Acute Kidney Injury 2

Transcription

1 South West Cardiovascular Strategic Clinical Network Acute Kidney Injury 2 Audit review meeting 18/07/2014 Redwood Education Centre Author: Summary of results: Dr Preetham Boddana Consultant Nephrologist Clinical Audit Department GHNHSFT 80% had an acute illness 100% had serum creatinine measured 53% suspected AKI at time of ordering blood test 67% had medical review to clinically assess the pt following blood test 80% had cause of AKI identified 2 patients referred to renal clinic/nephrologist 5 patients were admitted to hospital A copy of the data collection proforma can be found at the end of the report Contents Introduction... 2 Aim... 2 Standards... 2 Methodology... 3 Analysis of Results... 3 Demographic data... 3 Acute Illness... 4 Blood Test... 4 Timings of initial consultation, blood test, results and action... 6 Medications... 7 Cause Identified... 7 Hospital Admission... 9 Conclusion... 9 Appendix 1 Data collection proforma

2 Introduction Nationally it is reported that 5-20% of critically ill patients experience an episode of AKI during the course of their illness at a cost of over half a billion pounds in The beginning of the injury is commonly in primary care with 20-30% of AKI cases estimated to be preventable. Within Gloucestershire in 2010/11 the AKI admission rate per 1,000 emergency admissions was 7.0 with a median LOS of 10 days, this is higher than the English average of 6.7 per 1,000 emergency admissions with a median LOS of 9 days (Kidney Disease Clinical Commissioning Group Profile 2012). Admissions refer to inpatient spells where AKI appears as the primary diagnosis within one of the episodes The Cardiovascular Strategic Clinical Network has developed a project called Opportunities to PRevent Admissions (OPRA). OPRA identifies potentially preventable emergency admissions under four headings: Cardioembolic stroke in a patient with AF, Readmission with heart failure, Diabetic foot amputation, and Acute Kidney Injury. The OPRA audit tool provides a link back to Primary Care from Secondary Care to identify and support the learning from individual cases, as a means of improving practice and preventing admissions, across the whole patient pathway (primary care, secondary care etc). Each of these problem areas is being assessed in a different CCG in the Southwest. Gloucestershire CCG has agreed that Acute Kidney Injury can be assessed using the OPRA tool in Gloucestershire - as part of a collaboration between Gloucestershire Clinical Commissioning Group, NHS England and Gloucestershire Hospitals NHS Foundation Trust. Aim This project aims to reduce the incidence of preventable AKI Standards Assessing risk of acute kidney injury Identifying acute kidney injury in patients with acute illness 1. All adults with acute illness are investigated for acute kidney injury if any of the following are likely or present: Chronic kidney disease Heart failure Liver disease Diabetes History of acute kidney injury Oliguria Neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer Hypovolaemia Age 65 years or older. Use of drugs with nephrotoxic potential within the past week, especially if hypovolaemic Use of iodinated contrast agents within the past week Symptoms or history of urological obstruction, or conditions that may lead to obstruction Sepsis Deteriorating early warning scores Assessing risk factors in adults having iodinated contrast agents 2. All adults are investigated for chronic kidney disease before being offered iodinated contrast agents for non-emergency imaging. 3. All adults are assessed for the risk of acute kidney injury before they are offered iodinated contrast agents for emergency or non-emergency imaging. 2

3 Detecting acute kidney injury 4. All adults with or at risk of acute kidney injury have their serum creatinine monitored regularly. Identifying the cause(s) of acute kidney injury 5. All adults with acute kidney injury have the cause identified and details recorded in their notes. Managing acute kidney injury Referring to nephrology 6. All adults have the management of acute kidney injury discussed with a nephrologist as soon as possible and within 24 hours of detection when one or more of the following is present: a possible diagnosis that may need specialist treatment acute kidney injury with no clear cause inadequate response to treatment complications associated with acute kidney injury stage 3 acute kidney injury (according to (p)rifle, AKIN or KDIGO criteria) a renal transplant chronic kidney disease stage 4 or 5. Methodology The pathology system at Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) was interrogated to provide a list of patients who had flagged AKI2 in Primary care. These GP practices were contacted and asked if they would like to participate in the audit. Where a positive response was received the practice manager was sent a copy of the data collection proforma (see appendix 1) and also the patient details. Analysis of Results Demographic data Gender Male 8 53% Female 7 47% Age Min 61 Max 94 Average 79 Median 79 Ethnic background White British 11 British/Mixed British 1 Not stated 2 3

