think kidneys primary care and commissions workshop 240315 master slide deck final

Managing acute kidney injury alerts in primary care event Primary Care and Commissioners Workshop

24th March 2015

Welcome, housekeeping and plan for the day

Annie Taylor Communications consultant to the Think Kidneys Programme

24.03.2015 Managing acute kidney injury alerts in primary care | 2

Housekeeping

24.03.2015

Managing acute kidney injury alerts in primary care | 3

We need your help?

28.11.2014 Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 4

Programme for the day

10:00 Welcome, housekeeping and plan for the day

10:10 Setting the Scene; The ambition and the ask

10:40 The opportunity for primary care: How to get it wrong for Marjory and right for Nellie

11:15 Q & A Panel Session

11:30 Break

11:45 Preventing, Detecting and Managing Acute Kidney Injury in Primary Care - Minding the Gap; NHS England’s guidance for general practice staff on reporting patient safety incidents; Living well with your kidneys

12:45 Q & A Panel Session

13:00 Lunch

13:40 Group work

14:40 Feedback from group work

15:10 Involving CCGs in managing acute kidney injury

15:40 What will happen next, priorities and summary of the day

16:00 Close

Acute kidney injury The national programme Final Version 24th March 2015 Richard Fluck National Clinical Director for Renal, NHS England

What is acute kidney injury?


Acute kidney injury (AKI) is a rapid deterioration of renal function, resulting in inability to maintain fluid, electrolyte and acid-base balance. It normally occurs in the context of other serious illness (e.g. sepsis) on a background of risk.

Who is most at risk?

• Two patients are admitted via accident and emergency on a Friday night.

• George, an 86 year old man has crushing chest pain and ECG changes consistent with a large heart attack.

• Julia, a slim 56 year old, with long standing diabetes, has not been feeling right - the GP did a blood test and her serum creatinine is 456 umol/L.

• Who should we most be worried about?


Why is it important?

Associated with other serious illness “Force multiplier” for poor outcomes Potential to improve care Reduce avoidable harm - death and morbidity Reduce cost Important marker of illness


24.03.2015


”One in five emergency admissions to hospital will have AKI”

"AKI is 100 times more deadly than MRSA infection”

”Around 20 per cent of AKI cases are preventable”

”costs of AKI to the NHS are £434-620m pa”

‘reducing avoidable death, long-term disability and chronic ill

health…’

• VTE prevention: estimate 25,000 deaths pa

Data derived from: Hospital Episode Statistics Annual Report 2010, DoH VTE Prevention Programme 2010 and Selby et al 2012

The purpose of today

To develop the primary care solutions for acute kidney injury that focus on the pathway

• Prevention

• Early detection

• Effective intervention

• Enhanced recovery


www.england.nhs.uk

The pathway and commissioning levers

Risk assessment

• CQUIN in test in SDH

Improved diagnosis

• Safety alert NHS England

Treatment

• NICE guidance

• Care bundles

Recovery

• Proposed national CQUIN

Secondary care

Primary care

Who

Who is at risk?

Determining the vulnerable population

Pre existing comorbidities


When

When do people sustain AKI?

How is early diagnosis supported?

60% of AKI arises in the community

A trigger event e.g. infection, sickness, cardiac event


How

How should AKI be managed? How does that look in primary care?

Prevention

Treatment

Recovery


What

What do people need to know?

Education for the public

Education for patients and carers

Education for professionals


Who is at greatest risk?

• For George, his risk of death is 32.2%

• For Julia, her risk of death is 53.1%

24.03.2015 Managing acute kidney injury alerts in primary care

| 19

Data adapted from Chawla et al Clin J Am Soc Nephrol 2013

24.03.2015 Managing acute kidney injury alerts in primary care 20

The primary aim of Think Kidneys is to ensure avoidable harm related to acute kidney injury is prevented in all care settings

www.england.nhs.uk

Think Kidneys programme – what it is not about

Bad doctors or nurses

• AKI is a patient safety issue and it is recognised that clinicians need the support of robust systems, education, risk assessment, improved diagnosis and reliable interventions

It is not a failing of the NHS

• This is a global healthcare issue

• The NHS will have the first national system to measure the problem and to improve outcomes for patients


‘Think Kidneys’ Programme objectives

Develop and implement tools and interventions for prevention, detection, treatment and enhanced recovery

Promote effective management of AKI

Provide evidence-based education and training programmes

Highlight importance of AKI to commissioners, health care professionals and managers



| 24

Hydration Theme

Expert Reference Group

Algorithm Sub-Group

NHS England Patient Safety Steering Group

UK Renal Registry

Risk workstream

Education workstream

Detection workstream

Intervention workstream

Implementation workstream

Measurement workstream

Acute Kidney Injury National Programme Board

Method by which NHS can rapidly alert the healthcare system to patient

safety risks, or to provide guidance on preventing harm

What are NHS patient safety alerts?

