulation – stick
– Parachuting in troops
– Generating social movements
Goodman et al (2015)
Promoting Quality of Life in Care Homes
• Comprehensive assessment of new residents
• Recognise end of life & plan/support
• Structured 6 monthly multidimensional review (earlier if indicated)
• Including medication review
• Including risk assessments (e.g. falls, nutrition)
• Advance care plan for acute events/end of life
• Reliable systems to support telephone consultations and out of hours events
• Regular scheduled visits by GP/Specialist Nurse, Geriatrician to Review targeted residents
• Clarification of referral pathways and response times for specialist services
• Enhanced clinical interventions e.g. fluids, IVs, palliation
• Robust interagency, interdisciplinary governance
Promoting Quality of Life in Care Homes
5 New Care Models
• Multispeciality community Providers
• Integrated primary and acute care
systems
• Urgent and emergency care
• Acute care collaboration
• Enhanced health in care homes
– NHS Wakefield CCG
– Newcastle Gateshead Alliance
– East and North Hertfordshire CCG
– Nottingham City CCG
– Sutton CCG
– Airedale NHS FT
Promoting Quality of Life in Care Homes
MHL Mission
Promoting quality of
life for those living,
dying, visiting and
working in care
homes for older
people.
Promoting Quality of Life in Care Homes
SupportAge UK, City University, Joseph Rowntree & Dementia UK
Other key organisations:
Relatives & Residents Association
National Care Forum
English Community Care Association
National Care Association
Registered Nursing Home Association
Care Forum Wales
Scottish Care
Independent Health & Care Providers
National Care Home R&D Forum
Promoting Quality of Life in Care Homes
Phases of My Home Life
Phase One: Vision
(2005-7: HtA)
Phase 2: Dissemination
(2007-9: BUPA)
Phase 3: Implementation
(2009-13: JRF, DH, LA,
City Bridge etc)
Phase 4: Sustainability
(2013-19: Age UK, Henry Smith)
Promoting Quality of Life in Care Homes
Began small, now social movement
Secret of success?
• Evidence-based
• Relationship-centred
• Appreciative
• Making a difference
Promoting Quality of Life in Care Homes
New online tool
• Providers will also be able to
add flags to their individual
Provider Quality Profile (PQP) to
show they have adopted
recognised quality schemes
such as My Home Life, the new
NICE social care quality
standards and the Dementia
Care and Support Compact.
https://www.gov.uk/government/news/new-online-tool-to-search-and-
compare-local-care-providers
Promoting Quality of Life in Care Homes
What we know residents, relatives and staff ‘want’ and
‘what works’ in LTCNeed shared evidence-
based and relationship-
centred vision that cuts
across:
– health & social care
– policy & practice
– regulation &
commissioning
– public & private
– NCHR&D (2007)
Promoting Quality of Life in Care Homes
Relationship-centred Care
Security: to feel safe
Belonging: to feel part of things
Continuity: to experience links and
connections
Purpose: to have a goal(s) to aspire
to
Achievement: to make progress
towards these goals
Significance: to feel that you matter
as a person
Nolan et al (2006)
Positive relationships between residents,
relatives and staff and between care
homes and their local community and
wider health and social care system
Promoting Quality of Life in Care Homes
MHL Leadership Support & Community
Development (LSCD) programme
Leadership and Support for care home managers to take forward quality improvement (4 day work shop, supported by action learning for one year)
Community Development for LAs/CCGs to work in better partnership with care homes (understand context, value & respect, resolve local issue)
Supportive network for care homes to share best practice and learn from each other (reduce ‘islands of the old’)
Promoting Quality of Life in Care Homes
My Home Life:
Promoting quality of life in care homes
• Positive relationships (voice, choice
and control)
• Pivotal role of care home managers
(ongoing support)
• Consider our own attitudes, practices
and policies (reduce capacity to care)
• Stronger partnership working (agree a
vision & supportive ways of working)
• Negative press (impact on confidence)
Promoting Quality of Life in Care Homes
Commissioning Relationship-Centred Care
• Essex CC has shifted its
commissioning approach from top-
down monitoring, inspection and
regulations to one that builds
relationships, invests in the
development of care home staff and
instils a shared vision for care and
support for older people
(www.myhomelifeessex.org.uk)
Promoting Quality of Life in Care Homes
My Home Life Admiral Nurse
• Improved quality of care and well
being
• Increased staff knowledge, skills and
confidence
• Enhanced relationships between
residents, relatives and staff
• More with care home as option for
care
Promoting Quality of Life in Care Homes
The future...•Vital part of care spectrum
•Demand increasing (40,000
beds needed in next ten years)
•Greater specialism
•Reducing pressure on NHS
•A sector that is emerging as
having the potential to deliver
quality for our frailest citizens in
community and in care homes
Promoting Quality of Life in Care Homes
References• Age UK (2015) Later Life in the United Kingdom. London: Age UK
• BGS (2011) Quest for Quality British Geriatrics Society. British Geriatrics Society Joint Working Party Inquiry into the Quality of
Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement. BGS: London
• BUPA/CPA (2011) The Changing Role of Care Homes. Centre for Policy on Ageing: London.
