Acute Kidney Injury Capacity Survey

(England and Wales)

March 2011

Principal Recommendation V:

“There should be

sufficient critical care

and renal beds to allow

rapid step up in care if

appropriate”

Context

• Structured questionnaire sent to renal unit clinical

directors and Intensive Care Society local

representatives

• Snapshot audit of bed state on March 10th 2011

• Online completion of questionnaire using SurveyMonkey

• All stages of AKI were included

• Data analysis using Excel and SPSS

• Full list of questions available in the Appendix

Method

Completion – Renal units

Complete data obtained from 41 trusts in England and

Wales with dedicated nephrology services

Completion – Critical Care

Complete data obtained from critical care units in 45

trusts in England and Wales

Hub renal

unit

District

General

Hospitals

Other acute

hospitals

Specialist

hospitals

Community

services

The ‘hub and spoke’ model of

specialist care

Critical Care

Percentage of renal units offering

outreach to other hospitals

How many trusts with critical care

units also have a renal unit?

42/45 trusts have

arrangements for

nephrology referral

or transfer

…but most have arrangements for

nephrology referral or transfer

Models of outreach from

renal units vary…

• Onsite nephrologist

• Visiting nephrologist

• Telephone referrals

• Shared care with other specialties (critical care, acute

medicine etc)

• 9-5 vs 24/7 cover

87% of renal units have arrangements

to admit appropriate patients from

other hospital sites

Models of inpatient kidney care

vary…

• 35 sites have dedicated renal beds

• Median number of beds 26 (IQR 21-30)

• Three sites share all their beds with other

specialties, with no dedicated renal beds

• Several units have a mixture of dedicated and

shared beds

• The median number of whole time equivalent

nephrologists per renal unit is 6.8 (IQR 4.5-9.3)

AKI Capacity in Critical Care

• Median number of Level 2 and 3 beds available per

trust is 14 (IQR 12-30)

• The median number of critical care beds typically

available per trust for Renal Replacement Therapy

(RRT) is 4 (IQR 3-8)

• Both the number of critical care beds and the

availability of RRT is flexible in many units, with the

ability to bring in extra capacity if needed

A minority of renal units have

dedicated High Dependency Unit

(HDU) facilities

England

Wales

Glossary

Inotrope/ Adrenaline, Nor-adrenaline,

Vasopressor Dobutamine, Dopamine

infusion

NIV Non invasive ventilation

IABP Intra-arterial blood

pressure monitoring

CVVH Continuous veno-venous

haemofiltration

Many units share the management

of patients requiring level 2 or 3 care

with local critical care services

“Our renal inpatient beds with level 2 care are

geographically placed next to ICU. The joint venture

model of looking after AKI with critical care specialists

works very well with a tight interface between critical

care and nephrology.”

Protocols and algorithms

• Most units have protocols concerning contrast

nephropathy prophylaxis and the management of AKI

• Only a minority of units have agreed protocols

concerning the transfer of patients to the renal unit,

referrals from outside the unit and the step down of

patients to the renal unit from critical care

• Several respondents commented that they worked

closely with critical care or carried out a daily ward

round of critical care patients and therefore did not

need written protocols concerning ICU step down

England

Wales

Protocols concerning the step down of

patients from ICU to Renal Units

Number of trusts

Utilisation on 10th March 2011

Utilisation

Renal Units

97 % median bed occupancy

23% of beds occupied by patients with AKI

57% of the patients with AKI had RRT dependent

AKI

Critical Care

9% of beds occupied by patients with RRT

dependent AKI

Delayed Transfers

• 66 patients were waiting transfer to a renal unit for

investigation or management of AKI

• The survey did not ask how long these patients were

waiting, but delayed transfers and referrals were

highlighted as important factors by NCEPOD into their

report on deaths from AKI

• 57 patients who had been admitted to renal units because

of AKI were waiting transfer to a social care, rehabilitation

or other clinical setting

Additional activity

Several respondents commented that there was

a significant level of additional activity not

captured in the audit: patients not in dedicated

beds but who were being primarily managed by

the renal or critical care teams, and patients

under other specialties who were under active

renal review.