Level 3:

Directive: requires specific action(s) within timeframe

Level 2:

Specific resource and information sharing

Level 1:

Warning of emerging risk

| 26 Managing acute kidney injury alerts in primary care

24.03.2015

http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/aki-algorithm/

ACB scientific committee

•Met July 2013 • Biochemists, nephrologists and software providers • Algorithm and minutes available online

Renal Association guidelines committee • Met October 2013 • Nephrologists, biochemists, acute physicians, ICU, patients • Ratified algorithm • Guidelines to be produced

British Association Paediatric Nephrologists • Met Sept 2013 • Paediatric nephrologists, biochemists • Ratified algorithm with one adaptation for paeds

National groups

| 28

Detection Alerting

Terminology ‘e-alerts’

http://www.bbb.org/blog/wp-content/uploads/2011/12/warnin.jpg

http://fuelfix.com/?attachment_id=427

http://trulyrichclubbosanchez.com/wp-content/uploads/2014/05/alert.jpg

Specific actions:

Work with LIMS provider to integrate NHSE AKI detection algorithm into Laboratory Information Management System (LIMS)

Ensure test results are sent:

To hospital patient management systems

Into a data message for transmission to a central point (UK Renal Registry)

Educate primary care physicians as to the use of AKI detection

Managing acute kidney injury alerts in primary care

| 29 24.03.2015

Measurement can drive improvement

Managing acute kidney injury alerts in primary care

LIMS level ‘result’ Patient

management system

Alert Response

Local systems

Message Master patient

index

Other data systems

AKI Registry

Regional, National

Research

QI

| 30 24.03.2015

The challenge

24.03.2015 | 31 Managing acute kidney injury alerts in primary care

Understanding of the kidneys IPSOS Mori poll 2014 general population 51% knew kidneys make urine 8% thought the kidneys pumped blood 12% were aware of role on medicines processing

The challenge


Understanding of the kidneys (2) Risks to the kidney 68% alcohol 53% dehydration 22% medications 1% smoking

The challenge


Understanding of the kidneys (3) What is acute kidney injury? 15% had heard of it 16% might of heard of it 69% had never heard of it Physical injury identified as principle reason Only 1 in 5 guessed correct causes

Today: Think about the strategy:

Who is at risk?

When do people sustain AKI?

How should patients with AKI be managed?

What do people need to know?

Managing acute kidney injury alerts in primary care | 34 24.03.2015

Today: which hat?

The ask How should it work for primary care at three levels? • Clinician to patient

• At a commissioning level

• At a system level


Visit our website at www.thinkkidneys.nhs.uk


Contact Think Kidneys or find out more

Richard Fluck National Clinical Director for Renal NHS England [email protected] Joan Russell Head of Patient Safety NHS England [email protected] Ron Cullen Director UK Renal Registry [email protected]

www.linkedin.com/company/think-kidneys

www.twitter.com/ThinkKidneys

www.facebook.com/thinkkidneys

www.youtube.com/user/thinkkidneys

www.slideshare.net/ThinkKidneys

www.thinkkidneys.nhs.uk

Karen Thomas Think Kidneys Programme Manager UK Renal Registry [email protected]

Teresa Wallace Think Kidneys Programme Coordinator UK Renal Registry [email protected]

Julie Slevin Think Kidneys Programme Development Officer UK Renal Registry [email protected]

http://www.thinkkidneys.nhs.uk/

mailto:[email protected]






The opportunity for primary care: How to get it wrong for Marjory and right for Nellie

Kathryn Griffith GP and representative of the Royal College of General Practitioners


Think Kidneys!! How to get it wrong for Marjory

and right for Nellie!! AKI in primary care

Kathryn E Griffith GP Unity Health York YO10 5DE

RCGP Clinical Champion for Kidney Care [email protected]

12.01.2015 Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign |

Karen Thomas 39

The primary aim of

Think Kidneys is to ensure

avoidable harm related

to acute kidney injury is

prevented in all care settings

Declaration of interests • Dr Griffith is a principal in General Practice in York

• She completed the Bradford University course for PwSI in Cardiology and is now a senior clinical tutor on the course

• She was a member of the KDIGO CKD Guideline Update Group

• She is RCGP Clinical Champion for Kidney Care

• She is a member of the NICE Guideline Group for the update of the CKD and Renal Anaemia Guidelines and follows the NICE rules for conflicts of interest

• She is Chair of the HQIP National Primary Care CKD Audit project board

Who are you please?

Disease

Terminology: Acute Kidney Injury?

Causes of AKI Exposures Susceptibilities

Sepsis Dehydration or volume depletion

Critical illness Advanced age

Circulatory shock Female gender

Burns Black race

Trauma CKD

Cardiac surgery especially bypass Chronic heart, lung or liver disease

Major surgery Diabetes mellitus

Nephrotoxic drugs Cancer

Radiocontrast agents Anaemia

Poisonous plants and animals

The Story of Marjory’s Kidneys What can we do to harm them??

Marjory Aged 83 Group1

• Marjory lives alone and enjoys life

• What can she do to damage her kidneys?

Marjory Aged 83 • Marjory attends the

practice for her Flu Jab

• She hasn’t had her blood pressure taken for a while

• You need it for QOF!!

• It is 170/90

Marjory Aged 83 Group 2

• You see her in the practice vascular clinic

• What can you do to damage her kidneys?


• She has dysuria and frequency and feels very unwell

• What can you and she do to damage her kidneys?


• She has chest pain and is admitted to hospital

• What can the cardiologists do to damage her kidneys?

Marjory Aged 83 Group 5 • She has AMI and

heart failure

• She is taking low dose ramipril and eplerenone


The Story of Marjory’s Kidneys

How to damage Marjory’s Kidneys

Group 1: Age 83 what can she do?

Group 2: BP 170/90 what can you do?

Group 3: Dysuria and frequency ?

Group 4: AMI What can Cardiologist do?

Group 5: Heart Failure ramipril and eplerenone what can you do?