• Noble H, Meyer J, Bridges J, Kelly D, Johnson B (2010) Examining renal patients' death trajectories without dialysis, End of Life Care,
4(2)26-34,
• Goodman C, Davies S L , Gordon A L , Meyer J, Dening T, Gladman JRF, Iliffe S, Zubair M, Bowman C, Victor C, Martin F C (2015)
Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents' Access to Health Care. An Interview Study
From England. Journal of the American Medical Directors Association 02/2015; DOI:10.1016/j.jamda.2015.01.072 ·
• Goodman, C; Davies, L; Gordon A L; Meyer, J; Dening, T; Gladman, JRF; Iliffe, S; Zubair, Bowman, C; Victor, C; Martin FC
(accepted) Supporting care home residents’ access to health care what works when in what circumstances: An interview study from
England JAMDA
Promoting Quality of Life in Care Homes
Contact DetailsProfessor Julienne Meyer
My Home Life
City University London
Adult Years Division
School of Health Sciences
Northampton SquareEC1V 0HB, London, UK
Tel: +44 (0)20 7040 5776
Email: [email protected]
www.myhomelife.org.uk
www.city.ac.uk/dignityincare
www.city.ac.uk/bpop
Prosper
Promoting Safer Provision of Care for Elderly Residents
36
• Funded by The Health Foundation - Closing the Gap in Patient Safety
• First time a Social Care scheme has been chosen
• Essex County Council & UCLPartners working in partnership with Essex
Residential Care & Nursing homes
• Overarching aim to reduce the number of emergency hospital admissions
• Focus on Prevention - reducing the prevalence of falls, pressure ulcers
and Urinary Tract infections across care homes.
• 38 homes involved, with another 25 homes starting June 2015
Prosper Methodology
37
• Building staff capability through education in quality improvement methodologies – PDSA cycles (plan do study act) of small tests of change for continuous improvement
• Using data measurement over time to inform improvement cycles –moving homes away from feeling that data is only used for negative reasons
• Changing staff culture & behaviour on safety from being reactive to proactive & preventative
38
Outcome/Aim Primary Driver Secondary Driver
To achieve a 50%
reduction of UTI’s by
December 2015
Risk Identification
Risk Assessment
Reliable implementation of
Infection Prevention & Control procedures
Nutrition & Hydration
Education/Training
Understand UTI risk factors
Understand resident history, medical condition, cognitive impairment, invasive devices.
Utilise Safety Handovers/Safety Huddles
Assess UTI risk on admission
Reassess regularly / when a change in condition
Communicate risk status to resident, staff and families
Incident Reporting / RCA
Reinforce the use of Infection prevention and control procedures
Reinforce hand washing techniques
Reinforce use of PPE
Introduce Nutrition and Hydration tool’s
Utilise DN’s, dietician and specialist nurse experience
Introduce visual cues to raise Staff awareness
Increase nutritional intake – shakes/grazing station
Staff education & training – IP&C, GULP tool
Resident & family/carer education
Utilise ‘How to guides’
Review and monitoring
Management of catheter & continence procedures
Infection control Champion
Audit checks ,monitoring of competency
40
Check for Urine Infection
If concerned call
the Community
Matron:
Check urine colour
Good
Good
Dark
Dark
If urine is dark –
give extra fluids.
