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

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, 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… 11 th June 2009

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 11 th June 2009

Acute Kidney Injury Acute Kidney Injury Quality requirement three Acute renal failure: People at risk of, or suffering from, acute renal failure are identified t l f il id tifi d promptly, with hospital services delivering high quality, clinically g g q y, y appropriate care in partnership with specialised renal teams. 11 th June 2009

Acute Kidney Injury Acute Kidney Injury Stage 3 AKI: Age at Presentation in a single large nephrology centre 80 70 60 50 50 Acute on Chronic 40 AKI 30 30 20 10 10 0 16-29 30-39 40-49 50-59 60-69 70-79 80+ Age g 11 th June 2009

Acute Kidney Injury 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 16-29 30-39 30-39 40-49 40-49 50-59 50-59 60-69 60-69 70-79 70-79 80+ 80+ 11 th June 2009

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 11 th June 2009

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 11 th June 2009

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 of prevention and treatment of AKI. p 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 reagent strip urinalysis and presence or absence of obstruction. Guideline 2.10 Therapeutic drug dosing must be adapted to altered kinetics in AKI. 11 th June 2009

Acute Kidney Injury 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 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. 11 th June 2009

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 guidelines and transfer protocols. id li d t f t l Guideline 3.4 Nephrologists and intensivists should work together to provide care for patients 11 th June 2009

Newcastle Sunderland Middlesborough CKD - haemodialysis y Cumberland Inf S Scarborough b h York Skipton Hull Preston St james Leeds Hope MRI Aintree Sheffield Arrowe Park Arrowe Park Countess of Chester Royal Lpool Derb Stoke y Notts Main Units Shrews wolv Norwich Leics es es Heartlands Satellite Units Addenbrookes Russells Co Hall Planned Units v Ipswich New Main Units Gloucester ListerRoyal Free Colchester oxford oxford St St Marys southend Hammersmith Southmead Kings Kent & Cant College Portsmouth Exet Royal Sussex er Truro Dorset County 11 th June 2009 Derriford

Acute Kidney Injury Acute Kidney Injury “There is more variation in arrangements for the management of AKI in 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 and beyond the base hospital. They are often managed in 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 11 th June 2009

Acute Kidney Injury Acute Kidney Injury Can we afford to do this? Can we afford to do this? 150 140 130 Growing funding 120 gap? gap? 110 100 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 NHS: real change Wanless: Fully engaged 11 th June 2009 Kings Fund 2009

Acute Kidney Injury Acute Kidney Injury Newcastle Sunderland Middlesborough Cumberland Inf Scarborough York Skipton Hull Preston St james Leeds Hope Hope MRI Aintree sheffield Arrowe Park Countess of Chester Royal Lpool Derby Stoke Notts Main Units Shrews wolve Norwich Leics s Heartlands Satellite Units Addenbrookes Russells Hall Co v Planned Units Ipswich New Main Units Gloucester Gloucester Lister Lister Royal Free Colchester Colchester oxford St Marys southend Hammersmith Southmead Kings College Kent & Cant Portsmouth Exete Royal Sussex r Truro Dorset County 11 th June 2009 Derriford

Acute Kidney Injury Acute Kidney Injury Does Quality Have to Cost more Money? Q y y 11 th June 2009

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 40 35 30 25 20 20 15 10 5 0 16-29 30-39 40-49 50-59 60-69 70-79 80+ Age 11 th June 2009

“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 11 th June 2009

System Improvement System Improvement • Start with evidence-based guidelines – RA guidelines • Understand the current system – Process mapping – Measurements Act Plan • Set clear aims • Look for a “change package” Study Do – Steal shamelessly – Encourage innovation • Form a quality improvement team 11 th June 2009

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 11 th June 2009

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 Education ti • Audit 11 th June 2009