Marjory Aged 83 Group1

• Marjory lives alone and enjoys life

• What can she do to damage her kidneys?

Marjory Aged 83 Group1 • Get older!!

• Pick and eat wild mushrooms

• Get fat and diabetic

• Eat salt and get hypertension

• Eat liquorice and raise BP

• Take OTC aspirin-paracetamol combination and get analgesic nephropathy

• Take OTC ibuprofen and have 3x risk AKI

• Smoke and have renal arterial disease

• Take too much alcohol and raise her BP

• Develop renal stones with high protein diet or spinach, nuts and rhubarb increasing oxalate levels

• Take large quantities of osmotic laxatives

If you go down to the woods… Cortinarius orellanine Nephrotoxic 1-2 weeks Amanita smithani nephrotoxic 3-6 days

Marjory Aged 83 • Marjory attends the

practice for her Flu Jab

• She hasn’t had her blood pressure taken for a while

• You need it for QOF!!

• It is 170/90


• You see her in the practice vascular clinic



• Ignore her BP

• Not discuss diet and lifestyle

• Not check kidney function

• Not check sugar

• Treat ineffectively

• Treat with large doses of an ACE or ARB and not monitor creatinine

Marjory Aged 83 Group 2 • Confirm BP 24hr

• Check U and E, sugar, ACR and dip stick

• eGFR 45ml/min and ACR 3

• Consider causes of possible CKD/AKI

• Repeat creatinine

• Consider CVD risk factors and diabetes

• Advise lifestyle advice especially salt

• Start CCB as per NICE Hypertension Guideline


• She has dysuria and frequency and feels very unwell

• What can she and you do to damage her kidneys?

Marjory Aged 83 Group 3 • Not drinking risks pre renal damage • Delayed treatment risks pyelonephritis • Risk of glomerular damage with penicillins and

sulphonamides • Risk of tubular damage with aminoglycosides • Risk of post renal damge with crystals in urine with

high dose sulphonamides • Risks of AKI with NSAID used as analgesics • Risk of toxicity with nitrofuratoin eGFR<60


• She has chest pain and is admitted to hospital

• What can the cardiologists do to damage her kidneys?

Marjory Aged 83 Group 4 • On trolley in A and E for 6 hours

• Cardiogenic shock not managed

• X-ray contrast material without checking creatinine

• Cardiac surgery with bypass

• Over diuresis/ under hydration

• ACE/ARB/MRA

• Failure to monitor kidney function with change in medication or clinical status

• Risk of Norwalk or other infections in hospital

• NSAID given for pericardial pain

Contrast induced nephropathy • 25% increase in creatinine Risk factors • Systolic BP <80mmHg • Congestive heart failure • Age >75 • Anaemia • Diabetes • Large contrast volume • Occurs when eGFR <60 worse when <20ml/min • Reason for creatinine on scan forms

Marjory Aged 83 Group 5 • She has AMI and

heart failure

• She is taking low dose ramipril and eplerenone


Marjory Aged 83 Group 5 • Don’t monitor Creatinine with each dose

change

• Don’t measure BP

• Don’t weigh and continue high doses of loop diuretic

• Give her top doses of all drugs

• Use NSAID for diuretic induced gout

• THE BEST WAY TO DAMAGE KIDNEYS

• Don’t tell her that she has CKD

Marjory Aged 83 Group 5 • Monitor Creatinine with each dose change

• Watch BP and weight to avoid hypotension and dehydration

• Stop diuretics when dry

• What is the evidence for top doses age 88?

• Don’t use NSAID

• Risks Aldosterone antagonists eGFR <30

• Make sure she understands CKD

SAD MAN?

SAD MAN: Drugs to be aware of if patient is hypotensive and unwell

• S

• A

• D

• M

• A

• N

SAD MAN • Sulphonylureas

• ACE and ARB

• Diuretics

• Metformin

• Aldosterone antagonists

• NSAID

CKD and NSAID: Nephrotoxic • NSAID impact kidney function in at least 8 ways ( R Fluck)

• Prostaglandins are important to maintain perfusion within the kidney

• Block of prostaglandins reduces renal blood flow with fluid retention, increased creatinine and potassium

• Acute use reversible fall in GFR

• Chronic use linked with hypertension and CKD progression

• RECOMMEND annual U and E and BP with NSAID

• RECOMMEND avoid NSAID with ACE/ARB and diuretic combination

Potential causes of AKI in Margory Exposures Susceptibilities




Burns Black race

Trauma CKD



Nephrotoxic drugs Cancer


Poisonous plants and animals

Thank you for looking after me!

Real Primary Care Getting it right for Nellie age 84

• Creatinine 89

• 3 months ago creatinine 88

• eGFR MDRD

• 53 ml/min/1.73m2

• CKD?

Nellie aged 84

• MI aged 76

• Breathless on exertion

• LVSD on Echo

• Heart Failure clinic

• Life saving drugs

• Bisoprolol 5mg

• Ramipril 5mg

• Furosemide 40mg

• Spironolactone 25mg

• Atorvastatin 20mg

• Aspirin 75mg

Nellie aged 84

• BP 108/70

• Creatinine 112

• eGFR 42ml/min/1.73m2

• CKD 3B

• Do you tell her??

• How do you describe this?

Nellie aged 84

• Back from winter break in Egypt 1 week ago

• Both had D and V • Nellie isn’t well • BP 70/50 • Poor urine output • Creatinine 302 • eGFR 13ml/min • Diagnosis? • Why??

