Think Kidneys programme update 2017

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Role of Think Kidneys Preventing the avoidable harm caused by acute kidney injury Julie Slevin UK Renal Registry 11/27/2017 Think Kidneys Autumn 2017 | 1

Transcript of Think Kidneys programme update 2017

Role of Think Kidneys

Preventing the avoidable harm caused by acute kidney

injury

Julie Slevin UK Renal Registry

11/27/2017Think Kidneys Autumn 2017 | 1

UK Renal Registry

Collects data on all things Kidney

Think Kidneys Improvement programmes:

Acute Kidney Injury

Improving the care of people at risk of, or with, acute kidney injury.

Transforming Participation in CKD

A unique NHS programme to help people with CKD live their best life.

Kidney Quality Improvement Partnership

Working together to develop, support and share improvement in kidney services to improve people's health and add value

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Acute Kidney Injury

Acute kidney injury is a sudden and recent reduction in a person’s

kidney function. It is often referred to as AKI.

Acute kidney injury is identified by blood tests when a raised level of

creatinine shows the stage of AKI.

Acute kidney injury can be caused by a number of things such as:

Stress on the kidneys due to illness or infection

Severe dehydration

Side effects of some drugs when you are unwell

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Is Acute Kidney Injury (AKI) really a problem?

In the UK up to 100,000 deaths

each year in hospital are associated with acute kidney injury.

Up to 30% could be prevented with

the right care and treatment

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One in five people admitted to hospital in the UK each year

as an emergency has acute kidney injury

Just one in two people know their kidneys make urine

About 65% of acute kidney injury starts in

the community

NCEPOD. Adding insultto injury, 2009

Wang, et al. 2012 Ipsos MORI survey,July 2014

Selby, et al. 2012

The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Adding insult to injury’ http://www.ncepod.org.uk/2009aki.html found:

Only 50% of care for AKI was considered good

Unacceptable delays in identifying post admission AKI in 43% of the patients

Considerable knowledge gaps in identifying and managing someone with AKI

A fifth of all cases were predictable and avoidable

Predictable, avoidable AKI should not occur

Acute Kidney Injury (AKI)

Shared purpose: reduce harm related to AKI

Support commissioners and organisational leads in driving and championing the need to improve acute kidney injury care.

Provide clinicians and patients with the education, information and access to and about acute kidney injury to inform individual care

Establish the data flows to allow successful audit and quality improvement

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A focused effort across all care settings

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Using IT: improving diagnosis

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Using IT: Awareness, education, sharing, information

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Think Kidneys public campaign

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https://www.thinkkidneys.nhs.uk/campaign/

Identifying AKI

AKI is detected by a rise in Creatinine (Cr) and/or a decrease in urine outputIt’s severity (stage) is related to the change from the patients baseline CrIt can occur without symptoms

chronic kidney disease

heart failure

liver disease

diabetes

history of acute kidney injury

oliguria (urine output less than 0.5

ml/kg/hour)

Hypovolaemia

Sepsis

deteriorating early warning scores

(NICE Guideline 169, 2014)

Risk factors

Drugs can also affect kidney

function, these include:

NSAIDs,

angiotensin-converting enzyme

[ACE] inhibitors,

angiotensin II receptor

antagonists [ARBs] and

diuretics within the past week,

especially if hypovolaemic

use of iodinated contrast agents

symptoms or history of urological

obstruction, or conditions that may

lead to obstruction

Age 65 years or over

Are any of your patients at risk??

Pre- Renal

Most common cause of AKI and caused by reduced blood flow to the kidneys

Causes include:

• Hypotension• Dehydration• Heart Failure

Assess hydration and NEWS

With prompt correction this AKI rapidly resolves

Intrinsic

Involves damage to the kidney itself. Some causes include:

• Acute tubular necrosis• Glomerulonephritis• Drugs/toxins

Hardest to treat and likely to need Renal Team involvement

A urine dip will aid diagnosis

All AKI will eventually become intrinsic if it is not treated promptly

Post-RenalA consequence of urinary tract obstruction

• Blocked catheter• Enlarged prostate• Tumours

An obstruction can be above or below the bladder so consider bladder scan +/-USS KUB

May need a Urology review

Treatment of AKI depends on its cause

Pre- renal factors in preventing AKI-HYDRATION

Assessing hydration is essential for the prevention and management of AKI

Dehydration is the most common cause of pre-renal AKI

REMEMBER

Fluid BalanceUrine ColourDaily weights

Lying/standard BP

Intravenous fluid are often used to treat pre renal AKI. Only 72% of 366 patients seen by an AKI Team in a small scale study actually received them as prescribed

Healthy wee is 1-3, 4-8 you must hydrate!

In a hydrated patient with stable NEWS, rule out obstruction and consider

intrinsic causes!

Why is fluid balance so important?

Accurate fluid balance charting can also prevent life threatening complications of AKI

Optimum fluid balance

Assessment of fluid

Fluid overload

Oedema

Hypertension

Reduced oxygenation

Fluid loss

Hypotension

Shock

AKI

Too much fluidToo little fluid

DIP, MEASURE & DOCUMENTAll patients with AKI should have a urine dip. Blood and Protein in urine is a sign of kidney disease and intrinsic AKI

THINK: Have your patients passed urine in the last 6 hours?Cumulative totals should be done every 6 hours as

well as dailyIs your fluid balance chart accurate? In a small scale

study in one trust 85% of 570 patients seen by the AKI team did NOT have accurate in/out put monitoring!

Symptoms of AKI

In the early stages there may be no real symptoms or signs. A blood test

is needed to detect it.

