Quality standard

Quality statement 4: Response to acute kidney injury warning stage 3 test result

Quality statement 4: Response to acute kidney injury warning stage 3 test result

Quality statement

Adults with an acute kidney injury warning stage 3 test result have a clinical review within 6 hours or, if they are acutely ill in the community, an immediate review to consider admission to hospital. [new 2023]

Rationale

NHS England has mandated a national acute kidney injury algorithm which, when integrated within laboratory information management systems, identifies potential cases of acute kidney injury using laboratory data in real time and produces an acute kidney injury warning stage test result to inform clinical teams. Timely and effective communication of and response to an acute kidney injury warning stage 3 test result (current creatinine 3 or more times the baseline level, or creatinine 1.5 times baseline and more than 354 micromol/litre) will prevent delays in treatment and improve outcomes. An acute kidney injury warning stage 3 test result should prompt an urgent clinical review to determine the management approach or an immediate review to consider hospitalisation. The precise timing of the review should be tailored to the clinical context.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are included for quality improvement purposes only; in practice some patients may require a more rapid response based on acute kidney injury risk factors and clinical features. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of processes for pathology providers to communicate acute kidney injury warning stage test results urgently to primary and secondary care clinicians.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, service protocols.

Process

The time frames included in these measures are dependent on timely communication of acute kidney injury warning stage test results to clinicians responsible for follow-up.

a) Proportion of acute kidney injury warning stage 3 test results for adults who are admitted to hospital or clinically stable in the community that are followed up by a clinical review within 6 hours of the reported result.

Numerator – the number in the denominator that are followed up by a clinical review within 6 hours of the reported result.

Denominator – the number of acute kidney injury warning stage 3 test results for adults who are admitted to hospital or clinically stable in the community.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records or local monitoring systems.

b) Proportion of acute kidney injury warning stage 3 test results for adults who are acutely ill in the community that are followed up by an immediate review to consider admission to hospital.

Numerator – the number in the denominator that are followed up by an immediate review to consider admission to hospital.

Denominator – the number of acute kidney injury warning stage 3 test results for adults who are acutely ill in the community.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records or local monitoring systems.

Outcome

30-day mortality associated with acute kidney injury.

Data source: Mortality statistics from the Office for National Statistics.

What the quality statement means for different audiences

Service providers (such as laboratories, hospitals, GP practices, out-of-hours services and community pharmacists) ensure systems are in place to communicate acute kidney injury warning stage test results urgently to primary and secondary care clinicians. Providers ensure processes are in place for adults with an acute kidney injury warning stage 3 test result to have a clinical review within 6 hours or, if they are acutely ill in the community, an immediate review to consider admission to hospital.

Healthcare professionals (such as doctors, pharmacists and nurses) carry out clinical reviews for adults with an acute kidney injury warning stage 3 test result within 6 hours. If the person is acutely ill in the community, healthcare professionals carry out an immediate review to consider admission to hospital.

Commissioners (integrated care boards and NHS England) ensure that the services they commission have agreed processes for urgent communication of acute kidney injury warning stage test results. They also have follow-up processes and time frames for clinical review for adults with an acute kidney injury warning stage 3 test result.

Adults with blood test results that show an acute kidney injury warning stage 3 are seen by a healthcare professional urgently for further assessment and to plan how to manage their condition.

Definitions of terms used in this quality statement

Clinical review

The UK Kidney Association's (formerly the Renal Association) guideline on acute kidney injury, audit measures 12 to 14, identify physiological assessment, documented volume assessment and documented medication review as priorities following an acute kidney injury warning stage test result in secondary care.

The approach to clinical review in primary care is described in Think Kidneys' resource on responding to AKI warning stage test results in primary care.

For specific information on medication review for adults with acute kidney injury see Think Kidneys' documents on acute kidney injury - potentially problematic drugs and actions to take in primary care and guidelines for medicines optimisation in patients with acute kidney injury. Information on dose adjustment in renal impairment is available from the British National Formulary (BNF) or the manufacturers' summary of product characteristics (available at www.medicines.org.uk/emc). Healthcare professionals should seek specialist advice if unsure. [NICE's clinical knowledge summary on acute kidney injury, management of acute kidney injury]

Equality and diversity considerations

Healthcare professionals should be aware that acute kidney injury is less likely to be identified in young adults under 30 and some minority ethnic groups. A timely and effective response to an acute kidney injury warning stage 3 test result will help to improve detection in these groups.