Nellie aged 84

AKI= Acute Kidney Injury AKI Stage Serum creatinine Urine output

Stage 1 Increase of more than or equal to

26.5 umol/l or increase of 150-200%

from baseline

Less than 0.5ml/kg/h for

more than 6 hours

Stage 2 Increase of 200-300% from baseline

i.e. 2-3 fold


more than 12 hours

Stage 3 Increase to more than 300% i.e.3 fold

increase from baseline or more than

354 umol/l


more than 24 hours. Or

anuria for 12 hours

Causes of AKI Exposures Susceptibilities




Burns Black race

Trauma CKD



Nephrotoxic drugs ? Cancer


Poisonous plants and animals Doesn’t know the risks

• Refuses admission as sister just died in hospital

• What do you do?

Nellie aged 84

• Stop ACE and diuretics

• Push fluids + commode!

• Rapid response team

• Repeat bloods in 1 week and monitor symptoms

• 2 weeks later creatinine 170

• eGFR 26

Nellie aged 84

• Is this avoidable?

• Will she get back on all her lifesaving drugs?

• What would have happened over the weekend??

• Next session and group work!!!

Nellie aged 84

Heart Failure Card

RCGP Kidney Care Network • Improving knowledge and management in primary care

• Supporting primary care research in CKD including the National Primary Care CKD Audit

• Developing educational programmes for patients and primary care teams

• Working with British Kidney Patient Association

• Supporting Clinical Champion and Clinical Support Fellow

• UK wide

• [email protected] if you are interested!!


Thank you

Question & Answer Panel Session

Kathryn Griffith GP and representative of the Royal College of General Practitioners Richard Fluck National Clinical Director for Renal NHS England


11.30-11.45 – Tea/coffee break

24.03.2015


Preventing, Detecting and Managing Acute Kidney Injury in Primary Care – Minding the Gap Tom Blakeman GP


Preventing, Detecting and Managing Acute Kidney Injury

in Primary Care Minding the Gap

Dr Tom Blakeman

GP & Clinical Lecturer in Primary Care

NIHR CLAHRC for Greater Manchester

[email protected]

Outline:

A Whole Systems Approach

• Patient level:

Make kidney health (AKI) meaningful for patients

• Professional level:

Make AKI meaningful for health professionals

• Systems level:

Establish structures and processes to support

prevention and management of AKI

What is high quality care?

• Accessible

• Clinically effective

• Patient-centred

Campbell, Roland & Buetow,

Social Science & Medicine, 2000

• Safe

• Efficient

• Equitable

US Institute of Medicine

Achieving High Quality Care:

AKI - a driver of Quality across the NHS?

‘If we can get it right for AKI, we will get basic care right

across the NHS.’

Minding the Gap:

AKI Quality Framework for Primary Care Examples Patient

Level

Professional Level Systems Level

Preventing AKI

?

?

?

Detecting & Managing

AKI

?

?

?

Post AKI care

?

?

?

AKI: A Driver of Quality across the NHS?

Doing the basics well in primary care:

• Preventing AKI:

Review appointments

• Detecting & Managing AKI:

Managing acute illness

• Post AKI care:

Post discharge care

Learning from Case Studies:

http://www.thinkkidneys.nhs.uk

Case Study:

Addressing AKI in the community AB 68 year old man: Type 2 Diabetes, COPD & stage 3 CKD without proteinuria

Multiple medicines including repeat scripts for an ACE Inhibitor and Ibuprofen (NSAID)

Case Study:



Experiences an episode of gastroenteritis

Without GP assessment, leads to an unplanned hospital admission

Episode of illness complicated by AKI requiring a period of intensive care

Case Study:




Without GP assessment leads to an unplanned hospital admission


Hospital Discharge summary included AKI and coded in GP records

Recommendation ACE Inhibitor to be stopped but no mention of NSAIDS

Neither was discontinued by the primary care team

Kidney function not rechecked post-discharge

Case Study:










Further GP appointments and treated for exacerbations of COPD

No temporary cessation of medicines during these episodes of acute illness

Case Study:












Case discussion at weekly clinical meeting with Community Support Pharmacist



• Preventing AKI:

Review appointments



• Post AKI care:

Post discharge care

Doing the basics well:

Preventing AKI in Primary care • Identify high risk groups

Consider ‘sick day rules’ for high risk patient groups

Ensure flu vaccination for high risk patient groups

• Avoid prescription of long term NSAIDs where possible

particularly in high risk patients including those with CKD

Avoid ‘triple whammy’ prescribing

• Consider monitor renal function one week after the introduction of medication –

with clear advice

ACEI/ARB; Spironolactone, Loop Diuretics (CKD)

Minding the Gap:

Preventing AKI in Primary care Key factors to consider:

• Patient level

Develop ‘Sick day rules’ that are meaningful for patients

Recognise the key role of carers

• Professional level

How to discuss risk of AKI (Kidney Health) in routine practice

Recognise the key role of practice nurses

• Systems level

Ensure use of Read codes from April 2015 – ‘8OAG’

Clarify roles & responsibilities e.g. pharmacists and GPs

Resource Implementation e.g. dossette boxes & the delivery man!

Acute Kidney Injury:

NICE Guidance

‘Discuss the risk of developing acute kidney injury…with people who

are at risk of acute kidney injury, particularly those who have:

• History of AKI (QS1)

• chronic kidney disease with an eGFR less than 60 ml/min/1.73 m2

• neurological or cognitive impairment or disability, which may mean

limited access to fluids because of reliance on a carer.

