Linking NICE AKI Quality Standards with Think Kidneys Resources

Our main aim is to prevent the avoidable harm caused by acute kidney injury.

Think Kidneys’ programme of work leads to fewer preventable cases of acute kidney injury, resulting in a reduction in the number of deaths linked with acute kidney injury.

We have driven the transformation that will lead to well-informed, proactive multi-professional teams, supporting patients, carers and the public. Health and care professionals will understand the risk and impact of acute kidney injury better and how it can be prevented. They will know the best way to treat, and care for, patients.

Think Kidneys will help patients, their carers and families, as well as the fit and well, understand their personal risk of acute kidney injury. Think Kidneys will help everyone know where to get help, support and information.

Think Kidneys’ work has focussed on developing the following:

• Tools and resources that can help to support the prevention, early detection, treatment and enhanced recovery of patients with acute kidney injury.
• Education and training programmes based on good practice, which can be shared and made freely available for all health and care professionals so that patients at risk or suffering from acute kidney injury are well cared for and supported.
• Awareness among health and care professionals and managers of the importance and risks of acute kidney injury so that local strategies can be developed to reduce the human and financial burden of acute kidney injury.
• Improved identification of acute kidney injury through the development of a central information system to identify patients with acute kidney injury so that services can be planned more efficiently and care improved.
• Patient and public understanding and awareness so that many more people understand what their kidneys do, how important they are, how to look after them and reduce the risk of acute kidney injury.
• Support for commissioners of local health and care services so that they can challenge the status quo and ensure the right pathways, including information and prevention and standards of care for people with acute kidney injury.

Research priorities for acute kidney injury, such as basic science, clinical care and service delivery, to better understand the complexity of the condition.

AKI has been recognised as a global health issue & safety challenge. Statistics support this and are a dramatic driver for change, pointing to the need to do things differently. The NHS is the first health system in the world to attempt to tackle AKI with a system-wide approach.

• Up to 100,00 deaths each year in hospital are associated with AKI₁
• Up to 30% of those deaths could be prevented with the right treatment and care₁
• 1 in 5 people admitted to hospital as an emergency has AKI₂
• Around 65% of AKI starts in the community₃
• Statistics for 2016 show almost 12 million people in the UK aged 65 or over & all regions of the country are seeing a faster growth in those aged 65 & over than in younger age groups₄ People of greater age are more at risk of AKI
• 15 million people in the UK live with a long term condition which are more prevalent in older people₅. This places them at greater risk of AKI
• The annual cost of AKI-related inpatient care in England is estimated at £1.02 billion, just over 1% of the NHS budget₆

NICE published guidelines on the clinical management of AKI in 2013 which stated:

“ NICE has published a new guideline which promises to save thousands of lives and hundreds of millions of pounds each year. Evidence suggests a lack of education about the condition among healthcare workers. The NICE guideline aims to raise awareness and recommends that AKI is tackled by people working in health across all specialties, not just renal units, from chief executives to healthcare assistants…. Early detection of AKI is a key priority and will prevent the patient's condition becoming critical… Small improvements in care have the potential to save thousands of lives each year.”

The NICE AKI quality standard covers the prevention, detection & management of non-traumatic AKI up to the point of renal replacement therapy in adults, young people & children older than 1 month.

Think Kidneys have developed resources to fulfil the needs of the quality statements. (Full details in matrix attached as supporting material)

Statement 1

People who are at risk of acute kidney injury are made aware of the potential causes. Resources include: Leaflets, public campaign, CPPE campaign, the CQuIN, the discharge guidance and medications guides.

Statement 2

People who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for this condition. Resources: guidance on the minimum contents of care bundles, a suite of resources for primary care, mental health and child health.

Statement 3

People in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored. Resources: secondary care matrix and algorithm.

Statement 4

People have a urine dipstick test performed as soon as acute kidney injury is suspected or detected. Resources: guidance for those working in care homes

Statement 5

People with acute kidney injury have the management of their condition discussed with a nephrologist as soon as possible, and within 24 hours of detection, if they are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant. Resources: AKI care bundles.

Statement 6

People with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist. Resources: guidance for paediatricians and the minimum care bundles

References

1. http://www.ncepod.org.uk/2009aki.html
2. http://www.karger.com/Article/FullText/337487
3. http://cjasn.asnjournals.org/content/7/4/533.long
4. https://www.ons.gov.uk/
5. https://www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/long-term-conditions-multi-morbidity
6. http://ndt.oxfordjournals.org/content/early/2014/04/17/ndt.gfu016.full.pdf

The Think Kidneys team is large in number. Taking advantage of the skills, knowledge and experience of people interested in the impact and challenge of AKI and what might be done to respond, the Programme Board identified that the work needed to be divided into workstreams to deliver on the original ambitions.

Ranging from the North East to the South West, with an invitation to representatives in the devolved nations to participate, team members worked virtually and met infrequently. The team members included patient representatives who were involved in all areas of work.

