Acute Kidney Injury Adding Insult to Injury Thursday

Acute Kidney Injury Adding Insult to Injury Thursday

Acute Kidney Injury Adding Insult to Injury Thursday 11th June 2009 RSM London Dr Kevin Harris Clinical Vice President Acute Kidney Injury A study of contributory factors in, recognition of, and response to, acute kidney injury in a cohort of patients dying in hospital where AKI has been contributory First national audit of a common, important problem Addresses clinical and organisational issues Findings and recommendations Will influence the prevention of AKI Will influence the management of AKI Make a difference 11th June 2009 Acute Kidney Injury Expert Group Members:

Mr David Mitchell, Vascular Surgeon: Bristol Dr Andrew Lewington, Nephrologist: Leeds Dr Alistair Hutchison, Nephrologist: Manchester Dr Philip Kalra, Nephrologist: Salford Dr Suren Kanagasundaram, Nephrologist: Newcastle Dr Paul Roderick, Public Health Medicine: Southampton 11th June 2009 Acute Kidney Injury Quality requirement three Acute renal failure: People at risk of, or suffering from, acute renal failure are identified promptly, with hospital services delivering high quality, clinically appropriate care in partnership with specialised renal teams. 11th June 2009

Acute Kidney Injury Stage 3 AKI: Age at Presentation in a single large nephrology centre 80 70 60 50 Acute on Chronic 40 AKI 30 20 10 0 16-29 30-39 40-49 50-59 Age

11th June 2009 60-69 70-79 80+ Acute Kidney Injury In patient mortality in a single large nephrology centre 80 70 60 50 Dead 40 Alive 30

20 10 0 16-29 11th June 2009 30-39 40-49 50-59 60-69 70-79 80+ Acute Kidney Injury Key issues identified in the report Clinical: Early detection

Identifying those at risk Appropriate observations (MEWS) Appropriate investigations Appropriate prompt intervention Organisational: Access to nephrology advice Access to nephrology services 11th June 2009 Acute Kidney Injury No real surprises There is work to be done Research into pathophysiolgy and treatment required We already have the knowledge to significantly improve outcomes The real challenge is to get people and organisations to do the right thing Education of clinical staff Quality improvement initiatives 11th June 2009 Acute Kidney Injury

Renal Association Guidelines: Dr Andrew Davenport, Dr Suren Kanagasundaram, Dr Andrew Lewington and Dr Paul Stevens http://www.renal.org/pages/pages/guidelines/current/arf.php Assessment, Prevention & Pharmacological Treatment Guideline 2.1 Patients at risk of AKI should be identified in the community and the hospital . Guideline 2.2 Undergraduate and postgraduate medical trainees should be taught the principles of prevention and treatment of AKI. Guideline 2.3 Initial assessment to determine the likelihood of whether their AKI is pre-renal, renal or post-renal in nature. This should encompass assessment of volume status; reagent strip urinalysis and presence or absence of obstruction. Guideline 2.10 Therapeutic drug dosing must be adapted to altered kinetics in AKI. 11th June 2009 Acute Kidney Injury http://www.renal.org/pages/media/download_gallery/GIFTASUP%20FINAL_05_01_09.pdf Lassen BJS, 96:123-124,2009. Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients is the first robust attempt

at a comprehensive system to reduce the potential hazards of salt and water administration to surgical patients. They are very welcome. 11th June 2009 Acute Kidney Injury Renal Association Guidelines: Dr Andrew Davenport, Dr Suren Kanagasundaram, Dr Andrew Lewington and Dr Paul Stevens http://www.renal.org/pages/pages/guidelines/current/arf.php Treatment facilities & referral to renal services Guideline 3.1 The critical care nephrology interface should be defined at each locality to ensure timely and appropriate placement of patients with AKI according to their clinical condition. Local critical care networks should be utilised to facilitate this process. Guideline 3.2 Appropriate transfer and triage of AKI patients from the non-specialist, non-critical care ward to the renal unit should be facilitated through the development of local guidelines and transfer protocols. Guideline 3.4 Nephrologists and intensivists should work together to provide care for patients 11th June 2009 Newcastle

Sunderland Middlesborough CKD - haemodialysis Cumberland Inf Scarborough York Skipton Preston Hope Aintree Arrowe Park Countess of ChesterRoyal Lpool Stoke Main Units Shrews Satellite Units Russells Hall

Planned Units New Main Units St james Leeds MRI Sheffield Derb y wolv es Heartlands Notts Norwich Leics Addenbrookes Co v

Gloucester oxford Southmead Hull St Marys Hammersmith Ipswich Lister Colchester Royal Free southend Kings College Portsmouth Exete r Truro 11th June 2009

Royal Sussex Dorset County Derriford Kent & Cant Acute Kidney Injury There is more variation in arrangements for the management of AKI in the UK than in any other aspect of the work of renal units. Patients wait too long to be admitted to the renal ward both from within and beyond the base hospital. They are often managed in inappropriate facilities. This reflects: the absence of any clear commissioning arrangements uncertainty about shared lines of responsibility lack of renal HDU beds lack of HD facilities in non-HDU renal beds Professor John Feehally Past President of the Renal Association 2007 11th June 2009 Acute Kidney Injury Can we afford to do this?

150 140 130 Growing funding gap? 120 NHS: real change 11th June 2009 Wanless: Fully engaged Kings Fund 2009 2016-17 2015-16 2014-15

2013-14 2012-13 2011-12 2010-11 2009-10 2008-09 2007-08 100 2006-07 110 Acute Kidney Injury Newcastle Sunderland Middlesborough

Cumberland Inf Scarborough York Skipton Preston Hope Aintree Arrowe Park Countess of Chester Royal Lpool Leeds MRI sheffield Derby Stoke Notts Main Units Shrews Satellite Units

Hull St james wolve s Heartlands Russells Hall Norwich Leics Addenbrookes Co v Planned Units Ipswich New Main Units Gloucester

Lister oxford Southmead St Marys Royal Free southend Hammersmith Kings College Portsmouth Exeter Truro 11th June 2009 Royal Sussex Dorset County Derriford

Colchester Kent & Cant Acute Kidney Injury Does Quality Have to Cost more Money? 11th June 2009 Acute Kidney Injury Can we afford not to? Average Length of stay in patients surviving until discharge in a single large nephrology centre 40 35 30 25 20 15 10 5 0 16-29

30-39 40-49 50-59 Age 11th June 2009 60-69 70-79 80+ The First Law of Improvement Every system is perfectly designed to achieve the results it achieves. Don Berwick, quoting Paul Batalden. Berwick D. Br Med J 1996; 312: 619

11th June 2009 System Improvement Start with evidence-based guidelines RA guidelines Understand the current system Process mapping Measurements Set clear aims Look for a change package Steal shamelessly Encourage innovation Form a quality improvement team 11th June 2009 Act Plan Study Do Acute Kidney Injury Improvement will require action by whole health community Commissioners (world class) NHS Kidney Care Renal Networks (Specialist Services) NHS Trusts

Chief Executives & Medical Directors Clinical Teams Deaneries Universities Professional bodies Patients 11th June 2009 Acute Kidney Injury RA actively participating in: Definitions for AKI Coding Guidelines for prevention Guidelines for appropriate referral and transfer Education Audit 11th June 2009

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