Involve parents and carers in the discussion if appropriate.’

NICE clinical guideline 169

guidance.nice.org.uk/cg169

Think Kidneys:

A need for patient-centred interventions

Minding the Gap:

Headline findings People don’t have a comprehensive understanding of

what their kidneys do,

how to keep them healthy

what acute kidney injury is

• Only 51% of the population know that kidneys make urine

• Only 12% of participants thought that the kidneys had a role to play in processing medicines

Why bother talking about

kidney health with the elderly?

A Gap in care for patients with CKD:

Reticence to discuss kidney health with older

people & patients with stage 3A

‘... if you’ve got CKD or you’re young and you’ve

got proteinuria, definitely that is a really important

thing to hammer in. But yeah, 80/90 year olds, I

wouldn’t suggest we’re probably discussing it, if

they’ve got a mild CKD3.’ (GP06)

Framing CKD discussions:

‘Nothing to worry about’

‘...But just to let them know, I feel that

they should know that they’re on a

(CKD) register and tell them not to

worry. If there’s anything to worry about

we’ll let them know.’ (nurse 11)

Making kidney health meaningful:

An opportunity to broaden & tailor conversations?

Kidneys in the context of

Supporting Vascular Health

Kidneys in the context of


Addressing ‘vulnerability’

‘Having a CKD 3 register is not

necessarily there for the progressive

disease or even vascular disease,

it's looking at vulnerability. These

patients should have a card. It

should say “…Do not give me

gentamicin in casualty. Do not

allow me to get dehydrated…’

(GP05)



• Preventing AKI:

Review appointments



• Post AKI care:

Post discharge care

Minding the Gap:

Detecting AKI in Primary care Key factors to consider:

Need guidance on when to consider checking kidney function:

Taking bloods needs to support management – both in terms of detection and

severity

A traffic light system to support decision making?

Need timely results – the van man!

Need coordination with Out of Hours – Clinical Context is key

System change needs resourcing - Cumulative workload


Assessment of acute illness

• Better assessment of acute

illness? E.g:

Postural vital signs

Dry Axillae

• Better documentation?


Assessment of acute illness

• Better assessment of acute

illness?

• Better documentation?

Detection:

AKI Risk Warning system

• Switched on in hospitals

9th March 2015

• Switch on in Primary Care by

Spring 2016

How to manage a patient with AKI

detected in primary care

Factors to consider:

• Is this definitely AKI?

• Is the patient acutely unwell?

• How severe is the AKI?

• What is the cause of AKI?

Need guidance:

Primary care management of patient with AKI

Avoid or correct ‘dehydration’

Consider temporary cessation of medicines

If no obvious cause, consider new drugs as cause of AKI

Early review and repeat renal function

Consider seek help from nephrology on call



• Preventing AKI:

Review appointments



• Post AKI care:

Post discharge care

Post AKI care:

Driving quality – A National CQUIN for AKI The percentage of patients with AKI treated in an acute

hospital whose discharge summary includes each of

four key items:

1. Stage of AKI

2. Evidence of medicines review having been

undertaken

3. Type of blood tests required on discharge

4. Frequency of blood tests required on discharge for

monitoring

Discussing AKI & Kidney Health in

secondary & primary care


Post AKI care • Review medications

Consider restart medications that have been stopped

check kidney function 1/52 after reintroduction

Update records if drug implicated in causing AKI (e.g. PPI & interstitial nephritis)

• Assess the degree of renal recovery

Consider repeat renal function in patients who have not returned to baseline

If evidence of new onset CKD, then recheck proteinuria and Creatinine at 3 months

Consider contact nephrology for advice

• Reduce risk of further episodes of AKI

Communication of risk and use of sick day rules – Code their use = ‘8OAG’

• Coding the occurrence of an AKI episodes

Read codes exist for AKI 1, AKI 2, AKI 3

Case Study:












Case discussion at weekly clinical meeting with Community Support Pharmacist

Learning from Case Studies:

Addressing AKI in the community Key learning points and actions:

• Coding of AKI in GP records (even when not the primary diagnosis)

• Establishing a register and e-alerts for patients who have experienced AKI

• Mechanisms to ensure GP review:

Medication review

Check renal function

Social and carer support

Action plan

Support recovery

• Resource System Change


AKI Register & e-alert

Doing the basics well

AKI Registers & e-alerts


Resourcing implementation of AKI initiatives Summary of Key Factors to consider:

• Preventing AKI

Takes time to communicate risk

Ensure coordination in roles between GPs and Pharmacy

Dealing with dossette boxes – The Delivery Man!

• Detecting & managing AKI

Checking renal function in primary care: Timely - The Van Man!

Coordination with Out Of Hours care

Nursing Home Care

Timely access with the on call Nephrology team

• Post AKI Care

Salient discharge summaries & establishing AKI Registers in Primary Care

Role of medicine management Pharmacists

Integrating AKI into incentives e.g. Unplanned Admissions Enhanced Service

Minding the Gap:


Level


Preventing AKI

?

?

?


AKI

?

?

?

Post AKI care

?

?

?

Minding the Gap:


Level


Preventing AKI

√

√

√


AKI

√ √

√

Post AKI care

√

√

√

Achieving High Quality Care:

AKI = a driver of Quality across the NHS?

‘If we can get it right for AKI, we will get basic care right

across the NHS.’