Check for bowels
open
Are any of these symptoms
present?
Urgent need to pass
urine/ incontinent
when not usually
Confused
more than usual
when not usually
Feeling feverish and
unwell
Low tummy or
suprapubic pain
Prolonged contact with urine
can encourage urine infection.
Therefore, it is important to
ensure that Incontinence Pads
are changed in a timely way
Clients with urinary
catheters are likely to
have bacteria in their
urine – encourage fluids
If symptoms present
Implementation
42
• Good Slipper guides at pre-assessment
• On spot debriefs• SBAR
• Prosper Champions
• Safety Cross
• Falls checklists
• Medication Reviews
Results – One Year On
45
• Interim evaluation has reported a change in staff culture across all 38 homes participating to date.
• Improved data recording, capturing information previously not recorded – Falls, UTI’s, pressure ulcers, hospital admissions
• Homes are using data to inform proactive approaches to prevention
• No statistical significant change at this stage –challenges in collecting historical data
By Products
46
• Integrated working between Health, Social Care and Care Homes
• Training
• Linking projects
• Community of Practice/Network meetings
• Consistent approach across CCG boundaries
• Influencing future commissioning
Prosper
47
Contact details;
Lesley Cruickshank
Prosper Project lead
07557 081571
Kieran Attreed-James
07557168059
Acute Kidney Injury (AKI)
Keeping kidneys healthy:
The AKI programme boardDr Richard Fluck
National Clinical Director (Renal) NHS England
What do they do?Public 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
– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al
The challenge
Risks to the kidney
68% alcohol53% dehydration22% medications1% smoking
– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 50
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 51
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.
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 53
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
1911-1986
AKI Harmful? Who is most at risk?
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21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 55
‘40000 excess deaths pa’ (Kerr et al April 2014)
‘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 | 57
‘Think Kidneys’ AKI Programme
The NHS campaign to improve the care of people at risk of or with, acute kidney injury| 58
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 | 59
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
How
• How should AKI be managed? How does that look in primary and secondary care?
• Prevention
• Treatment
• Recovery
What
• What do people need to know?
• Education for the public
• Education for patients and carers
• Education for professionals
Risk
VulnerabilityA fixed set of characteristics – e.g. age, co-morbidities including
CKDs, drugs
TriggerAn event that might precipitate AKI, e.g. surgery, sepsis
ResponseMitigating the risk e.g. sick days rules, monitoring
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 63
Method by which NHS can rapidly alert the healthcare system to
patient safety risks, or to provide guidance on preventing harm
What are NHS patient safety alerts?
Level 3:
Directive: requires specific action(s) within timeframe
Level 2:
Specific resource and information sharing
Level 1:
Warning of emerging risk
| 67The NHS campaign to improve the care of people at risk of or with, acute kidney injury
21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 68
Care bundles and response
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Influencing the System: Levers
Safety collaboratives: AHSN/SCNSign up for safetyHealth Foundation
Forward view: into action 2015/16NHS 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.
‘AKI warning stage’
Patient management
system
Alert Response
Local systems
Message
Master patient index
Other data systems
AKI Registry
RegionalNational Research
QI
Measurement
The pathway and commissioning levers
Risk assessment
• CQUIN in test in SDH
Improved diagnosis
• Safety alert NHS England
Treatment
• NICE guidance
• Care bundles
Recovery
• National CQUIN
Secondary care
Primary care
The ask for you
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 72
2/3 of AKI starts in the community
How do we help you understand the vulnerability of your clients?
What education do you need?
What interventions can we support you with?
What are the practicalities
Summary
AKI is
Common
• 1 in 5 of all emergency admissions
• 2/3 starts in the community
It is costly
• It increases the risk of death and harm
• It costs resources
It is treatable
• Education• Early detection
• Better intervention
Karen ThomasThink Kidneys Programme ManagerUK Renal [email protected]
Teresa WallaceThink Kidneys Programme CoordinatorUK Renal [email protected]
The chairs and co-chairs of all the workstreams in ‘Think Kidneys’
Joan RussellHead of Patient SafetyNHS [email protected]
Ron CullenDirectorUK Renal [email protected]
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
The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 74
Richard John Parfitt
Born 1948
Smoked 1966-2014
Excess alcohol (and other substances)
Three myocardial infarctions (quadruple bypass 1997, stent 2011 and 2014)
But still performing
Ageing population
432,000 in care homes
The largest number of practices visiting one care home was 30.
