m bgyvu patients care of aki c m - kdigo
TRANSCRIPT
MULTIDISCIPLINARYCAREOFAKIPATIENTS
CONFUSIONMATRIXAzraBihorac
KDIGO
AKICAREISACONTINUUM
From Kashani et al, ADQI XXii
KDIGO
MULTIDISCIPLINARYCARE
• Whenprofessionalsfromarangeofdisciplinesworktogethertodelivercomprehensivecarethataddressesasmanyofthepatient'sneedsaspossible.
KDIGO
PROFESSIONALS
• Physicians• Advancedpractitioners(NPandPA)• Nurses• Nurseassistants• Pharmacists• Dieticians• Respiratorytherapists• Socialworkers/Casemanagers• EMS• Clergy
KDIGO
Outpatient
Primary Care Pharmacy Nursing Home Home Care EMS
RANGEOFDISCIPLINES
Inpatient
Emergency Room
Operating Room
ICU
General Ward
Pharmacy
Nephrology
KDIGO
COMPREHENSIVECARE• SinglePathway-Primarydisease?• Jointpathway-Overlapwithotherdiseasesandprocesses
• ComplicationorSide-effect?• PreventableorAvoidable?• TreatableorCurable?
• Context-SpecificGoals,ComponentsandOutcomes
Before AKI episode
During AKI episode
After AKI episode
KDIGO
Al-Jaghbeer&Kellum,JASN2018;29:654.
KDIGO
USEOFNEPHROTOXICDRUGS
KDIGO
COMPUTERDECISIONSUPPORTSYSTEMFORDETECTIONOFAKI
SelbyNM&FluckRJ,JASN2018;29:352-354
EHR
No Increase in consult rate for Nephrology, ICU and Pharmacy
KDIGO
Outpatient Primary Care Specialty Care Pharmacy Nursing Home Home Care EMS
RANGEOFDISCIPLINES
Inpatient
Emergency Room
Operating Room
ICU
General Ward
Pharmacy
Nephrology
KDIGO
SelbyNMetal,JASN2019;30:505
KDIGO
INTERVENTION• AnAKIelectronicdetectionandalertingsystem-UNIFORMinUK,laboratorydigitaldata
• StageofAKIwithmessageadvisingaclinicalresponse/reviewofthepatientandsignpostingoflocalAKIresources
• Disruptiveelement-biochemisttelephonetotheclinicalareasforAKIstage2/3• AnAKIcarebundle
• AneducationalprogramtoraiseawarenessandknowledgeofAKI.SelbyNMetal,JASN2019;30:505
KDIGO
INTERVENTION
KDIGO
REDUCTIONINLENGTHOFSTAY
SelbyNMetal,JASN2019;30:505
KDIGO
CHANGEINPROCESSESOFCARE
SelbyNMetal,JASN2019;30:505
KDIGO
ORGANIZATIONALLEVELINTERVENTIONFORDETECTIONOFAKIANDIMPLEMENTATIONOFBESTPRACTICESUPPORTIVECARE
SelbyNMetal,JASN2019;30:505
Digital data Computable Phenotype
+/- Nephrology PI-led education and care bundle
KDIGO
MANAGEMENTOFAKIANUDGETOHACKNEWHABIT
Digital data Computable Phenotype
+/- Nephrology PI-led education and care bundle
New Habit Care Bundle
KDIGO
PREVENTIONOFAKI• ICUpatients• Context-SpecificGoals,ComponentsandOutcomes
Before AKI episode
During AKI episode
After AKI episode
KDIGO
BIGPAKRCTNon-Cardiac High Risk Surgery 237 tested 125 T2I7 + (53%) Randomized: 63 intervention 62 control
Gocze, Ann Surg 2018
Intervention: 1. Nephrology Consult 2. CVP guided IV fluid 3. Nephrotoxic drugs
High risk for AKI Elective surgery > 4 hrs
AND Age>75 or ICU or CKD or Contrast during surgery
Nephrology Recommendations 1. Nephrotoxic medications 35%. 2. Higher MAP target levels 10%. 3. Acid-base/albumin/electrolytes 53%
KDIGO
BIGPAKRCTPatie
ntsrem
aininginth
eICU(%
)
DaysinICU
ProportionofpatientsremaininginICU
Control(Standardcare)
Intervention
Cost savings of 2031 euros per patient getting 2 tests. 0%
5%
10%
15%
20%
25%
Control Intervention
Patie
ntsW
ithM
oderate-SevereAKIW
ithin7Days(%)
Moderate-SevereAKI(7days)
66.1%reductionp =0.035
Gocze, Ann Surg 2018
KDIGO
DOBETTER?COMBINETESTS!
“AND rule” Increase Specificity Test is positive, if both are positive Test is negative, if either test is negative SpeC (Combo Test) = SpeC1 + SpeC2 –SpeC1*SpeC2 SenS (Combo Test) = SenS1*SenS2
Test in series- Cheaper!
KDIGO
ORGANIZATIONALLEVELINTERVENTIONFORAKIPREVENTION
Detect AKI risk Alert
Respond with standardized
bundle Reinforce
T2I7
New Habit Care Bundle
Nephrology led education and care bundle
KDIGO
KDIGO
KDIGO
Outpatient Primary Care Specialty Care Pharmacy Nursing Home Home Care EMS
RANGEOFDISCIPLINES
Inpatient
Emergency Room
Operating Room
ICU
General Ward
Pharmacy
Nephrology
KDIGO