Think Kidneys programme update

Presentation give by Think Kidneys Chair, Richard Fluck

1. Dr Richard Fluck National Clinical Director (Renal) NHS England [email protected] Think Kidneys: The NHS campaign to improve the care of people at risk of or with, acute kidney injury Where have we got?

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

3. KDIGO Clinical Practice Guideline for Acute Kidney Injury Kidney International Supplement 2012; 2(1): 1-138 How is AKI defined? The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 3

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

5. Who is most at risk? The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 5 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 ?

6. | 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. | 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. | 8 NCEPOD report published in 2009 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations 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

9. | 9 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 For George, his risk of death is 32.2 % For Julia, her risk of death is 53.1 %

10. | 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 ? | 11 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

12. ‘Think Kidneys’ AKI Programme | 12 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care

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 | 13

14. The vulnerable population Fixed factors The elderly The frail Existing comorbidities Chronic kidney disease Previous history of acute kidney injury Modifiable risk factors Drugs NSAID – auto-regulation Diuretics – volume status ACEi /ARB and other BP targeted medications – BP and auto-regulation Metformin – side effects enhanced The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 14

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 | 15

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 | 16

17. National Algorithm Based in LIMS Compares serial creatinine measures | 17 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

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

19. Is it enough to do a test? | 19 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations 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.

20. | 20 Detect Alert Lets talk about ‘alerts’ Respond The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations

21. | 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 | 22 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations 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

23. The national CQUIN and recovery The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 23 Year 1 Discharge communication Communication of AKI Need for follow up Medications Why? High readmission rates Primary care knowledge Future risk Medicines management

24. ‘AKI warning stage’ Patient management system Alert Response Local systems Message Master patient index Other data systems AKI Registry Regional National Research QI System Measurement 24

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 | 26 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

27. Engaging with safety and improvement partners | 27 The NHS campaign to improve the care of people at risk of or with, acute kidney injury Patient First. Preventing Harm. Improving Care Patient Safety Collaboratives

28. Summary AKI is: Common 1 in 5 of all emergency admissions 2/3 starts in the community Costly It increases the risk of death and harm It costs resources Treatable Education Early detection Better intervention The NHS campaign to improve the care of people at risk of or with, acute kidney injury Secondary Care Considerations | 28

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

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