Some GPs did weekly clinics, while others visited only on request.
Up to eight different types of nurses providing in-reach services, with multiple different nurses often providing in-reach to the same home.
Risk, Prevention and Care
Drugs
Prescribing in care homes is a particular area of concern.
The Care Home Use of Medicines study:
256 residents across 55 homes
69.5% of residents to be subject to one or more error
mean of 1.9 errors per participant
Risk Factors
Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria
Age >75 years
Heart failure
Liver disease
Cardiovascular disease (previous MI, stroke, PVD)
Diabetes mellitus
Recent use of nephrotoxins, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers
Risk Factors
Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria
Age >75 years
Heart failure
Liver disease
Cardiovascular disease (previous MI, stroke, PVD)
Diabetes mellitus
Recent use of ‘nephrotoxins’, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, diuretics
Acute Risks
Hypotension
Sepsis
Dehydration
Diarrhoea
Decreased intake (acute illness, cognitive impairment)
High urinary output (Cf CKD, Diabetes)
Prevention
Identify patients at risk
Optimise volume status especially when losing excess (diarrhoea, heat etc)
Treat infection promptly
Avoid nephrotoxins if better alternatives
NSAIDs + ACEI bad combination
Review medications,e.g. adjust drug doses, withhold antihypertensives if hypotensive
Summary
Care home residents are a special case. They represent the most frail, most dependent, most vulnerable members of our society
Prevailing models of care and routine practice have been demonstrated to be inadequate to meet their needs.
How should we modify the system to diminish the risk from AKI?
Group work 1 – Nesta Hawker
Learning from you about the care and nursing home environment – challenges and influences
1. What motivates / influences change in clinical/care
practice?
2. What are the greatest challenges you face in care
homes?
30 mins + 15 mins feedback
Background
GP partner in Birmingham
GP Trainer/Appraiser
Honorary Clinical Lecturer, University of Birmingham
NICE Acute Kidney Injury, GDG member
Think Kidneys Intervention work-stream member
NHS England: working group member of discharge standards
Macmillan GP Facilitator
Causes of AKI
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
Marjory aged 83 Group 2
Lives in a N/HHas dementia, heart disease, diabetesWhat can you do to damage her kidneys?
Marjory aged 83 Group 3
Lives in a R/HShe feels unwell with urinary symptoms and feverWhat can you and she do to damage her kidneys?
Marjory aged 83 Group 5
Lives in a N/HOff her food/drink10 different tablets
Lithium/Ramipril/ Spironolactone/Metformin/ Ibuprofen
What can you do to damage her kidneys?
How to damage Marjory’s kidneys
Group 1: R/H: Age 83 what can she do?
Group 2: N/H: dementia, heart disease, diabetes
Group 3: R/H: Unwell and UTI
Group 4: N/H and “tummy bug”
Group 5: R/H: “off food/drink”, on lots of tablets
Get older!!
Pick and eat wild mushrooms
Get fat and diabetic
Eat salt and get hypertension
Eat liquorice and raise BP
Take OTC aspirin-paracetamol combination and get
analgesic nephropathy
Take OTC ibuprofen and have 3x risk AKI
Smoke and have renal arterial disease
Take too much alcohol and raise her BP
Develop renal stones with high protein diet or spinach,
nuts and rhubarb increasing oxalate levels
Take large quantities of osmotic laxatives
Marjory Aged 83 Group1
Marjory Aged 83 Group 2
Do not check BPUnhealthy and fatty dietFluid restrictDo not register with GPDo not access GP/OOHNo blood testsMiss off tablets
Marjory Aged 83 Group 3
Do not speak to her
Ask her NOT to drink fluids
Give her ibuprofen
Do not inform GP/OOH
Tell her that she will be fine after a few days
Marjory Aged 83 Group 3
Not drinking risks pre renal damage
Delayed treatment risks pyelonephritis
Risk of glomerular damage with penicillins and sulphonamides
Risk of tubular damage with aminoglycosides
Risk of post renal damge with crystals in urine with high dose sulphonamides
Risks of AKI with NSAID used as analgesics
Risk of toxicity with nitrofuratoin eGFR<60
Marjory Aged 83 Group 4
Fluid restrict herGive ibuprofenGive her extra medsDo not inform seniorDo not inform GP/OOHDo not isolate
Marjory Aged 83 Group 5
Do no talk to her
Keep her isolated
Do not encourage her to eat/drink
Do not ask her how she is feeling?
