Plenary presentations 1

Transcription

1 Wessex Cardiovascular Strategic Clinical Network Acute Kidney Injury Launch Event Wednesday 15 April 2015, Plenary presentations 1

2 Wessex Acute Kidney Injury Clinical Forum Dr Mark Uniacke Chair, Wessex Acute Kidney Injury Forum Consultant Nephrologist Queen Alexandra Hospital, Portsmouth

3 Acute Kidney Injury (AKI) is everybody s business. Mark Uniacke Consultant in Renal and Transplantation Wessex Kidney Centre Chair Wessex AKI Clinical Forum Wessex Strategic Clinical Network

4 1. Why are we here today? Outline 2. What is AKI and why is it important? 3. AKI is everbody s business. 4. The Wessex AKI Clinical Forum: Approaching the whole pathway. Wessex hospital AKI Care Pathway.

5 Why are we here today?

6 NICE AKI Guidance (CG169): August 2013 National Patient Safety Alert: June 2014 Implementation of AKI ealerts by March 2015 NHS England Five Year Forward View: Forward into Action Dec National CQUIN: 2015/2016

7 What is AKI and why is it important?

8 Acute Kidney Injury AKI refers to an abrupt decline in kidney function resulting in the inability to excrete metabolic wastes and maintain fluid and mineral balance. It occurs over hours to days.

9 KDIGO 2012

10 The Causes Loss of effective circulation. (Pre-renal) Internal damage. (Intrinsic) Obstruction. (Obstructive)

11 Who is at risk? The elderly > 65 Chronic kidney disease Pre-existing illnesses Diabetes Heart/Liver disease Vascular disease Malignancy Regular Medications ACE Inhibitors NSAIDs Diuretics

12 AKI is Common Incidence varies with the population and the patient groups studied: Pooled Incidence from 154 studies worldwide using a KDIGO equivalent definition was 21.6% in adults (Susantitaphong CJASN Sept 2013) One in five people admitted to hospital in the UK each year as an emergency has acute kidney injury

13 There is some evidence the incidence is rising: US Medicare beneficiaries 1992 to 2001 AKI incidence increased by 11% per year (Xue 2006) Attributed to an aging population with increases in admission with sepsis, increased use of contrast agents, nephrotoxic drugs, and interventional procedures.

14 AKI is associated with poor outcomes 1. Increased mortality adjusted mortality increased 4 fold in hospital and extends beyond discharge 2. Increased hospital length of stay LOS 12 days v 7 days (p=.002) (QA Portsmouth) 3. Increased incidence and progression of CKD and ESRD.

15 4. Increased risk of hospital readmission. 5. Increased risk or repeat AKI episodes. Portsmouth a repeat AKI episode increased the risk of death after 6 months more than 4 fold 6. Increased risk of discharge to rehabilitation facilities.

16 Portsmouth AKI/CKD Outcome Data 375 patients recruited with AKI: After 6 months 18.1% (95% CI: 14.1% to 22.9%) demonstrated a fall in egfr of 25% from baseline. This included 9.2% (95% CI: 5.2% to 15.7%) of AKIN stage 1!

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18 NCEPOD 2009 Only 50% of AKI care was rated good by the panel. A fifth of post admission AKI was both predictable and avoidable.

19 The Impact Annual cost of AKI-related inpatient care in England estimated at 1.02 billion. (1% of the entire NHS budget) Estimated annual number of excess deaths associated with AKI in England may be > 40,000. The Economic impact of Acute Kidney Injury in England. Kerr M. et al. NDT July 2014

20 AKI is everybody s business.

21 Distribution of AKI episodes across acute specialties, stratified by AKI stage. Selby N M et al. CJASN 2012;7:

22 AKI is not just a hospital concern Portsmouth data: 375 prospectively acquired AKI cases (2010/2011) AKI was found on admission and hence community acquired in 68% - community AKI was more severe by staging - sepsis was an important trigger In those without CKD at baseline community acquired AKI was associated with a higher hospital and 6 month mortality (OR 3.5, 95% C.I , p=.03) Royal Derby Hospital: 61% community acquired (Selby 2012)

23 What are we doing about it?

24 AKI is not about bad doctors and nurses AKI is a patient safety issue but it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions Acute Kidney Injury National Programme

25 ealerts Biomarkers Education Guidelines Research The Whole Pathway Nephrology Referral The Patient Prevention Sick Day Rules? Follow after discharge Care Bundles

26 Wessex AKI Clinical Forum

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28 AKI Network Forum Wessex SCN Regional AKI Leads Local Renal Units Wessex/Dorset Local Trust Leads Renal ITU MAU

29 The Remit harmonising the AKI pathway based on evidence and national guidelines will embed best practice and help education and learning improve advice/guidance and referral practices to the regional renal units sharing of expertise, manpower and other resources a network provides a stronger platform to lobby for resources pooling of audit data will increase its power collaborative research a point of accountability

30 The Forum Nephrologists NHS England SCN manager Trust AKI leads currently 6 CCG representatives Public Health Consultant Laboratory Lead Nurse specialist University of Southampton Wessex CLARCH and HHR AHSN representative Acute Medicine SPR

31 Wessex AKI Workstreams 1. Hospital Education/Awareness Wessex wide guidelines Electronic Alerts AKI Outreach Research 2. Primary Care/Community Education/Awareness Primary care guidelines Electronic Alerts Public Health Community Pharmacy Research

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33 AKI appears to be a proxy indicator of a vulnerable subpopulation with high comorbidity who are at risk of future hospital admissions, recurrent AKI episodes, progressive decline in renal function and death.