The small programme team has worked to keep the workstreams on track, on time and on budget. The team members included nephrologists and a huge range of other multidisciplinary team members, primary care colleagues, care home managers, commissioners. Everyone worked collaboratively and at pace.

The name ‘Think Kidneys’ was created with the involvement of renal staff from two trusts. The website was developed by considering the user journey and requirements. It was built in a unique way – in five days, with a facilitator, the developers, a researcher, programme experts & a writer. The website has been well received and the original aim for it to become the online go to place for all matters AKI is a reality with almost 200,000 page views in two years.

The overall budget for this programme was £1.2 million to be spent over a period of two-three years. This funding was provided by NHS England as a grant to the UK Renal Registry to deliver this programme. The project has actually run for a period of 3.5 years and has achieved an enormous amount as detailed below. The total cost of this project is circa £1.3 million. The funding has provided the infrastructure to be able to deliver the Master Patient Index alongside a whole suite of resources providing education and guidance for all healthcare professionals. In addition to this a public campaign was run to educate the general public on the importance of their kidneys and how to look after them. Circa £20k was spent on this, from the £1.3 million and the reach was enormous cemented with winning the Health Business Award for Best Publicity Campaign which provided excellent value for money.

The result of this programme with both the development of the technological solutions and the far reaching education for patients and healthcare professionals will have the ability to provide early recognition and management in patients who have an episode of acute kidney injury. Once we have a complete Master Patient Index we will be able to provide more accurate figures of the impact on patients from acute kidney injury including the incidence, severity and impact on mortality rates. We will then be able to look at a health economics study around this data to indicate the total cost of acute kidney injury on the NHS and the savings associated with the early detection and improved management of those patients with acute kidney injury.

• Since the April 2015, the total number of laboratories compliant with the national Patient Safety Alert has increased to 84.
• The number of laboratories sending AKI warning level data has increased from 27 in April 2015 to 59 in July 16, reaching a peak in December 2016 at 84.
• There were 1,273,714 AKI warning levels in 390,960 patients with completed NHS numbers and date of warning level present.
• Amongst all AKI warning levels, level 1 was the most common in both adult and paediatric patients (77.9% and 78.4% respectively).
• The median age of adult patients with all levels of AKI warning was broadly similar (AKI-1 = 75 years, AKI-2 = 76 years and AKI-3 = 74 years)
• There was an upwards trend in the percentage of patients from most deprived areas with increasing AKI warning level (AKI-1 = 31.9%, AKI-2 = 32.7%, AKI-3 = 34.4%, p<0.001 for trend)
• The gender/Index of Multiple Deprivation (IMD) score adjusted mortality was lowest for AKI warning level 1 for each adult age group and highest for AKI warning level 3 (AKI-1 = 14.1%, AKI-2 = 29.2% and AKI-3 = 31.4).
• The age/gender adjusted 30-day mortality post AKI increased with increasing deprivation.
• Further analysis is planned after linkage with other datasets - Hospital Episode Statistics (HES) and Intensive Care National Audit and Research Centre (ICNARC).

The National AKI Think Kidneys programme was initially established with limited objectives though it was clear that a longer-term view was needed. Improvement in care may require strategic direction but for it to work the work needs to be owned by the professionals and patients.

This has been achieved. In three years, the understanding of AKI in England within the NHS has been transformed. Think Kidneys is an example of how the NHS change model being used, with a strong focus on a shared vision, can bring about improvement in the outcomes for people who have AKI.

The legacy of the programme:

The UK Renal Registry is now the custodian of the largest database of episodes of acute kidney injury in the world. Over 75% of laboratories in England return data on a regular basis to the Registry. This master patient index provides a rich picture of the extent and impact of AKI on the population and as the back bone of systematic improvement it will enable and support the improvements to come.

It has utilised and supported several system-wide initiatives. The two national patient safety alerts have been effective and had a long-lasting impact. The national CQUIN only ran for one year but demonstrated benefit in a short time. It is a matter of regret the CQUIN did not continue for the planned three years although many local health economies continued the work. AKI became a separate theme within the Patient Safety Collaboratives, with its own cluster and several high profile national projects for improvement have been funded in support for more work – for example, Tackling AKI sponsored by the Health Foundation and the Google Deepmind work.

It has created the now recognisable brand ‘Think Kidneys’ under which the resources have been developed and made available. Those resources are broad in their nature, allowing individual teams to adjust, develop and improve the services and care they provide and they are key to jump starting improvement work. Under the umbrella of the UK Renal Registry, the Think Kidneys brand has supported two other important initiatives – Transforming Participation in CKD and the Kidney Quality Improvement Partnership (KQuIP). Using the brand we developed an award winning public campaign on kidney health – recognising that the public fail to understand the value of healthy kidneys for their wellbeing. The reason everyone needs to “Think Kidneys”.