Acute kidney injury (AKI) - if not identified and treated early enough - can lead to significant patient harm, morbidity, increased length of hospital stay, and also loss of life. Many acutely ill patients are at risk of developing AKI, and after recognising that around 60% of patients at Derby Hospital were presenting with AKI on admission, the renal unit team collaborated with the medical assessment unit to create and deliver an AKI awareness and education programme for the MAU nursing team; to maximise the initial management of patients who may be at risk of AKI. In addition to the training programme, a system of AKI refresher sessions and ongoing support is being established for the MAU nursing team.
This example was originally submitted to demonstrate implementation of NICE CG169. The guideline has now been updated and replaced by NG148. The example has been reviewed and the practice described remains consistent with the updated guideline. NG148 should be referred to when replicating any aspect of practice described in this example.
Aims and objectives
- Early identification and treatment of AKI has a significant bearing on the clinical outcomes for patients with this condition. Recognising that the majority of patients admitted to Royal Derby hospital came via the Medical Assessment Unit, the project team focussed on aiming to improve the detection and management of AKI within the initial hours of a patient's hospital admission. They aimed to do this by equipping the MAU nursing team, who have frontline, ward level contact with patients in their first 6-12 hours after admission, with knowledge and information regarding AKI. Through the delivery of a tailored renal education programme to the MAU nursing team, the project objectives were to:
- Improve the MAU nursing team's knowledge of AKI
- Emphasise the importance of the role of initial nursing care in the detection of AKI
- Highlight the key input that the MAU nursing team could bring to the detection of AKI cases
- Increase knowledge regarding the role of observations, fluid balance assessment and urinalysis in the detection of AKI
- Provide information across the MAU nursing team, including healthcare assistants.
The education programme aimed to provide a comprehensive overview of AKI for the MAU nursing team, including covering some of the common causes and risk factors for AKI, the role of observations, fluid balance assessment, urinalysis, and fluid management in AKI, and the management of hyperkalaemia.
Reasons for implementing your project
The project began in 2012, and was initially prompted by a renal consultant attending the medical assessment unit (MAU) within the hospital, and identifying an opportunity to increase the awareness of acute kidney injury amongst the MAU nursing team.
Following a National Confidential Enquiry report in 2009 into deaths across England involving acute kidney injury (Adding insult to injury, 2009), a national AKI task force was established. In addition to the national work delivered via NHS Kidney Care, the renal team at the Royal Derby Hospital had prioritised raising awareness of AKI prevention, identification and treatment across their trust. The renal team at Royal Derby Hospital is part of Derby Hospitals NHS Foundation Trust which serves a population of over 600,000 in and around Southern Derbyshire. The hospital provides a wide range of services including outpatients, inpatients, medical, surgical, maternity, intensive care, community and children's services and accident and emergency care with a total of 1,100 beds.
Acutely unwell patients may often already have, or be at greater risk of developing, acute kidney injury (AKI). Royal Derby Hospital had identified that 60% of the patients with AKI in the hospital were presenting with this condition on admission. Prompt assessment and combined medical and nursing management of AKI is of critical importance in optimising patient outcomes and minimising the long term effects of AKI. Early identification and intervention can prevent the escalation of AKI, and without intervention AKI can escalate to renal failure - requiring renal replacement therapy (dialysis).
The majority of patients are admitted to the hospital via the Medical Assessment Unit (MAU). This means that although patients with AKI would be under the care of a dedicated clinical team and routine observations would be conducted, the patient would not have access to a specialist renal nursing care or input during this initial critical period.
How did you implement the project
Building on an existing good working relationship with the Professional Development Advisor from the MAU department, the project lead began to scope what knowledge and information needs the MAU nursing team may have. In conjunction with the renal consultant and the MAU Professional Development Advisor, the AKI related training needs and competencies of the nursing team were established. And together both leads devised the structure and delivery format for the training programme.