34 Wessex Acute Kidney Injury Clinical Forum Dr Alastair Bateman Primary Care Lead, Wessex Acute Kidney Injury Forum General Practitioner Prescribing Lead South Eastern Hants CCG

35 Supporting Primary Care Alastair Bateman GP, Prescribing Lead South Eastern Hants CCG, NICE MPC Associate

36 Primary Care is Important! Good Basic Medical Care prevents and treats AKI Whole health economy issue 61% arise in the community(selby NM et al CJASN 2012; 7(4): 533) (68% in Portsmouth) (Uniacke 2012) Bournemouth stats AKI alerts in 8 weeksaround 30% did not have repeat test done after baseline

37 Background: prevention and early identification NICE CG 169 Aug 2013 AKI can be readily identified by close monitoring of routine serum creatinine and urine output results AKI can be prevented by early recognition and treatment of the underlying cause, for example: Early treatment of infections/sepsis Early treatment/prevention of dehydration Correcting hypovolaemia AKI can also be prevented by: Monitoring use of drugs such as NSAIDs and ACE inhibitors, especially if a patient is acutely unwell Taking care with at-risk patients who need iodinated contrast agents with scans Implementing NICE guidance

38 Patient information and support Discuss future risk of AKI, especially for patients with egfr < 60 or those with neurological or cognitive impairment. In particular, discuss the risk associated with: conditions that may lead to dehydration use of drugs with nephrotoxic potential, including over the counter NSAIDs. Implementing NICE guidance

39 Patients without obvious acute illness Consider acute kidney injury when an adult, child or young person with acute illness with no clear cause has any of the following: Chronic kidney disease, especially stage 3B, 4 or 5, or urological disease Symptoms suggesting complications of acute kidney injury New onset or significant worsening of urological symptoms Symptoms or signs of a multi-system disease affecting the kidneys and other organ systems. For example, signs of acute kidney injury, plus a purpuric rash. A rise in serum creatinine could indicate acute kidney injury rather than a worsening of any existing chronic kidney disease. Implementing NICE guidance

40 Initial Plans-How do we encourage change? Raising awareness of the importance of AKI recognition and prevention in all care settings AKI guidance flow chart for use in Primary Care ealerts from labs - mandated for Trusts from Apr 2015 and in Primary care from Apr 2016 but started in some areas last month Sick Day Rules Leaflet for patients on nephrotoxic drugs Working across Wessex and National programme via Wessex Cardiovascular Strategic Clinical Network (SCN)

41 Initial Plans-Methods Transforming the Local Awareness and Early detection Initiative ( LAEDI) originally used by the Cancer SCN primary care engagement model adding key points re AKI into discussion (Practice meetings GP peer) Talk to larger groups GPs e.g. via TARGET sessions Development of agreed local flow chart/guideline and make available through decision support e.g. DXS, Eclipse Development of agreed sick day rules leaflet and engage with GPs, nursing teams and pharmacies to encourage usage. Make sure education precedes introduction of ealerts to avoid CKD Chaos

42 Issues Short time scales Early release of ealerts Access to meetings e.g. TARGET Engaging with pharmacy and nursing teams Lack of evidence for interventions e.g. Sick Day Rules for population use - numerous different versions available Hard to get one set of rules to fit all clinical situations, e.g. Heart Failure and what about patients with NOMADs? Primary Care oriented guidelines difficult to find one all are happy with Workload fears from both primary and secondary care How to assess success?

43 Practical issues Phlebotomy Path Lab Collections Out of Hours results, follow up, weekends Response to ealerts Recognition / Acceptance of AKI and need to act ealerts already started in some areas Availability of advice and from whom? Workload for all

44 Survey results Fareham and Gosport CCG TARGET event 60% Q4. I would benefit from more education and advice about... acute kidney injury 60% 50% 40% 40% 30% 20% 10% 0% 0% 0% 0% Strongly agree Agree Don't know/neutral Disagree Strongly disagree

45 My preference for further education and advice would include: AKI online learning module and videos Smart phone app How to' or 'Top Tips' type guide Local guidelines on a page Peer-to-peer GP practice visit Multi-professional practice visit (incl. pharmacy, nursing) Refresher education workshop on managing the acutely unwell patient

46 Where are we now? 2 TARGETS done and more planned Pre TARGET Survey Monkeys on AKI AKI launch day Primary Care Guideline Ten Top Tips Hold engaging with community pharmacy / nursing until it is clear what the message is.

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48 Time for a break Refreshments and poster viewing See you back at 11.45