Acute Kidney Injury Adding Insult to Injury Adding Insult to Injury - - PowerPoint PPT Presentation

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Acute Kidney Injury Adding Insult to Injury Adding Insult to Injury - - PowerPoint PPT Presentation

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Acute Kidney Injury Adding Insult to Injury Adding Insult to Injury Thursday 11 th June 2009 RSM London Dr Kevin Harris Clinical Vice President Acute Kidney Injury Acute Kidney Injury A study of contributory factors in, recognition of,

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Acute Kidney Injury Adding Insult to Injury Adding Insult to Injury Thursday 11th June 2009 RSM London Dr Kevin Harris Clinical Vice President

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Acute Kidney Injury 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 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

g Will influence the prevention of AKI Will influence the management of AKI Will influence the management of AKI Make a difference…

11th June 2009

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Acute Kidney Injury 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 p p g Dr Suren Kanagasundaram, Nephrologist: Newcastle Dr Paul Roderick, Public Health Medicine: Southampton , p

11th June 2009

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Acute Kidney Injury Acute Kidney Injury

Quality requirement three Acute renal failure: People at risk of, or suffering from, t l f il id tifi d acute renal failure are identified promptly, with hospital services delivering high quality, clinically g g q y, y appropriate care in partnership with specialised renal teams.

11th June 2009

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Acute Kidney Injury Acute Kidney Injury

Stage 3 AKI: Age at Presentation in a single large nephrology centre

80 50 60 70 30 40 50 Acute on Chronic AKI 10 20 30 10 16-29 30-39 40-49 50-59 60-69 70-79 80+ Age

11th June 2009

g

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Acute Kidney Injury Acute Kidney Injury

In patient mortality in a single large nephrology centre

80 60 70 40 50 Dead Alive 20 30 10 16-29 30-39 40-49 50-59 60-69 70-79 80+

11th June 2009

16-29 30-39 40-49 50-59 60-69 70-79 80+

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Acute Kidney Injury Acute Kidney Injury

Key issues identified in the report Clinical: Clinical:

  • Early detection

– Identifying those at risk – Appropriate observations (MEWS) – Appropriate investigations

  • Appropriate prompt intervention
  • Appropriate prompt intervention

Organisational: g

  • Access to nephrology advice
  • Access to nephrology services

11th June 2009

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Acute Kidney Injury Acute Kidney Injury

No real surprises There is work to be done There is work to be done Research into pathophysiolgy and treatment required p p y gy q We already have the knowledge to significantly improve outcomes The real challenge is to get people and organisations to do the right thing thing Education of clinical staff Quality improvement initiatives

11th June 2009

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Acute Kidney Injury 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 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

  • f prevention and treatment of AKI.

p Guideline 2.3 Initial assessment to determine the likelihood of whether their AKI is pre-renal, renal

  • r post-renal in nature. This should encompass …assessment of volume status;

reagent strip urinalysis and presence or absence of obstruction 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

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Acute Kidney Injury Acute Kidney Injury

Lassen BJS, 96:123-124,2009.

http://www.renal.org/pages/media/download_gallery/GIFTASUP%20FINAL_05_01_09.pdf

Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients is the first robust attempt Patients is the first robust attempt at a comprehensive system to reduce the potential hazards of salt and p water administration to surgical

  • patients. They are very welcome.

11th June 2009

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Acute Kidney Injury 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 id li d t f t l guidelines and transfer protocols. Guideline 3.4 Nephrologists and intensivists should work together to provide care for patients

11th June 2009

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Newcastle Middlesborough Sunderland Cumberland Inf S b h

CKD - haemodialysis

Arrowe Park Hope Hull Leeds Aintree MRI Preston Skipton York Sheffield Scarborough St james

y

Arrowe Park Countess of Chester Stoke Royal Lpool Leics Derb y Notts wolv es Norwich Shrews

Main Units

Gloucester Co v Heartlands es

  • xford

Addenbrookes Colchester Ipswich ListerRoyal Free Russells Hall St

Satellite Units Planned Units New Main Units

southend Southmead

  • xford

Kent & Cant Hammersmith Kings College St Marys Portsmouth

11th June 2009

Dorset County Derriford Truro Exet er Royal Sussex

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Acute Kidney Injury

“There is more variation in arrangements for the management of AKI in

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 and beyond the base hospital. They are often managed in inappropriate facilities.” This reflects: the absence of any clear commissioning arrangements y g g uncertainty about shared lines of responsibility lack of renal HDU beds lack of HD facilities in non HDU renal beds lack of HD facilities in non-HDU renal beds Professor John Feehally Past President of the Renal Association 2007

11th June 2009

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Acute Kidney Injury

Can we afford to do this?

Acute Kidney Injury

Can we afford to do this?

150 140 120 130

Growing funding gap?

110

gap?

100 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

11th June 2009

NHS: real change Wanless: Fully engaged

Kings Fund 2009

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Acute Kidney Injury Acute Kidney Injury

Newcastle Middlesborough Sunderland Hope Hull Leeds Preston Skipton York Cumberland Inf Scarborough St james Arrowe Park Countess of Chester Hope Aintree Stoke MRI Royal Lpool Derby Notts sheffield Main Units Gloucester Co v Heartlands Leics wolve s Norwich Addenbrookes Colchester Ipswich Lister Shrews Russells Hall Satellite Units Planned Units New Main Units Gloucester southend Southmead

  • xford

Kent & Cant Colchester Hammersmith Kings College Lister Royal Free St Marys Portsmouth

11th June 2009

Dorset County Derriford Truro Exete r Royal Sussex

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Acute Kidney Injury Acute Kidney Injury

Does Quality Have to Cost more Money? Q y y

11th June 2009

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Acute Kidney Injury Acute Kidney Injury

Can we afford not to? Can we afford not to?

Average Length of stay in patients surviving until discharge in a single large nephrology centre

35 40 20 25 30 10 15 20 5 16-29 30-39 40-49 50-59 60-69 70-79 80+

11th June 2009

Age

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“The First Law of Improvement” The First Law of Improvement

Every system is perfectly designed to achieve the results it achieves results it achieves. Don Berwick, quoting Paul Batalden Berwick D Br Med J

  • Batalden. Berwick D. Br Med J

1996; 312: 619

11th June 2009

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System Improvement System Improvement

  • Start with evidence-based guidelines

– RA guidelines

  • Understand the current system

– Process mapping – Measurements

  • Set clear aims

Act Plan

  • Look for a “change package”

– Steal shamelessly

Study Do

– Encourage innovation

  • Form a quality improvement team

11th June 2009

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Acute Kidney Injury 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

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Acute Kidney Injury Acute Kidney Injury

RA actively participating in:

  • Definitions for AKI
  • Definitions for AKI
  • Coding

Guidelines for prevention

  • Guidelines for prevention
  • Guidelines for appropriate referral and transfer

Ed ti

  • Education
  • Audit

11th June 2009