NICE Clinical Guideline 169 Acute Kidney Injury Local Implementation Gap Analysis Please tick appropriate box in response to questions below and return to Michelle Timoney (michelle.timoney@nhs.net) by 20 December 2013. There is one questionnaire for adult services, and a separate questionnaire for children s services. Where possible please also send supporting evidence such as guidelines and pathways to help build up examples of good practice across the Region. NHS Trust: Name of person completing questionnaire: Contact email: 1. Assessing risk of acute kidney injury 1.1 Do you routinely assess risk of developing acute kidney injury in adult patients with acute illness? If yes, please send supporting evidence (eg patient pathway, screening tool etc) 1.2 Do you routinely assess risk of developing acute kidney injury in all adult patients with no obvious acute illness? If yes, please send supporting evidence (eg patient pathway, screening tool etc) 1
1.3 Do you routinely assess risk of developing acute kidney injury in adult patients having iodinated contrast agents? If yes, please send supporting evidence (eg patient pathway, screening tool etc). 1.4 Do you routinely assess risk of developing acute kidney injury in adult patients having surgery? If yes, please send supporting evidence (eg patient pathway, screening tool etc). 2. Preventing acute kidney injury Ongoing assessment of the condition of patients in hospital 2.1 Do you use the Acutely Ill Patient in Hospital (NICE CG 50) recommended track and trigger system to identify adults who are at risk of acute kidney injury because their clinical condition is deteriorating? If so, please send supporting evidence: 2
2.2 If your track and trigger system does not monitor urine output when adults are at risk of developing acute kidney injury, do you have a system in place to recognise and respond to oliguria? If so, please send supporting evidence: 3. Preventing acute kidney injury in adults receiving iodinated contrast agents 3.1 Do you have a pathway or guideline that includes prophylaxis such as volume expansion, temporarily stopping ACE inhibitors and discussion with nephrology for complex cases? If so, please send supporting evidence: 4. Monitoring and preventing deterioration in patients with or at high risk of acute kidney injury 4.1 Do you have Electronic Alerts or Clinical Decision Support Systems to aid decision making and prescribing? If yes, please provide more detail about system and it s stage of development: 3
4.2 Do you have pharmacy input into optimising medicines and drug dosing in adult patients with or at risk of acute kidney injury? If so, please provide details: 5. Detecting Acute Kidney Injury 5.1 Do you monitor serum creatinine regularly in all adults with or at risk of acute kidney? 5.2 Does your laboratory service provider generate AKI alerts based on changes in serum creatinine? If yes, what guideline or method is used: 4
6. Identifying the cause of acute kidney injury 6.1 Do you have a system in place to ensure that the cause(s) of acute kidney injury are recorded in the patients case notes? 6.2 Is urinalysis performed and documented in all patients as soon as acute kidney injury is suspected or detected? If so, please provide evidence (eg pathways, audits or guidelines). 6.3 When pyonephrosis is suspected can urinary tract ultrasound be performed within 6 hours of assessment? Please provide evidence (eg pathways, audits or guidelines). 6.4 When there is no cause identified for acute kidney or if there is a risk of urinary tract obstruction, can ultrasound be performed within 24 hours of assessment? Please provide evidence (eg pathways, audits or guidelines). 5
7. Managing acute kidney injury 7.1 Do you have immediate access to a urology service? Please describe the nature of urology support in your organisation. 7.2 Can nephrostomy and stenting be undertaken within 12 hours of patient assessment? 7.3 Do you ever use loop diuretics to treat acute kidney injury in the absence of fluid overload or hyperkalaemia? 7.4 Do you ever use low dose dopamine to treat acute kidney injury? 6
7.5 Do you have a pathway or guideline for referring for renal replacement therapy? If so, please provide a copy. 7.6 Do you have a pathway or guideline for when to refer adults with acute kidney injury to nephrology? If so, please provide a copy. 8. Access to renal services 8.1 How long does it take non renal clinicians to get an adult renal opinion? 8.2 Following referral, how long does it take for an AKI patient to be transferred to an adult renal unit or HDU? 8.3 Out of 5, how would you rate the support you get from adult renal services? 7
1 2 3 4 5 Poor Excellent 8.4 Please suggest the one most important improvement you would like to see in the support you get from adult renal services for acute kidney injury: 9. Information and support for patients and carers 9.1 Do you have any patient or carer information resources detailing long-term treatment options for adult patients with acute kidney injury? If so, please provide more detail and examples: 10. Clinical data capture Do you collect any local data around AKI? If yes, what system do you use to collect the data i.e. CyberREN; spreadsheet; PAS; lab system alerts; via submissions to renal registry; bespoke database; is data capture routine, or undertaken on an ad hoc basis for audit? 8
