Shared learning database

Papworth Hospital NHS Foundation Trust
Published date:
March 2015

The team at Papworth Hospital set out to implement the recommendations from NICE guidance for acute kidney injury (CG169) including the design of a risk identification pathway based on the criteria set out in recommendation 1.1.1 of the guidance. The example includes a fluid management procedure which incorporates the recommendations from the NICE guidance for intravenous fluid therapy for adults in hospital (CG164).

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aims and objectives of this project at Papworth Hospital NHS Foundation Trust were;
1) To investigate the incidence of Acute Kidney Injury (AKI) in the local cardiothoracic population
2) To raise awareness of AKI.
3) To follow the recommendations within NICE clinical guidelines and produce specific guidance that is appropriate for the assessment and management of both IV fluid administration and AKI within the cardiothoracic patient population.
4) To standardise the fluid management of all patients post cardiothoracic surgery
5) To standardise the treatment and management of Acute Kidney Injury by developing an AKI Pathway.
6) To reduce the incidence of AKI by early risk assessment
7) To ensure all cardiology patients have risk factors identified and assessed prior to their procedures to minimise the impact of treatment on kidney function.
8) To monitor the incidence of AKI by reviewing monthly prevalence data, referrals to the ALERT Team for reasons of oliguria and /or AKI and the number of readmissions to the Critical Care Area (CCA) for AKI.
10) To review and update the NBM policy to support the work surrounding AKI.

Reasons for implementing your project

Prior to our intervention, there was no standard practice for the identification of 'at risk' patients for AKI in either cardiothoracic surgery or cardiology. There were variable practices for fluid management post-operatively and no standard for the management of AKI once diagnosed. There were also high levels of waste on the critical care unit with regards to unused fluids post operatively and fluids were prescribed for each patient without thought for age, weight, pre-existing renal impairment or ventricular function.

The Alert Team (Acute Life threatening Event Recognition and Treatment) recorded every referral to them for fluid management complications and could see a repetitive incidence of AKI, they found that the number of monthly readmissions back to CCA for reasons of AKI were high and so an analysis of these events commenced to ascertain trends and to begin to understand the causative elements. Engagement from stakeholders was achieved through all parties being represented on the Fluid Management Group and then feeding back proposals and guidance to their respective team for comments and suggestions. The group consisted of a: Consultant Anaesthetist, Consultant Surgeon, Consultant Radiographer, Lead Nurse ALERT Team, Senior Sister in Cardiac Recovery, Pharmacist and a representative from clinical audit.

How did you implement the project

Our methods included the establishment of a Fluid & AKI Management Taskforce, with meetings taking place every 6 weeks. A prevalence audit was conducted to measure % creatinine rise and stages of AKI post operatively. We reviewed NICE clinical guidelines (CG169 and CG174) and produced Trust guidelines which reflect the NICE recommendations. We provided a report on quality standards 76 and 69 to evidence compliance with CG169 and 174, working together with local clinical audit department.

The team produced standardised guidelines for post-operative fluid management for Day 0 and Day 1 Introduce Day 0 and Day 1 fluid management guidelines on CCA and surgical wards. We recognised the need to improve links on CIS (Computerised Information System) in CCA to the fluid management algorithm.

Weekly meetings were held to review all readmissions to Critical Care between Lead Alert nurse and senior sister to look at trends for AKI. Monthly data was collected and run charts set up for the incidence of referrals to Alert for AKI / readmissions / creatinine rise on Day 1 post-operatively.

An AKI pathway was produced to standardise management of AKI. Greater education, training and awareness across the trust with mandatory training days, Grand rounds, new staff training, ?Sign Up to Safety? campaign, using social media to raise awareness.

Key findings

We have achieved trust wide awareness of AKI through ongoing education and training. CCA, Cardiac Recovery and surgical wards now use the Fluid Management guidelines for day 0 and day 1 post operatively as standard.

Trust guidelines have been written for fluid management of patients in hospital, AKI management and the introduction of a new AKI pathway. Preoperative patients are managed with particular emphasis on fluid management during the fasting phase. Readmissions to CCA are monitored and learning shared through the weekly CCA MDT meeting. Overall we have observed a reduction in the number of readmissions to CCA due to AKI.

We have shared our work both internally and externally at the East of England Critical Care Operational Delivery Group and the Society of Cardiothoracic Surgeons annual conference.

There will be ongoing audit to monitor outcomes and achievement of aims and objectives. We are hoping to start a quarterly review of compliance with the guidelines with spot checks across the surgical wards. We will be looking at if and when the AKI pathway was commenced and if this was appropriate.

Key learning points

The management of AKI has to be through a multi-disciplinary approach with all key stakeholders represented. Must be evidenced with best practice guidelines to ensure patients receive the most up to date approach. Training must be continuous and ongoing to ensure all members of staff are provided with information and explanations regarding the pathway. Ongoing audit to monitor outcomes and achievement of aims and objectives is important.

Contact details

Maire Gilhooly
Advanced Nurse Practitioner
Papworth Hospital NHS Foundation Trust

Is the example industry-sponsored in any way?