think kidneys and what?? - patient safety oxford...think kidneys … and then what?? ... primary...
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Think Kidneys … And then what??
Dr Emma VauxConsultant Nephrologist Royal Berkshire Hospital
Clinical Lead for AKI Oxford PSCOn behalf of the AKI working group
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
tAKIng note, tAKIng care
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
Prescribing practice in high risk patients
GP renal lead
tAKIng note, tAKIng care
Sick day rules
Hydration matters!
Care planning in primary care?
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
AKI Alert Project: secondary care
AKI Alert Project: primary care
tAKIng note, tAKIng care
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
AKI Care bundles
AKI Outcome measurement
tAKIng note, tAKIng care
Urinary catheter care bundle
Fluid balance charts
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
tAKIng note, tAKIng care
Key metrics for patient outcomes: Referral rate to secondary care, Medication Appropriateness Index, progression of AKI, need for renal replacement therapy, mortality, length of stay, transfer to critical care setting and referral rate to specialist renal services
Key metrics for sustainability: CO2 equivalents of patient pathways, financial cost of patient pathways and patient experience of care
Across the PSC region• W Berkshire focus• E Berkshire – alerts & care bundles
• Patchy across region• Geography• Personnel
• National AKI CQUIN
AKI CQUIN 2015/16WPH
AKI CQUIN 2015/16Swindon
0
10
20
30
40
50
60
70
80
90
100
Apr May June July Aug SEP OCT NOV DEC JAN FEB MAR
CQUIN (Swindon): Acute Kidney Injury
%
Target
AKI CQUIN 2015/16RBH
0
10
20
30
40
50
60
70
80
90
100
Apr May June July Aug SEP OCT NOV DEC JAN FEB MAR
CQUIN: Acute Kidney Injury
%
Target
Avoidable harm
related to AKI is
prevented in all care settings
Prevention
Recognition
Management
Risk identification
Education
Public Health
Diagnostics
Evidence base
Treatment resources
Oxford AHSN PSC AKI workstreamLaunched September 2015
• Baseline, benchmarking, impact of any implementation• Use of HES and Biochemical data• Community and secondary care• Incidence, progression & regression• Collaborations:
• Clinical biochemists, Dan Lasserson & Academic FY2• DFI• ICNARC• Consultants & Junior drs• CSU
• End 2016: outcome & process measures
Data & outcomes
PreventionAim To reduce urinary tract infections in the care home setting
Process Measure Introduction of a drinks diary and ensuring minimum of 10 drinks rounds in 24 hours
Area of test of change Windsor/Ascot/Maidenhead CCG – 1 nursing home and 3 residential homes (150 residents)
Baseline data collection Commencing 1st May 2016 – Using safety crosses
Outcome data 20% sample size of the completion of the drinks diary and monthly safety crosses
Test of change starts 1st July 2016
Next steps Planning and training of staff within the 4 areasEngaging with Oxfordshire Care Homes for similar project
Prevention
Aim To evaluate the effectiveness of the sick day rules cards
Method A discussion group for patients with long term multiple comorbidities.Looking if they have had the sick day rules cards, did they understand the aim of them and when to re‐start medication etc
Area of improvement
Bracknell CCG
Data Qualitative analysis of the discussions
Next Steps Awaiting to hear in regards to funding from Bracknell
RecognitionAim Facilitate early recognition of AKI for timely delivery of
appropriate clinical care for AKIProcess Measures • Time to completion of the Trust AKI care bundle
• % coverage of elements within care bundle.
Area of test of change Great Western Hospital Swindon, NHS Foundation Trust
Baseline data Review of all flagged + coded AKI in past 12 months, and process measures in sample from October 2015 to March 2016
Test of change End of April 2016
Outcome data Review of timing and delivery of elements in care bundle.
Test of change starts April 2016 with i) amendments to care bundle, and b) display of AKI flags on electronic ward displays
Next steps • Finalise baseline data• Identify change ideas for the AKI Care Bundle form and format.• Pilot use of revised care bundle and measure total / components of care
delivered in high (AKI) incidence areas. • Integrate AHSN collaboration with Sign Up to Safety Campaign after
harmonising coded and flagged outcome data for AKI.• Introduction of an ASK (Acute Sepsis and Kidney) Nurse to support above
processes (business plan submission completed).
Management – Secondary CareAim To reduce the progression of AKI for inpatients
Process Measures The introduction of an electronic care bundle which will trigger with an AKI alert
Area of test of change Oxford University Hospitals, NHS Foundation Trust
Baseline Data A years worth of data is being reviewed from alerts that have triggered AKI stage 1, 2 or 3 (AKI alerts not live as yet but have been running in the background in the laboratories)
Outcome Data Review of AKI alerts (disease progression as an inpatient) once “live” to the clinician ‐ % yet to be defined
Test of change starts End of April 2016 – Final amendments to care bundle underway at present
Next Steps Finalise baseline dataFinalise AKI electronic care bundle and release throughout the Trust
Local AKI CQUIN 2016/17WPH
Management – Primary CareAim To improve the identification and treatment of AKI in the
community
Process Measure Introduce a community AKI care bundle designed to assist GPs to recognise
Area of test of change Oxfordshire
Next Steps To design the AKI care bundle with GPs and ratifyTraining within locality areasPlanning QI methodology for project
Test of change starts Autumn 2016
Sepsis
Think Kidneys … And then what??
CKD
DXS
CKD CKD read codes
Interactive guidance
Conclusions• Systematic approach• Different starting points• Data & outcomes
KQuIP
Registry
Health Foundation
KRUK
PatientsBKPA/NKF
NHSEngland
RA/BRSBAPN
A BIG thank you to AKI workstream members