Children s AKI Baseline assessment - please complete this if your organisation provides services to children Please tick appropriate box in response to questions below and return to Michelle Timoney (michelle.timoney@nhs.net) by 20 December 2013. There is one questionnaire for adult services, and a separate questionnaire for children s services. Where possible please also send supporting evidence such as guidelines and pathways to help build up examples of good practice across the Region. NHS Trust: Name of person completing questionnaire: Contact email: 11. Assessing risk of acute kidney injury in children 11.1 Do you routinely assess risk of developing acute kidney injury in children with acute illness? If yes, please send supporting evidence (eg patient pathway, screening tool etc) 11.2 Do you routinely assess risk of developing acute kidney injury in children with no obvious acute illness? If yes, please send supporting evidence (eg patient pathway, screening tool etc) 9
11.3 Do you routinely assess risk of developing acute kidney injury in children having iodinated contrast agents? If yes, please send supporting evidence (eg patient pathway, screening tool etc). 11.4 Do you routinely assess risk of developing acute kidney injury in children having surgery? If yes, please send supporting evidence (eg patient pathway, screening tool etc). 12. Preventing acute kidney injury in children Ongoing assessment of the condition of patients in hospital 12.1 Do you use a paediatric early warning score to identify children at risk of developing acute kidney injury? If so, please send supporting evidence: 10
13. Monitoring and preventing deterioration in children with or at high risk of acute kidney injury 13.1 Do you have Electronic Alerts or Clinical Decision Support Systems to aid decision making and prescribing for children? If yes, please provide more detail about system and it s stage of development: 13.2 Do you have pharmacy input into optimising medicines and drug dosing in children with or at risk of acute kidney injury? If so, please provide details: 14. Detecting acute kidney injury in children 14.1 Do you monitor serum creatinine regularly in all children with or at risk of acute kidney? 14.2 Does your laboratory service provider generate AKI alerts for children based on changes in serum creatinine? If yes, what guideline or method is used: 11
15. Identifying the cause of acute kidney injury in children 15.1 Do you have a system in place to ensure that the cause(s) of acute kidney injury are recorded in the patients case notes? 15.2 Is urinalysis performed and documented in all patients as soon as acute kidney injury is suspected or detected? If so, please provide evidence (eg pathways, audits or guidelines). 15.3 When pyonephrosis is suspected can urinary tract ultrasound be performed within 6 hours of assessment? Please provide evidence (eg pathways, audits or guidelines). 15.4 When there is no cause identified for acute kidney or if there is a risk of urinary tract obstruction, can ultrasound be performed within 24 hours of assessment? Please provide evidence (eg pathways, audits or guidelines). 12
16. Managing acute kidney injury in children 16.1 Do you have immediate access to a urology service for children? Please describe the nature of urology support in your organisation. 16.2 Can nephrostomy and stenting be undertaken within 12 hours of patient assessment? 16.3 Do you ever use loop diuretics to treat acute kidney injury in the absence of fluid overload or hyperkalaemia? 16.4 Do you ever use low dose dopamine to treat acute kidney injury? 13
16.5 Do you have a pathway or guideline for referring for renal replacement therapy? If so, please provide a copy. 16.6 Do you have a pathway or guideline for when to refer children with acute kidney injury to nephrology? If so, please provide a copy. 17. Access to renal services 17.1 How long does it take non renal clinicians to get a paediatric renal opinion? 17.2 Following referral, how long does it take for an AKI patient to be transferred to a paediatric renal unit or HDU? 14
17.3 Out of 5, how would you rate the support you get from paediatric renal services? 1 2 3 4 5 Poor Excellent 17.4 Please suggest the one most important improvement you would like to see in the support you get from paediatric renal services for acute kidney injury: 18. Information and support for patients and carers 18.1 Do you have any patient or carer information resources detailing long-term treatment options for children with acute kidney injury? If so, please provide more detail and examples: 19. Clinical data capture Do you collect any local data around AKI? If yes, what system do you use to collect the data i.e. CyberREN; spreadsheet; PAS; lab system alerts; via submissions to renal registry; bespoke database; is data capture routine, or undertaken on an ad hoc basis for audit? 15
Thank you for taking the time to complete this we will summarise the findings across Cheshire and Merseyside and feed back. Regards, Dr Abraham Abraham, Consultant nephrologist and clinical lead of Cheshire & Merseyside strategic clinical kidney network; Chair of AKI group Queries, completed assessments and general comments please to: michelle.timoney@nhs.net Michelle Timoney, Quality Improvement Lead Cheshire and Merseyside Strategic Clinical Networks Cheshire, Warrington and Wirral Area Team, NHS England; Quayside, Wilderspool Causeway, Greenalls Avenue, Stockton Heath, WA4 6HL Tel: 07920 846 735 16