This example describes how the new acute kidney injury (AKI) service was developed and implemented at Lancashire Teaching Hospitals NHS FT. The example includes key learning points and plans for the future.
The NICE recommendations which have been implemented are:
1.1 Assessing risk of acute kidney injury
1.2 Preventing acute kidney injury
1.3 Detecting acute kidney injury
1.4 Identifying the cause(s) of acute kidney injury
1.5 Managing acute kidney injury
1.6 Information and support for patients and carers
Aims and objectives
- Implement recommendations in NICE guideline CG169 for all inpatients with an AKI.
- Meet recommendations within the commissioning and quality innovation for AKI Collaborative working with primary care to facilitate early recognition, treatment, appropriate referral and on-going management of patients with an AKI.
- Review of all AKI stage 3 patients within 24hours of an AKI alert.
- Review and minimise the risk of patients with stage 2 progressing to stage 3 AKI Pharmacy medication review of all patients with AKI
- Provide multi professional education across all specialities.
- Improve communication links with primary care regarding patient management and on-going care post discharge
- Disseminate patient information with regards to self-management
Reasons for implementing your project
Lancashire Teaching Hospitals NHS FT is the tertiary renal centre for the North West. Processes in place prior to implementation of the AKIT service could lead to a delay in recognition, referral and treatment of patients with an AKI.
Following the implementation of the AKI national algorithm and subsequent implementation of trust pathology alerts, a trigger to identify patients and implement current NICE Guidance is possible.
The Acute Kidney Injury Team developed a care bundle incorporating NICE guidance to ensure that urinalysis, an ultrasound of the urinary tract where indicated is performed, medication and pharmacist review, ongoing monitoring of creatinine, referral to critical care or a nephrologist as required and delivery of an acute kidney injury patient information leaflet is given to patients or their carers within 24 hours of the acute kidney injury alert being released by the pathology system.
Following an 18 month period of planning and confirmation of a funding stream a 12 hour, 7 days a week Acute Kidney Injury service at Lancashire Teaching Hospital NHS Foundation Trust was launched in October 2015. The AKI service has not incurred any new costs for the organisation. Recognition of AKI and appropriate coding at patient discharge now included in the Immediate Hospital Discharge Information letter facilitated the funding stream to support the service in the longer term.
During the planning phase key stakeholders in the service development were identified and included in the service development. The renal directorate clinical director, the consultant nurse for critical care services, the critical care outreach team (CCOT), the renal pharmacist, the Information Technology (IT) department, the radiology department, the pathology and phlebotomy services, the quality and effectiveness lead for the organisation, the coding department, other specialist services such as the palliative care and pain team and the heart failure nurses and finally to provide quality assurances the Advancing Quality Alliance (AQuA) are involved as external reviewers. All the stakeholders became key partners and had a significant impact on how the service was developed and implemented, especially the links with the IT and pathology department enabling robust processes to capture patient activity and documentation of AKI team interventions.
The anticipated benefits of introducing NICE guidance includes timely recognition, treatment and referral of those patients with AKI, leading to a potential reduction in hospital stay, mortality and reduction in chronic kidney disease.
How did you implement the project
Generating the AKI service as an expansion of the CCOT was a deliberate decision made to utilise the expertise and clinical knowledge of an established team of senior nurses familiar with assessing, planning, implementing and escalating care of patients. A care bundle has been developed incorporating NICE guidance this care bundle is used when reviewing patients with an AKI 2 and 3.
The Acute Kidney Injury Team (AKIT) identify their daily patient activity from a report on all AKI 2 and 3 flags generated by a search on the organisation’s pathology system. The AKIT, in consultation with the renal consultant, review all patients with a new AKI 2 and 3 every day and follow these patients for 2-3 days until their results are improving or management is taken over by the renal team.
The ward-based pharmacists identify and review all patients with an AKI working closely with the AKIT. The team perform a search of the pathology system regularly during the day to update and identify patients in real time with a new AKI. One of the quality standards for patients with an AKI 3 is an early expert review, as the service operates 12 hours a day, 7 days a week, the majority of patients are reviewed within a 12 hour window following their blood results. AKIT have an extended role to order renal ultra sound scan, facilitating early investigations. Patients reviewed by the AKIT are given a patient information leaflet, developed by Advancing Quality Alliance, we intend to roll this out to all patients with an AKI with the support of ward pharmacists.
The team are actively involved in identifying patients at risk of AKI and are supporting the Pre-operative clinics currently trialling an AKI risk assessment developed in Dundee and participating in the RISK study for patients admitted within acute medicine. The radiology department have introduced a risk assessment for all patients undergoing imaging with contrast. Education and raised awareness focuses on the junior doctor foundation year programme, the acute illness management study day, educational programmes for preceptor ship nurses and post registration studies in a franchised module for acute care from a local Higher Educational Institute.
Local events across all adult wards and departments have been organised across the trust and the AKIT service has a clear reporting structure within the organisation, Harm Free Care, chaired by the director of Nursing and the Safety and Quality group, chaired by the clinical governance lead.
Outcome measures and audit of the service run in line with the Advancing Quality Alliance clinical process measures which are also incorporated into the care bundle designed and used by the team.
The results of this will be displayed on the Advancing Quality Alliance website in the public domain. Monitoring and outcome measures will include numbers of patients seen by AKIT, numbers of visits per each patient group, numbers of patients requiring referral to the CCOT and any changes to critical care outreach activity.
Specific outcome measures for AKI stage 3 will include length of hospital stay, mortality, percentage of hospital acquired compared to community, subsequent development of CKD and progression to dialysis.
Specific outcome measures for AKI stage 2 include length of hospital stay, mortality, progression to AKI stage 3 and percentage of hospital acquired compared to that from the community.
Key learning points
Identifying and involving the stake holders of the service from the outset of planning has undoubtedly supported the successful development and introduction of the service.
In particular support from the IT department has been invaluable enabling rapid changes to identified problems in the initial stages of the service roll out.
Developing Links with primary care has enabled the renal physicians to deliver AKI education sessions for general practitioners upon the local CCG education sessions. These education sessions will also support the introduction of AKI alerts into primary care in the near future.