NHS England’s guidance for general practice staff on reporting patient safety incidents Joan Russell Head of Patient Safety NHS England


GP e-form for reporting patient safety

incidents to NRLS • Launched 26 February - quick and easy for practice staff to report to NRLS

• 360m patient consultations with GPs each year but very small number of reports to NRLS (compared to 1.5m a year from trusts)

• Can report anonymously; and can choose to share with local CCG to support local learning

• Following a report a CPD / Serious Event Analysis (SEA) template for appraisal and revalidation is emailed to the reporter (can also be used as evidence for CQC inspections)

www.england.nhs.uk

How we use your patient safety

incident reports to drive learning

www.england.nhs.uk 137

Looking after the kidneys

The patient view Primary care AKI meeting

24 March 2015 Fiona Loud, Policy Director British Kidney Patient Association

Framing the message

• Low (no) awareness of kidney health or what the kidney does

• Message can be lost in the bigger picture of cardiovascular health, diabetes etc

Health talk

• Attitudes to monitoring kidney health

– Bill’s thoughts

– Bernard’s thoughts

• ‘Mild kidney impairment’

• Healthtalk.org

• Newly released CKD resource

http://www.healthtalk.org/peoples-experiences/long-term-conditions/kidney-health/bill

http://www.healthtalk.org/peoples-experiences/long-term-conditions/kidney-health/bernard-and-shelley

Dialogue with patients

• Why this is important?

• What does it mean for you?

• What can we do about it?

Common questions – why this is important

• What are the kidneys and what do they do?

• Why do I need to know about this?

What does it mean for me?

• Can my kidneys get better?

• How serious is this - will it mean I have to go on dialysis?

Patient-developed description of CKD

“My kidneys are not working as well as they should, and so are not filtering out as much waste from my blood. This results in changes to the way my body works and my general feeling of well being. This is called chronic kidney disease and is a gradual process where kidneys may continue to deteriorate over months or years. I have to watch my diet and blood pressure from now on.”

What can we do about it?

• Are there tests?

• What will the results of the tests mean to me?

• Why I have I been given these tablets? – Side effects, warnings in medication leaflets

• Who else can help me – nurse, pharmacist etc

• What next?

What I can do • Simple tips

• Watch the wee

• Drinking enough – of the right stuff (i.e. not alcohol)

• Medicine/tablets

• Ask for advice especially if sick

• Blood pressure/blood sugar/smoking/diet if appropriate

What you can do

• Open the dialogue

• Signpost

• Educate

• Feed back on blood tests

• Reiterate to check understanding

• Avoiding language barriers

Lay description of AKI My kidneys have suddenly stopped working properly; this can happen if someone is being treated as an emergency, has a big problem like pneumonia or some types of cancer. While this is being concentrated on my kidneys are really struggling because of e.g. dehydration, or medicines which need adjustment. So it’s like a heart attack, but on the kidneys, and is every bit as damaging…

After AKI

• Risk of another episode

• Residual damage

• What to tell the pharmacist/other health professionals in future

• Bring the partner/family/care home into the discussion as appropriate

Kidney Management – how much clinician time in one year?

Reality of self-care in long term conditions

Another 727 hours/month and 8030 hours/year to self-care

The Person with the condition

retains: • Choices

• Control

• Consequences

– But still needs empathy

– AKI is a big shock

Signposting • Kidney charity sites • Counselling • Patient information (mainly in development)

• www.Thinkkidneys.nhs.uk • NHS Choices • www.Britishkidney-pa.co.uk

– Advocacy, grants, counselling, service improvement, information

http://www.Thinkkidneys.nhs.uk

http://www.Britishkidney-pa.co.uk



12.45 – 13.00 Question & Answer Panel Session

Kathryn Griffith, GP and representative of the Royal College of General Practitioners Richard Fluck, National Clinical Director for Renal, NHS England Tom Blakeman, GP Joan Russell, Head of Patient Safety, NHS England Fiona Loud, Policy Director, BKPA


13.00-13.40 – Lunch break


The purpose of today

To develop the primary care solutions for acute kidney injury that focus on the pathway

• Prevention

• Early detection

• Effective intervention

• Enhanced recovery


13.40-14.40 Group work

Group 2 – Primary Care Group 3 – Primary Care Group 4 – Commissioners Group 5 – Commissioners Group 6 - Commissioners Group 7 – Improvement organisations Group 8 – Improvement organisations


Group work instructions

On your name badge you will have a group number for this task –

find that table with your group number on it.

Once in your group you will find a series of questions for your group

and a pre-printed template that will need to be completed.

A facilitator will be in your group to assist with the timing of this task

You will be required to provide a summary of your discussions in a

feedback session lasting no more than 3 mins

Managing acute kidney injury alerts in primary care 24.03.2015

Groups 2 & 3 – Primary Care

What are we going to do to ensure AKI is properly managed across the

patient pathway in both primary and secondary care, considering the

following :-

Out of hours

Detection of AKI

Patients at risk


Groups 2 & 3 – Primary Care

What support do we need from the acute sector? How can secondary care help primary care manage AKI more effectively ie - Minding the Gap? – Things to consider :-

Discharge

Admission advice

General AKI advice

Guidelines

What support do we need from the national programme? What should we ask of them? i.e. education/awareness raising

What should they ask of us?


What are we going to do to ensure AKI is properly managed across the patient pathway in both primary and secondary care, considering the following – out of hours, detection of AKI, patients at risk

What support do we need from the acute sector? – How can secondary care help primary care manage AKI more effectively ie minding the gap?

