A Before and After Study to evaluate Acute Kidney Injury Outreach – preliminary results and two-year followup of a Complex Multifactorial Intervention Mark Thomas, Cathy Hatton, Carol Willis and Jyoti Baharani.

Declaration I have attended unpaid advisory boards and user groups run by Sunquest International.

Alert studies OBSERVATIONAL AUDIT 17 th Sept to 17 th Dec 2008 BEFORE STUDY OBSERVATIONAL 15 TH May to 12 th June weeks AFTER STUDY – SERVICE EVALUATION 12 TH June to 31 st July weeks 463 first Alerts in adults in study period61% 176 Alerts from dialysis patients 23% 52 repeat Alerts for same patient7% 21 Alerts from patients already on dialysis3% 411 first Alerts in adults in study period66% 144 Alerts from dialysis patients 23% 20 repeat Alerts for same patient3% 15 Alerts from patients already on dialysis2% Small numbers of Alerts with/in: CKD – no clear ACKD; Children under 16 years Alerts with suppressed low Creatinine; Poor data Thomas, Sitch and Dowswell Nephrol Dial Transplant 2011

BEFORE AND AFTER STUDY Alert messaging system set up on ICE Laboratory Information System – Sunquest Information Systems Inc. AKI Alerts – Creatinine rises of ≥ 75% from the last value notified to a messaging inbox Before phase: ‘Usual care’158 patients – Alerts collected without intervention – Referrals received as usual After phase:253 patients – Alerts reviewed early morning and late afternoon, five days a week – A Nephrology nurse or doctor discussed patient with any available primary clinician – Case details and recommendations recorded using standard proforma and faxed (when possible) According to National Research Ethics Service procedures, the project was classified as a service evaluation by the Heart of England NHS Trust Research and Development office and did not require separate ethical approval.

After study – service evaluation AFTER STUDY – SERVICE EVALUATION 12 TH June to 31 st July eligible Alerts Included in service evaluation 253 patients 1 st episode of AKI Eligible for survival analysis ≥ 2 nd AKI episodes in 9 patients Excluded from survival analysis Results of service evaluation 262 potential calls

After study: Outcome of Outreach Call successful in 89.7% (median 14.6h)235 – fully successful225 – partial success8 – referred and seen as a result of call2 No call / call unsuccessful in 10.3%27 – Patient deceased by time of call12 – Insufficient time8 – Could not contact / Call declined 7 Median of 3 recommendations (for all 262 Alerts)

Non Drug recommendations ‘Investigational’ recommendations306 – including urine dipstick, recheck of U&E, other Volume status related recommendations151 – including clinical reassessment; catheterisation – including advice on fluid prescription Care pathway recommendations45 – medical review, admission, appropriate transfer General medical recommendations38 – typically about underlying conditions Escalation / palliative care recommendations16

Drug recommendations Drugs stopped as potentially contributing to AKI ACE inhibitor / ARB60 Aspirin30 Diuretic (non K sparing)21 NSAID19 Other hypotensive 18 K sparing diuretic13 Aminoglycoside4 Aciclovir3 Other (incl. NSAID gel, CNI)7 Drugs stopped / reduced to avoid adverse events LMW heparin19 Metformin10 Hartmann’s 2 Reduced opiate dose8 Drugs recommended to be avoided Avoid contrast6 Avoid NSAID2 Total of :222 drug recommendations made In addition to: 64 similar actions taken by primary team before call

Conclusions A modest time input (15-20 hr per week) resulted in large scale changes to care of AKI patients Consistent 6-8% absolute survival benefit appeared rapidly and was maintained Further work needed on peak creatinine, dialysis usage, multivariate adjustment of survival analysis Further studies of the Alert + Outreach approach are clearly warranted

Thanks to colleagues Angela Price Annette Dodds Carl Richardson Carol Willis Cathy HattonClive Allen Harry NairIndranil Dasgupta Joanne WalkerJyoti Baharani Karen HarrisLisa Tebbit Lynette Groombridge Lynn Ivison Roger Adkins Sarah Powers Sharon DeakinSteve Smith Steven Ting Tami Stevenson Trudy Manji Vijay Suresh