Introduction

This quality standard covers the prevention, detection and management of non‑traumatic acute kidney injury up to the point of renal replacement therapy in adults, young people and children older than 1 month. It does not cover the management of acute kidney injury in people with renal transplants or in pregnant women, but does include when to involve nephrology services for people with renal transplants. For more information see the topic overview.

Why this quality standard is needed

Acute kidney injury occurs when the kidneys suddenly (within hours or days of normal functioning) stop working as they should. It encompasses a wide spectrum of injury to the kidneys, not just 'kidney failure'. The kidneys need a competent circulation for normal function, so acute kidney injury is a feature of many severe illnesses as a result of reduced blood flow. Other causes of acute kidney injury include dehydration, some drugs, severe infections, blockage of the urinary tract and the contrast medium used for some types of scan.

Acute kidney injury is seen in 13–18% of all people admitted to hospital, with older adults being particularly affected. These patients are usually under the care of healthcare professionals practising in specialties other than nephrology, who may not always be familiar with the best care for patients with acute kidney injury. However, studies suggest that acute kidney injury is under‑recorded on patients' notes and possibly under‑recognised. A recent study (Kerr et al. 2014), based on Hospital Episodes Statistics (HES) data 2010/11, found that acute kidney injury was recorded in 2.4% of inpatient admissions. The same study used laboratory data to estimate that age‑ and gender‑standardised prevalence estimates may be more than 5 times as high.

The number of inpatients affected by acute kidney injury means that it has a major impact on healthcare resources. The annual cost of inpatient care related to acute kidney injury in England is estimated to be £1.02 billion, which is just over 1% of the NHS budget (Kerr et al. 2014) and is more than is spent on breast cancer, lung cancer and bowel cancer combined (Health Service Journal 22 April 2014).

Inpatient mortality from acute kidney injury varies considerably, depending on severity, setting (intensive care or non‑intensive care) and many other patient‑related factors. HES data from 2010/11 show that patients died before discharge in approximately 28% of admissions where acute kidney injury was recorded. Because of its frequency and the associated mortality rate, prevention or amelioration of acute kidney injury would prevent a large number of deaths and substantially reduce complications and their associated costs.

Acute kidney injury is increasingly being seen in primary care, and so it is important to raise awareness of the condition among healthcare professionals working in primary care. It is also important that any identified cases of acute kidney injury are managed or referred appropriately.

Up to 30% of cases of acute kidney injury may be preventable (National Confidential Enquiry into Patient Outcome and Death 2009), and risk assessment and prevention, early recognition and management are key factors in preventing deaths and reducing complications. Because there is no specific treatment for acute kidney injury, management is mainly supportive. This involves treating the cause and managing the symptoms until the kidneys recover from the injury, and includes referral for renal replacement therapy if appropriate.

The quality standard is expected to contribute to improvements in the following outcomes:

  • Avoidable death (including primary causes other than acute kidney injury).

  • Deterioration to stages 2 and 3 in people with acute kidney injury stage 1.

  • The number of people who need acute renal replacement therapy.

  • Prevalence of chronic kidney disease.

  • Patient experience of hospital care.

  • The number of patient safety incidents.

  • Admissions to critical care (and dialysis).

  • Length of hospital stay for acute kidney injury.

  • Incidence of acute kidney injury.

  • Complications associated with acute kidney injury (for example, hyperkalaemia, fluid overload).

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following outcomes framework published by the Department of Health:

Table 1 shows the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014–15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i) Adults, ii) Children and young people

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

i) Hip replacement, ii) Knee replacement, iii) Groin hernia, iv) Varicose veins

Improving recovery from injuries and trauma

3.3 Survival from major trauma

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

Improvement areas

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicator

5a Patient safety incidents reported

5b Safety incidents involving severe harm or death

5c Hospital deaths attributable to problems in care

Improvement areas

Reducing the incidence of avoidable harm

5.4 Incidence of medication errors causing serious harm

Delivering safe care to children in acute settings

5.6 Incidence of harm to children due to 'failure to monitor'

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to acute kidney injury.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development source(s) for quality standards that impact on patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for acute kidney injury specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole acute kidney injury care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to people with acute kidney injury.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality acute kidney injury service are listed in related NICE quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating people with acute kidney injury should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with acute kidney injury. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.