What should the national programme ask of us?

What support do we need from the national programme? – What should we ask of them? ie education/awareness raising

PRIMARY CARE – GROUP:

Group 4, 5 & 6 - Commissioners

What are we going to do to ensure AKI is properly managed in primary care? Things to consider :-

What are your plans for monitoring prevalence of AKI?

What are the challenges?

What are your plans for reviewing management of AKI and performance in your CCG area

To help overcome the challenges we have a plan to develop national commissioning guidance. What would you want to be included in the commissioning guidance for AKI in primary care?

What support do we need from the acute sector?

What support do we need from the national programme? What should we ask of them?



What are we going to do to ensure AKI is properly managed in primary care? What are your plans for reviewing management of AKI and performance in your CCG area?

What are your plans for monitoring prevalence of AKI? What are the challenges?

To help overcome the challenges we have a plan to develop national commissioning guidance. What would you want to be included in the commissioning guidance for AKI in primary care?


What support do we need from the national programme? – What should we ask of them? ie education/awareness raising

COMMISSIONERS – GROUP:

What support do we need from the acute sector?

Groups 7 & 8 – Improvement organisations

What can we do to support the implementation

of Think Kidneys ?

What support do we need from the national

programme? – What should we ask of them?



What can we do to support the implementation of Think Kidneys?


What support do we need from the national programme? – What should we ask of them?

IMPROVEMENT ORGANISATIONS - GROUP:

28.11.2014 Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 168

Am I in the right group?

Group 2 Tom Blakeman Sandhya Dhingra Medhat Guindy Berenice Lopez Fiona Loud Rajib Pal Carol Picken Daniel Vernon Stuart Wright

Group 3 Ama Basoah Linda Bisset John Corlett Kathryn Griffith Anjana Hari Dan Lasserson Victoria Lloyd Pauline Miller

Group 4 Khalada Abdullah Sally Bassett Emma Evans Naveed Ghaffar Sarah Harding Sheila McCorkindale Rumit Shah Nigel Taylor Charlie Tomson

Group 5 Carmel Ashby Lindsey Britten Samantha Glynn-Atkins Joanne Gutteridge Nesta Hawker Mike Jones Sue Renwick Gang Xu

Group 6 Emma Alcock Ramaswamy Diwaker Linda Hunter Abid Mumtaz Deborah Oliver Joan Russell Janet Wilson

Group 7 Lorraine Burey Martin Cassidy Rebecca Elvey Richard Fluck Simon Fraser Richard Healicon Sara Owen Pauline Smith

Group 8 Hester Benson Ron Cullen Fiona Cummings Katy Gordon Susan Howard Aly Hulme Tracie Keats Neil Sandys

Involving CCGs in managing acute kidney injury

Nesta Hawker Regional Programme of Care Manager Internal Medicine (North) NHS England - Regional Team


www.england.nhs.uk

• Part of the national Think Kidney programme

• Commissioning – part of House of Care

• CCGs commission majority of pathway of AKI

Implementation Work Stream

www.england.nhs.uk

• Aim to test out commissioning levers e.g. CQUINS

• Access to advice and input from national experts to develop the commissioning levers

• Southern Derby CCG testing commissioning levers in primary and secondary care

• To develop a commissioner toolkit for the Think Kidney website

• Lessons learnt

• Examples of commissioning levers along the pathway

Implementation Work Stream

An example from Southern Derbyshire

Carmel Ashby Assistant Head of Clinical Quality & Patient Safety – Primary Care Southern Derbyshire CCG


NHS Southern Derbyshire Clinical Commissioning Group

Southern Derbyshire CCG

AKI Primary Care Event

Carmel Ashby

Assistant Head of Clinical Quality &

Patient Safety – Primary Care

https://www.thinkkidneys.nhs.uk/


Why we got involved • Strong drive to improve services especially

patient safety

• NCEPOD report ‘Adding Insult to Injury’

• Individual commitment

• CCG Board sign up: Patient Story: Board briefings


Structure • Steering group established: strong multi agency

team

• Governance through CCG Quality Assurance Committee and Contract Monitoring Group

• CQUIN developed during January 2014:

2 part secondary care assessment on admission and discharge information

High priority given = £1 million


Progress • Secondary care CQUIN year one almost complete.

Year 2 CQUIN agreed (to continue improvements and complement national mandated indicator)

• Primary care planning: Locally Commissioned Service Framework (LCSF)

• Baseline survey undertaken by clinical staff – 467 GPs and Practice Nurses responded

• Number of respondents • Key messages


Progress (cont) Programme of education & awareness raising sessions Strategic Clinical Network funding (AKI/CKD) Quality Forum – PC/SC input Academic detailing – working Promoting to practices, to include all staff, GPs,

PNs/APNs, practice managers etc. delivered in range of settings

Evaluation framework – building on GP survey


Progress (cont)

Policies, Procedures & Guidelines on AKI guidelines to support care planning on discharge

Shared Care Pathology website

Sick day rules

• Information

Read codes approved


Lessons Learnt

Senior Leadership

Ambition and Innovation to improve

patient care

Bringing together a strong team who

were committed to a shared vision

Moving at pace using contractual levers


Contact Details

Lynn Woods - [email protected]

Sally Bassett - [email protected]

Nick Selby - [email protected]

Nitin Kolhe - [email protected]





An example from NHS South Sefton CCG

Nigel Taylor GP/Clinical Lead NHS South Sefton CCG


http://www.cmscnsenate.nhs.uk

AKI ALERTS IN PRIMARY CARE

THE CHESHIRE AND MERSEYSIDE EXPERIENCE

Dr Nigel Taylor GP, Clinical Lead South Sefton CCG

Birmingham 24th March 2015

Cheshire and Merseyside

Strategic Clinical Networks &

Senate

http://www.cmscnsenate.nhs.uk

AKI ALERTS IN PRIMARY CARE • Declarations of interest.

