National Clinical Director (Renal) Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury Where have we got? Dr Richard Fluck National Clinical Director (Renal) NHS England richard.fluck@nhs.net

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. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

How is AKI defined? KDIGO Clinical Practice Guideline for Acute Kidney Injury Kidney International Supplement 2012; 2(1): 1-138 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

Who is most at risk? 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? The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

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

Mortality with AKI stage The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

NCEPOD report published in 2009 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 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% Who is at greatest risk? For George, his risk of death is 32.2% For Julia, her risk of death is 53.1% The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

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

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? The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

‘Think Kidneys’ AKI Programme The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

Understanding Risk Vulnerability A fixed set of characteristics – e.g. age, comorbidities including CKDs, diabetes, drugs Trigger An event that might precipitate AKI, e.g. surgery, sepsis Response Mitigating 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

The vulnerable population Fixed factors Modifiable risk factors The elderly Drugs The frail NSAID – auto-regulation Existing comorbidities Diuretics – volume status Chronic kidney disease ACEi/ARB and other BP targeted medications – BP and auto-regulation Previous history of acute kidney injury Metformin – side effects enhanced The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

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

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

National Algorithm Based in LIMS Compares serial creatinine measures The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

Is it enough to do a test? 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. The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

Lets talk about ‘alerts’ Detect Alert Respond The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

Care bundles and response The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

STOP-AKI Aintree University Hospital, Liverpool 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 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

The national CQUIN and recovery Year 1 Discharge communication Communication of AKI Need for follow up Medications Why? High readmission rates Primary care knowledge Future risk Medicines management The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

Patient management system System Measurement Message Master patient index Regional National Research AKI Registry Patient management system ‘AKI warning stage’ QI Local systems Other data systems Alert Response

Uptake of LIMS algorithm across England to date The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care

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 Primary care Secondary care The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

Engaging with safety and improvement partners Patient Safety Collaboratives The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care Focused on: Who: who is at risk, vulnerable population, important triggers When: when do people sustain AKI, how is early diagnosis supported How: how should AKI be managed, prevention+treatment+recovery What: what do people need to know, public patients/carers, professionals

Summary AKI is: Common Treatable 1 in 5 of all emergency admissions Education Early detection 2/3 starts in the community Better intervention Costly It increases the risk of death and harm It costs resources The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

Summary: a improvement project Think Kidneys Has delivered system levers Providing a framework for action Raised the profile It is supportive of other change agents The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care

Acknowledgements Joan Russell Head of Patient Safety NHS England joan.russell@nhs.net Ron Cullen Director UK Renal Registry Ron.Cullen@renalregistry.nhs.uk Karen Thomas Think Kidneys Programme Manager UK Renal Registry Karen.Thomas@renalregistry.nhs.uk Annie Taylor Communications Consultant to the Acute Kidney Injury National Programme anniemtaylor331@gmail.com The chairs, co-chairs and teams of all the workstreams in ‘Think Kidneys’ 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 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations