Quality statement 3: Monitoring in hospital for people at risk

Quality statement

People in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored.

Rationale

Acute kidney injury can be a 'silent' condition with no external signs or symptoms. Because many episodes of acute kidney injury are preventable, identifying people who are at risk and monitoring their clinical condition is important. Changes in serum creatinine level and urine output are indicators of risk, and it is important that these biomarkers are monitored alongside a 'track and trigger' system. Recognising and responding to these changes will ensure appropriate and quick intervention to prevent acute kidney injury developing.

Quality measures

Structure

Evidence of local arrangements to ensure that people in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored.

Data source: Local data collection.

Process

Proportion of admissions to hospital of people who are at risk of acute kidney injury where serum creatinine level and urine output are monitored.

Numerator – the number in the denominator where serum creatinine level and urine output are monitored.

Denominator – the number of admissions to hospital of people who are at risk of acute kidney injury.

Data source: Local data collection. Acute kidney injury (NICE guideline CG169), clinical audit tool adults, standards 5 and 6 and clinical audit tool children, standard 2.

Outcome

Incidence of acute kidney injury.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (district general hospitals) ensure that protocols are in place for trained healthcare professionals to monitor the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and to respond to any changes.

Healthcare professionals follow local protocols for monitoring the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and respond to any changes.

Commissioners (clinical commissioning groups) ensure that secondary care providers have protocols in place for trained healthcare professionals to monitor the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and to respond to any changes.

What the quality statement means for patients, service users and carers

People in hospital who are at risk of developing acute kidney injury should have blood tests to measure levels of creatinine (a substance that indicates how well their kidneys are working) and have their urine volume measured. Healthcare professionals should take action if they find any changes. This should be done for patients in acute hospitals and other hospital settings (such as psychiatric hospitals).

Source guidance

Definitions of terms used in this quality statement

People in hospital who are at risk of acute kidney injury

Adults in hospital at risk of acute kidney injury include those:

  • who have non‑elective admissions

  • who have any major planned interventions, such as interventional radiological procedures (including coronary angiography) and grade 3 or grade 4 surgery, neurosurgery or cardiovascular surgery (see preoperative tests [NICE guideline CG3] for definitions of surgery grades).

[Expert opinion]

NICE guideline CG169, recommendation 1.1.1 has a detailed list of risk factors for acute kidney injury in adults with acute illness.

Children and young people in hospital with acute illness are at risk of acute kidney injury if any of the following are likely or present:

  • chronic kidney disease

  • heart failure

  • liver disease

  • history of acute kidney injury

  • oliguria (urine output less than 0.5 ml/kg/hour)

  • young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer

  • hypovolaemia

  • use of drugs with nephrotoxic potential (such as NSAIDs [non‑steroidal anti‑inflammatory drugs], aminoglycosides, ACE [angiotensin‑converting enzyme] inhibitors, ARBs [angiotensin II receptor blockers] and diuretics) within the past week, especially if hypovolaemic

  • symptoms or history of urological obstruction, or conditions that may lead to obstruction

  • sepsis

  • a deteriorating paediatric early warning score

  • severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)

  • symptoms or signs of nephritis (such as oedema or haematuria)

  • haematological malignancy

  • hypotension.

[NICE guideline CG169, recommendation 1.1.2]

Monitoring of serum creatinine level and urine output

Physiological 'track and trigger' systems (early warning scores) should be used to monitor all adult patients in acute hospital settings. The serum creatinine level and urine output should be recorded at admission or in the initial assessment and then as part of routine monitoring.

Measurement of serum creatinine will vary according to clinical need, but daily measurement is typical while a person is acutely ill and/or in hospital. Serum creatinine levels should be compared with a baseline measurement to detect changes that would trigger a response. Details of baseline measurements and detecting acute kidney injury based on changes in serum creatinine level can be found in NHS England's national algorithm.

Frequency of urine output monitoring will also depend on clinical circumstances. When adults are at risk of acute kidney injury, systems should be in place to recognise and respond to oliguria (urine output of less than 0.5 ml/kg/hour).

For children and young people, physiological observations should be recorded at admission and then according to local protocols for given paediatric early warning scores.

The frequency of monitoring for adults, children and young people should increase if abnormal physiology is detected.

[Adapted from NICE guideline CG50 and NICE guideline CG169]

Equality and diversity considerations

Young age, neurological or cognitive impairment or disability may result in limited access to fluids and a risk of dehydration for some people because of their reliance on others to maintain adequate fluid intake. This may include frail older people, people with dementia in care homes and those with physical disabilities. Also, the risk of acute kidney injury might increase for people of Muslim faith during periods of fasting if they have other risk factors (for example, if they are taking diuretics).