4 Acute Illness Yes 12 80% Comments Initial admission in 24/3/14 with pre-syncope, possible dehydration, runs of VT and underlying AF. Discharged 27/3 on Amiodarone Worsening heart failure Diarrhoea and frequency of micturition. Also history of Parkinson s, diabetes, CHD, cabg and AF Unilateral leg swelling and tenderness treated initially as infection, then USS negative for DVT. Progressed to bilateral so treated with furosemide at which point bloods sent UTI, vomiting, pmh COPD, scleroderma, AF Acute on chronic retention of urine Palliative care from March Acute deterioration 5/6/14 Dehydrated Left hydronephrosis also palliative care UTI No 3 21% Comments Increase diuretics due to CCF. Scrotal/pedal osdema ++. Discussed prior to mediction change with cardiology Blood Test What was the indication for the blood test? Check renal function after increase bumetamide + spironoloctone. Oedema improved, managing urinary freq at night. Patient asked to attend surgery for blood test, not done until home visit 3 weeks later. On high dose diuretics and CKD Advised to monitor bloods after discharge Unwell with urinary tract infection recent introduction of NSAIDs for back pain increased diuretics Frequent falls and nocturnal micturition up to 5 times per night Routine Renal/electrolyte check following initiation and titration of furosemide Had had recent admission to GRH with COPD exacerbation and found to have AKI then. Ramipril had been stopped but restarted prior to discharge a week previously. Pt complained of general malaise and fatigue and I felt it would be useful to check renal function. Reduced urine output/retention Deterioration 5/6/14 Confusion Reduced renal function Routine bloods as part of methotrexate monitoring 4

5 Presence or likelihood of the following: Were any of the following likely or present?: Yes - Likely Yes - Present Chronic kidney disease 11 History of acute kidney injury 1 2 Liver disease Dehydration 6 1 Deteriorating early warning scores 5 Diabetes 9 Heart failure 3 2 Reduced urine output 6 3 Sepsis 1 3 Age 65 or over 14 Neurological or cognitive impairment or disability, which may mean limited 3 4 access to fluids because of reliance on a carer Use of drugs with nephrotoxic potential within 7 days, esp. if hypovolemic 8 Imaging requiring iodinated contrast agents within the past week e.g. CT scan?1 Symptoms/history of urological obstruction, or conditions that may lead to it Yes - Likely Yes - Present Was serum creatinine measured? Yes % 5

6 Was AKI suspected at the time of ordering the blood test? Yes 8 53% In view of past history AKI Palliative, acute deterioration, Bladder carcinoma with metastes Requested by palliative care No 7 47% Monitoring renal function after increase of diuretics Routine blood test; had been dehydrated on previous admission, although no indication of dehydration when seen Consultant letter after result advising of drop Routine bloods as part of methotrexate monitoring Timings of initial consultation, blood test, results and action Initial consultation to Blood test taken (days) 9 blood test taken on the same day as consultation, x1 test taken the day before (routine blood test) Min -1 Max 14 Ave 2.1 Median 0 Blood test taken to Blood test result available (days) 9 results available on the same day as test taken Min 0 Max 1 Ave 0.4 Median 0 Blood test result available to Blood test result reviewed (days) 11 results reviewed on the same day as available Min 0 Max 3 Ave 0.5 Median 0 Action taken following review of blood test -e.g. patient contacted (days) In 12 cases the patient was contacted on the same day as results available Min 0 Max 2 Ave 0.3 Median 0 6

7 In 3 cases the blood test was taken, results were available and the patient was contacted on the same day. Medications Were medications implicated in AKI stopped? Yes 7 47% x2 medication reduced not stopped No 4 x1 Found to have EBSL UTI and received treatment with IV tazocin. Ramipril 1.25mg continued. Na 4 Where applicable was this done before or after blood test results became available? Before 1 14% After 6 86% Was a medical review carried out to clinically assess the patient following blood test results? Yes 10 67% x2 by secondary care No 3 Unclear 1 Not completed 1 Cause Identified What was the cause of the AKI if identified? Yes 12 80% Uncertain 1 Patient felt was due to Atorvastatin Not completed 2 High dose diuretics and UTI Infection on background of significant frailty Voltarol tablets Increased diuretic usage for heart failure Sepsis/UTI Presumed due to initiation and titration of furosemide UTI Acute retention of urine Terminal phase of bladder carcinoma Dehydrated, alcohol Hydronephrosis and ACE When was a repeat blood test performed? 9 documented as being performed on checking pathology system 11 patients had repeat blood tests taken: 2 patients had repeated samples taken the following day 1 of which was as an inpatient 9 samples were taken > than 1 day after initial sample (Length of time from initial blood test: 2pts x 2 days, 2pts x 3 days, 1pt x 6 days, 2 pts x 7 days, 1 pt x 28 days, 1 pt x 31 days) 3 patients did not have repeat samples taken 1 not applicable as patient died 3 days later. 7