The training programme was delivered via a series of three straightforward teaching sessions incorporating a presentation format, which were developed specifically for the MAU nursing staff. Presentation content was created using nursing and medical knowledge input from both the renal and MAU teams. The presentations covered areas such as common causes and risk factors for AKI, the role of observations, fluid balance assessment, urinalysis, and fluid management in AKI, and the management of hyperkalaemia. They were tailored to meet the learning needs of the nursing team. The sessions delivered covered in turn:
- Session 1; Importance of observations, urinalysis and fluid balance monitoring in the context of AKI, as well as other nursing care aspects e.g. catheterisation;
- Session 2: Causes of AKI, detection and management of AKI;
- Session 3: Caring for Chronic Dialysis Patients.
Consideration was given by the project team to the intensity of the shift patterns that the MAU nursing staff worked, as attending a single, fixed date training session would have presented a barrier for many in the nursing team to attend. To overcome this, the timing of the AKI education sessions were arranged to fit around the nursing team's shift patterns, and avoided particularly busy periods such as shift handovers.
The learning and delivery needs of the MAU nursing team were established through close involvement of the MAU Professional Development Advisor in the planning of the project. Because of the nature of the shift patterns that the MAU nursing team covered, multiple, repeat sessions of each learning session were arranged to enable as many members of the nursing team to attend as possible. The training was also delivered on site in the MAU and each learning session lasted 30 minutes, again to fit around the availability of the nursing team.
To enable the full MAU nursing team - including healthcare assistants - to engage in the training as much as possible, it was conducted via small informal groups of 8 or 9 participants, and active input of all the staff attending was encouraged.
Evaluation of participant learning was gathered through the use of a multiple-choice questionnaire, which was completed by participants both before and after they attended the sessions. As mentioned above, a multiple-choice questionnaire was developed to establish the level of knowledge gain for participants attending the training.
The questionnaire was completed by participants both before and after they attended the sessions. The first session was delivered on 8 occasions over a 6 week period. Participants in this session included 11 ward sisters, 22 staff nurses, 1 assistant practitioner, 8 healthcare assistants, 3 nursing students and 2 medical students. This equated to approximately one third of the MAU nursing staff team. The second session was delivered on 9 occasions over an 8 week period. Participants in this session included 6 wards sisters, 19 staff nurses, 2 assistant practitioners, 9 healthcare assistants and 4 medical students. Staff did not need to attend the first session to attend the second. Some staff attended both whilst others only managed to attend one or the other.
Results from the participant questionnaires showed that the MAU staff generally had a good understanding of the initial nursing care in AKI, although lacked confidence in their knowledge. There were areas identified where knowledge improved after the teaching sessions, which was identified from the pre and post questionnaires.
These areas included:
- The significance of urinalysis results in the context of AKI (10/40 correct pre session; 26/40 correct post session).
- And appropriate management of hyperkalaemia for AKI requiring acute haemodialysis (18/40 correct pre session; 36/40 correct post session).
- Management of BP (21/34 correct pre session; 33/34 correct post session).
- Analgesia use for AKI (16/34 correct pre session; 30/34 correct post session).
Overall, the results of the pre and post questionnaire for the first 2 sessions demonstrated an increase in score after the session was delivered. For the first session, the mean pre score was 3.74/6 compared to a mean post score of 4.98/6. For second session, the mean pre score was 3.91/6 compared to a mean post score of 5.41/6.
Key learning points
It is important to recognise the valuable role of nursing staff in the detection and recognition of AKI. It was our intention for the nursing team's increased knowledge regarding AKI management to directly translate into their nursing practice on the MAU department. This has helped to assist the MAU medical and renal teams in the initial management of patients with AKI during this critical period, allowing prompt treatment and improved outcomes and resolution of AKI.
Key learning from the project was that it is important to be brave enough to 'just go for it'. Although initially unsure if the MAU nursing team would be interested in the AKI training programme, the project lead made use of a request from the MAU department for training on dialysis (end stage renal replacement therapy). This enabled the AKI training components to be delivered alongside the others, through being incorporated within a renal education package for the nursing team. Information was tailored for the MAU nursing team, so that examples were relevant for the audience, and feedback from participants was that this was very much appreciated. The training was well received by the MAU nursing team, and as AKI is not often covered in detail during undergraduate training it was a new area of learning for many participants.