*

* IQR

Bed occupancy

Limitations

• No data were returned from 16 hub renal units

• Only a snapshot of activity

• The variation in models of care makes defining the

scope of renal services difficult. This survey is likely to

underestimate the total volume of AKI related activity that

renal and critical care units are responsible for

Key findings

• There is much variation in the model of nephrology AKI

management across England

• HDU level care is only available in a minority of units but

close working with critical care is common

• 23% of renal inpatients had AKI in the snapshot bed state

survey – of these, 57% had dialysis dependent AKI

• 9% of critical care beds were occupied with patients with

dialysis dependent AKI

• Although most renal units have clinical protocols, only a

minority have protocols concerning the transfer and

referral of patients

Back to NCEPOD

“Every hospital should have a written guideline detailing

how the three clinical areas where patients with AKI are

treated (critical care unit, the renal unit and the non-

specialist ward) interact to ensure delivery of high

quality, clinically appropriate care for patients with AKI.

(Clinical Directors and Medical Directors)”

Only a minority of renal units are currently

meeting this recommendation. Clear guidelines

concerning the referral and transfer of patients

with AKI should help to ensure that patients

with AKI are managed in a timely and

appropriate manner

Acknowledgements

This survey was kindly facilitated by the Renal

Association and The Intensive Care Society

Appendix 1 – list of Renal Unit questions

1. Please provide the following information:

SHA region

Name of Acute Trust

Date of completion of form

Job Title of Person Completing Form

2. Does the renal unit offer an outreach service at other hospital sites within your trust?

If yes, how many other acute receiving hospital sites within your trust does the renal unit

provide an outreach service for?

3. Does the renal unit offer an outreach service at other hospital sites in other trusts?

If yes, how many other acute receiving hospital sites in other trusts does the renal unit provide

an outreach service for?

4. Does the renal unit have an arrangement to admit patients from other hospitals or trusts?

5. If possible, please name these hospitals or trusts

6. Please provide the following information:

Number of dedicated inpatient renal beds

Of these, how many are routinely resourced to offer Level 2/HDU care?

Number of dedicated renal surgical/transplant beds

Number of inpatient beds plumbed for haemodialysis or haemodiafiltration

7. What is the maximum number of inpatient renal beds where you would be routinely able to provide the following

interventions if required?"

CVVH

Intra-arterial blood pressure monitoring

Non-Invasive Ventilation (e.g. CPAP or BIPAP)

Vasopressor or inotrope infusions

8. Does the acute trust have a dedicated Medical Admissions Unit?

9. Is there a Medical Admissions Unit on the same hospital site as the Renal Unit?

10. Do you have documented protocols or written agreements for AKI that address the following issues?

Referrals from other clinical units or hospitals

Transfers from other clinical units or hospitals

Step down from ICU to Renal Unit

Clinical management of AKI

AKI prophylaxis for people at risk of contrast nephropathy

11. How many consultants provide care for patients admitted to the renal unit?

Consultant nephrologists

Substantive University Appointments at Consultant Nephrologist Level

12. Please provide the information for bed occupancy at 8am (or equivalent morning reporting time) on 10th March 2011:

Number of inpatient renal beds occupied

Number of inpatient renal beds where the primary cause of admission to the renal unit is AKI

Number of patients in renal inpatient beds receiving RRT for AKI

How many patients are currently awaiting transfer to the renal unit for management or investigation of AKI?

How many patients whose main reason for admission to the renal unit was AKI (including those in whom the main problem

was AKI but who have has now recovered) are currently awaiting transfer to another clinical area outwith the renal unit or

awaiting a social care package

Appendix 2 – list of Critical Care questions

1. Please provide the following information:

Region

Name of Acute Trust

Name of Hospital

Date of completion of form

Job Title of Person Completing Form

2. Does the trust have a renal unit providing inpatient care?

If yes, is the renal unit based in the same hospital as this critical care unit?

Are local mechanisms or agreements in place for arranging clinical advice and

review by a nephrologist?

Are there local mechanisms or agreements in place to transfer patients to a renal

unit for ongoing renal replacement therapy?

3. Please provide the following information:

Number of adult critical care (Level 2 or 3) beds available in the trust

Maximum number of patients in critical care beds (Level 2 or 3) able to receive RRT

on the same day?

4. Do you have a written protocol or agreed arrangements concerning step down of patients

to renal units?

5. Please provide the following information about bed utilisation:

% of patients in critical care beds (level 2 or 3) currently receiving renal replacement therapy

for AKI

Number of patients in critical care beds currently waiting step down to a renal unit