8 Criteria for discussion/referral to nephrologist: Criteria Number of patients A possible diagnosis that may need specialist treatment 6 Acute kidney injury with no clear cause 2 Inadequate response to treatment 1 Complications associated with acute kidney injury 0 Stage 3 acute kidney injury 5 A renal transplant 0 Chronic kidney disease stage 4 or 5 5 All 15 patients had at least one criteria for referral to a nephrologist present: Diagnosis that may need specialist treatment AKI with no clear cause Inadequate response to treatment Complications associated with AKI Stage 3 AKI Renal transplant CKD stage 4 or 5 5 patients had more than one criteria present: 2 patients had possible diagnosis that may need specialist treatment & Stage 3 AKI. 2 patients had AKI with no clear cause & Stage 3 AKI, 1 patient had AKI Stage 3 and CKD stage 4 or 5 Of these 5 patients: 1/5 was referred to a nephrologist/renal clinic 3/5 were admitted to hospital Referral/discussion with a nephrologist 2/15 patients were reported as being discussed with a renal clinic/nephrologist - 1 with a diagnosis that may need specialist treatment and stage 3 AKI, the other with possible stage 3 AKI 11/15 were not discussed with a nephrologist 2/15 were reported as N/A 8

9 Hospital Admission 5 patients were admitted to hospital, in addition 2 patients were documented as being frail, 1 pt died at home, the other deteriorated rapidly and died 13 days after the initial blood test. Conclusions Incidence of CA-AKI is equal to higher than HA-AKI Risks for developing CA AKI Age>65 years Pre-existing CKD Diabetes Majority of patients had criteria for discussion with a renal physician There is room for improvement Availability of lab results and action taken Review of patient and withholding drugs with nephrotoxic potential-sick day rule! Repeat creatinine within 24 hrs Discussion and presentation of results at Redwood Education Centre on 18 th July

10 Appendix 1 Data collection proforma South West Cardiovascular Strategic Clinical Network Data Collection Proforma Acute Kidney Injury: Prevention, Detection and Management in Adults Clinical Audit This data collection form can be completed electronically and returned via to Alexandra.purcell@glos.nhs.uk or alternatively printed off, completed manually and faxed to (secure location). The audit standards are based on the NICE guideline for Acute kidney injury. NB Individual GP practices will not be identifiable in results. Audit ID: Gender: Male / Female GP Practice: Age: Ethnic background: (if stated) Did the adult have an acute illness? Yes No Comments What was the indication for the blood test? Were any of the following likely or present?: Yes - Likely Chronic kidney disease History of acute kidney injury Liver disease Dehydration Deteriorating early warning scores Diabetes Heart failure Reduced urine output Sepsis Age 65 or over Neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer Use of drugs with nephrotoxic potential within the past week, especially if hypovolaemic Imaging requiring iodinated contrast agents within the past week e.g. CT scan Symptoms or history of urological obstruction, or conditions that may lead to obstruction Yes - Present No 10

11 Was serum creatinine measured? Yes No Comments Was AKI suspected at the time of ordering the blood test? Yes No Comments Timings Date Initial consultation / / Blood test taken / / Blood test result available / / Blood test result reviewed / / Action taken following review of blood test (e.g. patient / / contacted) Time Were medications implicated in AKI stopped? If yes was this before or after blood test results available? Was a medical review carried out to clinically assess the patient following blood test results? What was the cause of the AKI if identified? When was a repeat blood test performed? Yes No N/a Comments Before / After Were any of the following present?: Yes No A possible diagnosis that may need specialist treatment Acute kidney injury with no clear cause Inadequate response to treatment Complications associated with acute kidney injury Stage 3 acute kidney injury A renal transplant Chronic kidney disease stage 4 or 5 Was the management of the acute kidney injury discussed with a nephrologist? Did this happen within 24 hours of detection of acute kidney injury? Was the patient admitted to hospital? Yes No N/a Comments Yes No Comments If Yes, date of admission / / 11