1. 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

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

3. 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

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

5. 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

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

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

8. 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

9. 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

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

11. 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

12. ‘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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

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