Acute kidney injury patient safety programme Preetham Boddana 1 , Shiva Sreenivasan 2, Nerys Conway 2, Andrew Seaton 3 1. Department of Nephrology, 2. Unscheduled Care Division (Acute Medicine), 3. Department of Patient Safety •
[email protected]
Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, United Kingdom
Problem
Context Gloucestershire Hospitals NHS Foundation Trust sees more than 500 cases of acute kidney injury (AKI) monthly from a catchment population of 612000.
AKI is a common and harmful condition, which is often treatable and avoidable. The incidence of AKI in patients admitted to hospital is approximately 3 – 7%.
Assessment of problem and analysis of its causes An audit of patients with AKI showed deficiencies in care. We created an AKI care bundle (senior review, medication review, fluid balance, repeat creatinine) for those patients with AKI, prompted by an AKI sticker for the case notes.
100
Improving compliance with all elements of AKI care bundle
80
75%
60
60%
50
45%
40
30
eas
IN ta
rget
s
Intervention
Monthly sticker audit to measure effectiveness of system
30%
20
Design of sticker and education programme
10
0
Incr
Launch of sticker
Qu ing C
Apr-12 May-12 Jun-12
Jul-12
Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
Jan-13 Feb-13 Apr-13 May-13 Jun-13
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13
Jan-14 Feb-14 Mar-14 Apr-14
Date
Effects of changes There has been improvement in AKI bundle compliance. Latest figured from August 2014 show that compliance for AKI care bundle use is 81%. The compliance since its launch has generally exceeded the CQuIN targets set in place by the project.
Measurement of improvement For patients receiving an AKI flag, case notes were audited for appropriate use of the care bundle. We reviewed audit results over a 2–year period to see if the AKI bundles were being used appropriately and if patient care had improved. We also did complete root cause analysis for 2 patients’ notes that had AKI every month.
Further study is required to assess if this has reduced patient mortality, morbidity and length of stay in hospital. The peformance dip every year in June/July is being investigated to see if it reflects holidays by regular staff taken during this time, and also if a similar dip is seen in other patient safety projects, e.g., VTE, sepsis, and antibiotic compliance.
AKI Learning
All medical staff were educated about the AKI bundle during their Trust induction. A question and answer session about the pathway was done at this stage. AKI was also discussed at Trust safety hubs and cafes. The details of the AKI care bundle and sticker were also advertised on the Trust intranet. There were numerous posters and computer screensavers about AKI.
Junior doctor eLearning module
ea s
m ent vem o r p
ure
u hro dt
Im
A P S D
We have shown improved care in patients with acute kidney injury by using an electronic alert system prompting early management.
Nurses’ fluid balance briefings
Strategy for change
PDSA testing ramp
Safety café briefings
Lessons learnt
We launched an AKI care bundle and created an electronic alert in our chemical pathology reporting system based on serum creatinine. The care bundle was clearly stated on the AKI sticker, which was to be placed within the patients’ case notes.
AKI covered in Trust induction
it
aud
A P S D
Cycle 2B Spread sticker to wider Trust through Safety cafés and induction
Cycle 2A Development of sticker and wider testing
Cycle 1B Develop eLearning for AKI to support launch of sticker
A P S D
Cycle 1A Design and complete local testing of sticker on renal ward
Message for others All health personnel can easily identify AKI through an AKI flag, and if managed early and appropriately results in reduction of avoidable harm and cost of expensive treatment such as dialysis and ITU care.
gh
ly nth mo
A P S D
70
A P S D
Percentage of patients with completed AKI bundle
90
AKI FLAG
Senior review
Fluid balance review
Medication review
AKI care bundle Repeat creatinine
Early Warning Score