However, someone with AKI can deteriorate quickly and suddenly

experience any of the following:

Changes to urine output, particularly a major reduction in the

amount of urine passed

Changes to urine colour/smell

Nausea, vomiting

Abdominal pains and feeling generally unwell, similar to a hangover

Dehydration or thirst

Confusion and drowsiness

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Treatment of AKI

Treatment of AKI is about identifying the cause to help you address the actions needed.

Certain drugs can affect the kidneys and these include:

Non-steroidal anti-inflammatory drugs (eg Ibuprofen)

Drugs that lower blood pressure (eg Ramipril)

Drugs used for people with diabetes (eg Metformin)

Drugs used by Mental Health patients (eg Lithium)

The doctor may decide that some of drugs need to be stopped for a day or two

The patient will need some more blood tests

The doctor might recommend to increase fluids or to admit the patient to hospital to have some fluid replacement

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Think Kidneys

The kidneys don’t usually complain

The kidneys can lose up to 90% of their function before you may even begin to notice

The kidneys are clever organs but need a good blood supply to work effectively

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Context for TP-CKD Programme

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The Wanless report (2002): Costs will be unsustainable unless radical reform takes place in the NHS with patients enabled to take more responsibility for their care

NHS England’s Five Year Forward View: (2014): “a more engaged relationship with patients and communities to promote well-being and prevent ill-health”

“to support people to manage their own health and care”

Collaboration between NHSE and UKRR

Terminology – Your Health Survey

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PAMPatient Activation MeasureSkills, knowledge and confidence to manageyour long term condition

PROMsPatient Reported Outcome MeasureQuality of life

GenericDisease specific

PREMPatient Reported Experience MeasureQuestions relating to their healthcare experienceAll Renal Units X 1 per year

EQ-5D-5L

POS – S Renal

Self developed

Patient Activation

Measure (PAM)

Clinician-support for

PAM (CS-PAM)

Implementation

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14 of the 52 adult renal units in England participated in the implementation of ‘Your Health Survey’ to measure patient activation, disease symptoms and quality of life outcomes.

Each unit used a different approach to implementation resulting in survey returns across the whole patient pathway.

The survey was handed out to patients as a paper copy by patient volunteers, nursing and medical staff who had previously attended an initiation event and was supported by information such as leaflets and posters.

Completed surveys were returned to the UK Renal Registry (UKRR) and scanned into a database. Results returned to patients via Patient View and units via nhs.net

Achievements

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3,700 Your Health Surveys collected from patients across 14 renal unitsOver 450 CS-PAM Surveys collected from renal unit staff across 14 renal unitsAnnual Patient Experience survey has been rolled out nationally – 10,000 surveys collected in 2017 across England and Wales

How can we use this data to support the patient?Tailor conversations to individualsAcknowledge symptom burdenAddressing things that matter to themBuilding knowledge, skills and confidence – PAM level

Can interventions improve activation for teams and patients? Intervention Toolkit developed by patients and professionals in the Interventions work-stream

Kidney Quality Improvement

Partnership (KQuIP)

Graham Lipkin, Co Chair KQuIP

Louise Wells Co chair KQuIP

James McCann, KQuIP Programme Lead

Victoria Powell, KQuIP Regional Project

Manager

TBC, KQuIP Regional Project Manager

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Kidney Quality Improvement Partnership (KQuIP)

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KQuIP is a dynamic network of

kidney health professionals, patients

and carers who are committed to

developing, supporting and sharing

quality improvement in kidney

services in order to enhance

outcomes and quality of life for

patients with kidney disease.

KQuIP Structure

KQuIP Board

A representation of the KQuIP Partnering organisations and

stakeholder groups that meet twice a year.

KQuIP Chairs

Chairs of the workstreams that meet every six weeks

KQuIP Operational Group

GWL, LW, RC, KT and JM that meet on a monthly basis.

KQuIP Workstreams

Development, Projects and Measurement and Understanding

workstreams

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KQuIP project priorities

Improving access to kidney transplantation; Transplant First

Pre-emptive transplant listing and kidney transplantation rates vary widely. Transplant First, developed in the West Midlands under KQuIP. This has been packaged to provide resources and support to enable other interested regions to implement.

Improving access to home therapies for suitable patients

There is wide variation of access for patients to peritoneal and home haemodialysis. KQuIP is currently developing a national QI project to increase home therapies.

Improving vascular access; MAGIC - Managing Access by Generating Improvements in Cannulation

Aiming to reduce variation, improve incidence and prevalence rates, improve patient

experience, and reduce complications of cannulation of arteriovenous fistulae and

grafts.

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KQuIP regional days and delivery

West Midlands

Yorkshire and the Humber

East Midlands

North West

Potential future regions: South West, North East, Oxford and Thames Valley, Wales, Paediatrics and SPR club….

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KQuIP Website, Hub and E-Learning

KQUIP is working with the renal community to identify a suitable online E-learning platform that will:

Be owned by the renal community

Be free to use at the point of access

Support the sustainability of embedded quality improvement

The KQuIP Hub features:

QI stories from renal teams around the country

abstracts from presentations on QI projects

Signposting to educational resources to help enhance QI knowledge

Tools to help with QI projects as well as renal specific tools.

The hub aims to bring all of these resources and tools together in one place to help

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KQuIP welcomes you……enabling you and your team to improve quality and

safety

www.thinkkidneys.nhs.uk/kquip/

For further information and resources regarding

Acute Kidney Injury, Transforming Participation in CKD and KQuIP, please see the

Think Kidneys website

www.thinkkidneys.nhs.uk