The role of the AKI Specialist Nurse At Maidstone & Tunbridge Wells NHS Trust Senior Sister Louise Morris (AKI Educator/CCOT)
The Past – AKI poorly managed It is estimated that there may be more than 40,000 deaths every year in England associated with AKI and the annual cost of in-patient care for patients with AKI is more than £1billion per year – greater than 1% of the NHS budget in England NCEPOD (2009) reported results of an enquiry into the deaths of a large group of adults with AKI, ‘only 50% of these patients received good care’ AKI leads to significant increase in mortality, morbidity, complications, length of stay and care costs (NCEPOD, 2009) 30% of AKI cases can be prevented with simple interventions such as stopping nephrotoxic medications, identifying early clinical deterioration, prompt treatment of sepsis, urinary dipstick, senior medical review and reassessment of U&E’s and creatinine levels (NCEPOD, 2009;NICE, 2013)
Where to Begin? MTW conducted an audit of 112 patients with AKI from September to December 2012 - Medication review 8.93% within 12 hours - Senior clinical review (registrar/consultant) 19.64% within 12 hours - Dipstick urinalysis 9.91% within 24 hours - Renal imaging 1.8% within 24 hours
How was this addressed? Local AKI CQUIN implemented at MTW in April 2014, its target to reduce AKI 3 by 15%. As a result of this; - AKI Strategy group formed an ALERT system was put into place - AKI educator employed - A key element in delivering good AKI care is improving the identification and recording of cases of AKI (KSS PSC)
ALERT system AKI stage 1,2 & 3 CREATININE RESULT DETERMINED AND REPORTED ALERT SENT VIA E-MAIL TO AKI EDUCATOR, CCOT & PHARMACISTS DAILY @ 07.30, 13.30 & 18.30 AKI ALERT ADDED TO PATIENT CENTRE AND Edn FOR EACH AKI PATIENT CLINICAL INTERVENTION PATIENT REVIEWED BY AKI EDUCATOR/CCOT – LIASE WITH WARD DOCTORS AND NURSES AKI STICKER IN PATIENT’S NOTES AND DRUG CHART INSTIGATE AKI CARE BUNDLE DOCUMENT INTERVENTION * 24/7 CCOT – TO FOLLOW-UP OVERNIGHT DATA COLLECTION AKI EDUCATOR/CCOT COMPLETE ENHANCING QUALITY AUDIT
Stickers Medical Notes Drug Chart
AKI Educator AKI educator employed in October 2014 On commencing post analysed all data collected by the outreach teams re number of stage 2 & 3 AKI patients throughout the trust and top 12 wards were targeted initially for teaching along with FY1/FY2 doctors
AKI Educator Teaching strategies; - Formal lectures on the wards/education centre/outreach link nurses - By the bed, involving ward doctors and nurses - Intranet AKI quiz with a prize - Pocket size AKI information cards - Written information regarding urinalysis and copy of presentation provided for staff at each teaching session
AKI Educator Liason with other specialities and organisation of AKI strategy group monthly meetings - Lead sonographer to achieve timely renal imaging - Biochemists - Pharmacists to ensure timely review of drug charts - EPR team, IT and Teleologic to ensure AKI alerts enter eDNs of all AKI patients
AKI Educator Initiation of the AKI National CQUIN in April 2015 Patient discharge; AKI section added to edN to inform GP’s of AKI stage, cause of AKI - and treatment whilst in hospital. This has since been extended to satisfy the National AKI CQUIN and includes 4 key items: - AKI stage on discharge from hospital - recommended blood tests for AKI - frequency of blood tests - medication review regarding AKI There is also a link to the London AKI network website
AKI National CQUIN 2015-2016
National AKI CQUIN Stage of AKI Added to eDN by automated IT system which updates so that the worst stage of AKI is recorded during the patient’s hospital admission
National AKI CQUIN Medication review Must be clearly documented which medications have been stopped or doses reduced due to AKI and whether or not they have been or can be restarted. If no change was required, ‘No changes required’ had to be documented. ‘Nil’, ‘NA’ or ‘…….’ was not acceptable for the audit
National AKI CQUIN Type of blood tests Must be clearly documented if further bloods tests were required to monitor renal function after discharge. If no bloods were required, ‘Not required’had to be documented. ‘N/A’ , ‘Nil’ or ‘………..’ was not acceptable for the audit.
National AKI CQUIN Frequency of blood tests Must be a clear statement detailing type of bloods required with regards to AKI and a clear statement of when and who is to perform the test. Ie . U&E’s to be checked by GP in one week and weekly thereafter until stable
Electronic discharge summary Rationale for these indicators: - 65% of AKI occurs in primary care - Improving the provision of information to GPs at the time of discharge will start to develop their knowledge base of AKI and will also positively impact on readmission rates for patients with AKI
AKI Educator - Development of AKI patient leaflet on Q- Pulse - The AKI Team expanded in October 2015 and January 2016, the team now comprises of 3 (2 wte)
Achievements so far AKI 3 2012 2014 2015 Jan - Dec These strategies have led to a Medication 8.93% 45.5% 60.4% significant improvement in the AKI review (within enhancing quality programme 12 hours) Senior clinical 19.64% 63.8% 65.9% review (within Local CQUIN showed a 22% reduction 12 hours) of AKI stage 3 patients (2014 Urine dipstick 9.91% 45.1% 65.9% compared to 2013) (within 24 hours) Renal imaging 1.8% 21.5% 45.5% (within 24 hours) Repeat U&Es No data 74.5% 77.7% and Creatinine (within 24 hours) PAR scoring No data 95.7% 96.4% (Within 24 hours)
National AKI CQUIN Results National AKI CQUIN 4 key items audited – AKI stage, Medication review, - Blood tests & Frequency of blood test Quarter 1 – April 19%, May 20%, June 25% = 21.3% (Baseline) Quarter 2 – July 53%, August 68%, September 72% = 64.3% (Target 55.7%) Quarter 3 – October 73% November 88% December 92% = 84% (Target 72.8%) Quarter 4 - January 88%, February 97%, March 99% = 94.7% Target 90%
Quality Improvement and CQUIN Results AKI stage 3 2013-2015 120 100 80 Percentage 2013 60 2014 2015 40 20 0 Medication Senior Urine Renal Repeat PAR U&Es within review Clinical Dipstick Imaging U&Es and scoring 6 hours of (within 12 Review (within 24 (within 24 creatinine (within 24 admission hours) (within 12 hours) hours) (within 24 hours) hours) hours) Compliance categories
AKI Performance Recognition Mortality MoMo Mortality rate have improved by 10%
Research Risk Study AKORDD Participating in a Acute Kidney Outreach prospective national, to Reduce Deterioration multi-centre study in and Death - A feasibility order to develop a study to determine the national risk assessment best implementation for AKI in secondary leading to a Cluster trial care
What now? IN PROGRESS: Currently working on AKI trust guidelines to be implemented across the trust - Pharmacist has devised an A4 quick reference guide to nephrotoxic medications that - will be attached to the ward drug trolley Ward Urinalysis teaching - Updating stickers and data collection form - THE FUTURE: Explore the possibility of AKI alerts and mandatory fluid balance charts via Nerve - Centre Development of AKI mandatory e-learning - Build a relationship with Nephrology team -
Summary We have made a significant improvement to patient care. With a multi-disciplinary approach with widespread teaching and implementation of a care bundle throughout the trust thus ensuring AKI is more widely recognised and treated in a timely fashion.
Any Questions?
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