Continue all medication
Do not inform senior/GP/OOH
SAD MAN
Sulphonylureas e.g. gliclazide
ACE and ARB e.g. ramipril/losartan
Diuretics e.g. furosemide
Metformin
Aldosterone antagonists e.g. spironolactone
NSAID e.g. ibuprofen, naproxen
CKD and NSAID: renal risk
NSAID impact kidney function in at least 8 ways ( R Fluck)
Prostaglandins are important to maintain perfusion within the kidney
Block of prostaglandins reduces renal blood flow with fluid retention, increased creatinine and potassium
Acute use reversible fall in GFR
Chronic use linked with hypertension and CKD progression
RECOMMEND annual U and E and BP with NSAID
RECOMMEND avoid NSAID with ACE/ARB and diuretic combination
Potential causes of AKI in Marjory
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
Real Primary CareGetting it right for Nellie age 84 (1)
R/H
Exercise and healthy diet, fluid intake
Non-smoker
Alcohol Xmas
Regular medication
BP/cholesterol ok
Seen by GP every 6 months
Nellie aged 84 (2)
Dementia, Diabetes, Heart Disease
N/H
Caring environment
Regular medication
Healthy diet/fluids
GP ward rounds
Good BP control/lipids ok/HbA1c ok
Lives in R/H
Suspected UTI
Encourage fluids
GP informed (or OOH)
Antibiotics
MSU sent
Script/meds collected same day, Rx started
Feels much better 48 hrs
Nellie aged 84 (3)
Lives in N/H
“tummy bug”
Encourage fluids
Light diet
Advice from GP
Sick day rules
Likely viral gastroenteritis
Settled after 72 hours
Nellie aged 84 (4)
Lives in a N/H
Off her food/drinks
10 different tablets
Lithium/Ramipril/Spironolactone/Metformin/Ibuprofen
Speak to her
Encourage fluids/food
Inform senior/GP/OOH
Depression
Reviewed and treated
Nellie aged 84 (5)
AKI - Acute Kidney Injury
AKI Stage Serum creatinine Urine output
Stage 1 Increase of more than or equal to
26.5 umol/l or increase of 150-200%
from baseline
Less than 0.5ml/kg/h for
more than 6 hours
Stage 2 Increase of 200-300% from baseline
i.e. 2-3 fold
Less than 0.5ml/kg/h for
more than 12 hours
Stage 3 Increase to more than 300% i.e.3 fold
increase from baseline or more than
354 umol/l
Less than 0.3ml/kg/h for
more than 24 hours. Or
anuria for 12 hours
Causes of AKI
Exposures Susceptibilities
Sepsis Dehydration or volume depletion
Critical illness Advanced age
Circulatory shock Female gender
Burns Black race
Trauma CKD
Cardiac surgery especially bypass Chronic heart, lung or liver disease
Major surgery Diabetes mellitus
Nephrotoxic drugs Cancer
Radiocontrast agents Anaemia
Poisonous plants and animals
119
The primary aim ofThink Kidneys is to ensure
avoidable harm relatedto acute kidney injury is
prevented in all care settings
Thank you
Group work 2 with Nesta Hawker
1. What resources do care home staff need to help them
manage acute kidney injury?
2. How do we engage and educate staff?
3. What do you need from the Think Kidneys programme?
30m + 15m feedback
08/07/2015 123
The clever (academic) approach
Build a blender with rubber blades.Install a kitten detector
The simple (implementation) approach
Don’t stick a kitten in a blenderDon’t press the start button if you see a
kitten in the blender
What you might need
A chart to help you tell the difference between a kitten and food
Education