1. Acute Kidney Injury: The Wessex Experience Mark Uniacke Consultant in Renal and Transplantation Wessex Kidney Centre Chair Wessex AKI Clinical Forum Wessex Strategic Clinical Network

3. Outline  AKI is everyone’s business.  The Challenge.  The Wessex AKI Clinical Forum.  The impact.  The Future.

4. AKI is everyone’s business

5. Distribution of AKI episodes across acute specialties, stratified by AKI stage. Selby N M et al. CJASN 2012;7:533-540

6. AKI is not just a hospital concern Portsmouth data: 375 prospectively acquired AKI cases (2010/2011) AKI was found on admission and hence community acquired in 68% - community AKI was more severe by staging - sepsis was an important trigger In those without CKD at baseline community acquired AKI was associated with a higher hospital and 6 month mortality (OR 3.5, 95% C.I. 1.135 – 10.6, p=.03)

7. The challenge

8. Community Hospital Community - acquired AKI Predisposing factors e.g. CKD, ACE inhibitors, diuretics, BPH Protective factors e.g. Vaccination, hydration, antibiotics Precipitating factors Pre-renal: e.g. D+V, sepsis, trauma, GI blood loss Renal: glomerulonephritis Post-renal: obstruction Elective hospital admission Other condition requiring hospital admission - no AKI on admission Hospital discharge Predisposing factors e.g. CKD, cardiac surgery Protective factors e.g. good fluid balance Precipitating factors Pre-renal: e.g. hypovolaemia, sepsis Renal: e.g. nephrotoxic drugs, contrast Post-renal: e.g. obstruction Hospital - acquired AKI Community - acquired AKI in hospital Emergency hospital admission Consequences Longer length of stay Renal replacement therapy Death Costs Consequences New or worse CKD Chronic renal replacement therapy Medication change Rehab/Nursing Home Death Costs Risk of recurrent AKITotal AKI in hospital

9. The Whole Pathway Guidelines Nephrology Referral Care Bundles Research Education eAlerts Biomarkers Prevention Sick Day Rules Follow up after discharge The Patient

10. “Physicians are people who pour medicine, of which they know very little, into people of whom they know less” Voltaire 18 th Century ‘What does it take to be good at something in which failure can be so easy, so effortless?’ Atul Gawande 2007

11. AKI is not about bad doctors and nurses AKI is a patient safety issue but it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions Acute Kidney Injury National Programme

12. 2.8 million population 7 Acute Trusts 9 CCGs 3 Community Trusts Two regional renal units

13. Wessex AKI Clinical Forum

14. AKI Network Forum Wessex SCN Regional AKI Leads Local Renal Units Wessex/Dorset Local Trust Leads Renal ITU MAU

15. The Forum Nephrologists NHS England SCN manager Trust AKI leads – currently 6 CCG representatives Public Health Consultant Laboratory Lead Nurse specialist University of Southampton – Wessex CLARCH and HHR AHSN representative Acute Medicine/Renal Trainees

16. Founding principles harmonizing the AKI pathway based on evidence and national guidelines will embed best practice improve advice/guidance and referral practices sharing of expertise, manpower and other resources a network provides a stronger platform to lobby for resources collaborative research/audit a point of accountability

17. Wessex AKI Clinical Forum 2014/15 Work streams Acute hospital care E-alert subgroup AKI Care Pathway AKI hospital education course Primary care AKI education workshops AKI Care Pathway for Primary Care Stakeholder engagement AKI Awareness and Education Launch Event 15/4/15 AKI Outreach

18. Impact

21. Education steps in Wessex Hospital Structured AKI Educational Programme targeting foundation and core trainees – based on the ALS model using practical scenarios -Local leads Primary Care CCG Target events - AKI workshops run by local nephrologist and GP

22. LAEDI Local awareness and early diagnosis scheme McMillan GPs Now supporting one GP to provide peer to peer AKI education in the community

23. AKI Outreach Bournemouth Hospital 2014-2015 One specialist nurse (5 half days per week) QA Portsmouth Appointed AKI specialist nurse August 2015 University Hospital Southampton Appointed AKI specialist nurse August 2015

24. Results of intervention Data provided by Martin Southgate Clinical audit RBH Paul Broom Biochemistry PGH Julia Knott Diabetes Secretary RBH BLIntervention 2014June-AugSept-Dec New AKI flags N=188148( n = 96 seen by ST) RIP23 (14%) 8 (5%) Readmission (in 28 days)45 (27%)14 (9%) LOS (Mean /St Dev) 15 days (19)9 days (9) (*p=0.002) Creatinine BLX163 AdmissionX275 DischargeX192 Nephrologist referralsUnknown29 (30% of those seen) Stage 2 & 3

25. The Future

26. Wessex AKI Clinical Forum 2015/16 Work streams Acute hospital care Primary careCommunity Stakeholder engagement AKI CQUIN guidance for commissioners Nurse Education Expand Outreach Undergraduate AKI medical education Implement new AKI core medical teaching module Local Awareness & Early Detection Initiative (LAEDI) Develop AKI topic for GP Trainees LMC engagement & education GP ‘Train the Trainers’ module Out of hours GP engagement Set up community trust subgroup Set up community pharmacy subgroup Set up commissioners’ AKI meeting Develop AKI Network website Patient and family education.

27. To Finish AKI appears to be a proxy indicator of a vulnerable subpopulation with high comorbidity who are at risk of future hospital admissions, recurrent AKI episodes, progressive decline in renal function and death.