The role of the AKI Specialist Nurse At Maidstone & Tunbridge - - PowerPoint PPT Presentation

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

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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

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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’

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AKI leads to significant increase in mortality, morbidity, complications, length of stay and care costs (NCEPOD, 2009)

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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

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ALERT SENT VIA E-MAIL TO AKI EDUCATOR, CCOT & PHARMACISTS DAILY @ 07.30, 13.30 & 18.30

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AKI ALERT ADDED TO PATIENT CENTRE AND Edn FOR EACH AKI PATIENT CLINICAL INTERVENTION

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PATIENT REVIEWED BY AKI EDUCATOR/CCOT – LIASE WITH WARD DOCTORS AND NURSES

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AKI STICKER IN PATIENT’S NOTES AND DRUG CHART

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INSTIGATE AKI CARE BUNDLE

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DOCUMENT INTERVENTION *

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24/7 CCOT – TO FOLLOW-UP OVERNIGHT DATA COLLECTION

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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’

• r ‘…….’ 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

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These strategies have led to a significant improvement in the AKI enhancing quality programme

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Local CQUIN showed a 22% reduction

• f AKI stage 3 patients (2014

compared to 2013)

AKI 3

2012 2014 2015

Jan - Dec

Medication review (within 12 hours) 8.93% 45.5% 60.4% Senior clinical review (within 12 hours) 19.64% 63.8% 65.9% Urine dipstick (within 24 hours) 9.91% 45.1% 65.9% Renal imaging (within 24 hours) 1.8% 21.5% 45.5% Repeat U&Es and Creatinine (within 24 hours) No data 74.5% 77.7% PAR scoring (Within 24 hours) No data 95.7% 96.4%

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

20 40 60 80 100 120 Medication review (within 12 hours) Senior Clinical Review (within 12 hours) Urine Dipstick (within 24 hours) Renal Imaging (within 24 hours) Repeat U&Es and creatinine (within 24 hours) PAR scoring (within 24 hours) U&Es within 6 hours of admission Compliance categories Percentage 2013 2014 2015

AKI Performance

Recognition Mortality

MoMo Mortality rate have improved by 10%

Research

AKORDD Acute Kidney Outreach to Reduce Deterioration and Death - A feasibility study to determine the best implementation leading to a Cluster trial Risk Study Participating in a prospective national, multi-centre study in

• rder to develop a

national risk assessment for AKI in secondary care

What now?

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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

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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?