• Employers:- South Sefton CCG and Liverpool Community Health.

• Memberships:- Diabetes UK and the Primary Care Diabetes Society

for a number of years.

• I have chaired meetings for a number of companies which have

included:-BMS; Schering; Pfizer; MSD; Sanofi; AstraZeneca; Lilly and

Boehringer SB Communications. I have received travel awards from

Sanofi and Takeda and attended Pioneers in Diabetes meetings as a

delegate

AKI ALERTS IN PRIMARY CARE • Rationale

• Action Taken

• Future Plans

• Barriers NHS | Presentation to National AKI Meeting 24th March 2015 184


• RATIONALE

• Problem Identified

• AKI-Common in Hospital

• Bad Outcomes

• Suggested look at beyond confines of hospital

• More in Primary Care but milder forms

• Possibly amenable to minimal interventions NHS | Presentation to National AKI Meeting 24th March 2015 185

AKI ALERTS IN PRIMARY CARE • AKI Alerts

• Local Foundation Trust system generated a total of 6198 alerts - approx 1030 per month.

• 546 were from GPs - approx 90 per month. 64 - AKI 3 alerts - rest were AKI1 and 2

• 1029 alerts from AED

• 3514 alerts from Inpatients

• 765 alerts from Outpatients NHS | Presentation to National AKI Meeting 24th March 2015 186

AKI ALERTS IN PRIMARY CARE • Total Number of AKI Alerts in Primary Care for University Hospital Aintree Catchment for

six months 1/8/14 to 31/1/15 = 546 (AKI 1 & AKI 3)

• Further 1029 Alerts from A&E.

• South Sefton CCG-Population approx 155,000

• 33 GP Practices

• AKI 1- CCG Total for six months 287 (Range 1 to 27) i.e. 48 for one month.

• AKI 3- CCG Total for six months 35 (Range 1 to 5)i.e. 6 in one month.

• AKI 1,2 & 3= 0.4 per 1000 per month. NHS | Presentation toNational AKI Meeting 24th March 2015 187


NHS | Presentation to [National AKI Meeting 24th March 2015 188

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

AKI 1

AKI 1


NHS | Presentation toNational AKI Meeting 24th March 2015

[XXXX Company] | [Type Date] 189

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

AKI 3

AKI 3

AKI ALERTS IN PRIMARY CARE • ACTIONS: GP-what to do if alert-assessment & prevention.

• Discharge letter for those with AKI on their diagnosis.

• Patient & Carer Information

• Education-Primary Care

• Royal Liverpool Hospital-Pilot with GP Practices on AKI Alerts-Only

sending alerts to individual practice-identifying how many are serious &

how many need to come into hospital.

• Plan to Link Alert to Guidance Documents NHS | Presentation to National AKI Meeting 24th March 2015 190

AKI ALERTS IN PRIMARY CARE • Future Plans:-

• More Education for Nursing and Care Homes & Carers

• Community Pharmacists

• Drug Holiday Information

• Direct Link for health care professionals on results

• http://www.cmscnsenate.nhs.uk/strategic-clinical-network/our-

networks/cardiovascular/within-network/kidney/kidney-network-group/

• AQuA -Secondary Care-CCG Standards-Primary Care? NHS | Presentation to National AKI Meeting 24th March 2015 191

http://www.cmscnsenate.nhs.uk/strategic-clinical-network/our-networks/cardiovascular/within-network/kidney/kidney-network-group/














AKI ALERTS IN PRIMARY CARE • BARRIERS:-

• Phlebotomy Services

• GP feeling of ensuing Tidal Wave and being swamped.

• Siloed working-Primary Care; Secondary Care Community & Voluntary Sector.

• Overall Population Unawareness (74% no knowledge of kidney disease-recent

Kidney Research UK commissioned UKGov poll of 2000 people)..

• Common & deadly-need to look for diagnosis-it is not going to overwhelm the

system but need to treat. It is possible to get good outcomes

NHS | Presentation toNational AKI Meeting 24th March 201 192


If this works for Secondary Care then we can make it work for Primary

Care. 193

| Presentation to National AKI Meeting 24th March 2015 194

AKI ALERTS IN PRIMARY CARE • Acknowledgements:-

• Dr Abraham, Clinical Lead Cheshire & Mersey Renal Network;

• Members to the Cheshire and Merseyside Renal Network;

• Dr Peter Chamberlain GP Quality and Strategy Lead South Sefton CCG:

• Dr Chandrasekar, Consultant Nephrologist, University Hospital Aintree. NHS | Presentation to National AKI Meeting 24th March 2015 195

What will happen next, priorities and summary of the day

Richard Fluck National Clinical Director for Renal, NHS England Tom Blakeman GP Dan Lasserson GP


25/03/2015 197

The clever (academic) approach

Build a blender with rubber

blades.

Install a kitten detector

The simple (implementation)

approach

Don’t stick a kitten in a blender

Don’t press the start button if you

see a kitten in the blender

What you might need

A chart to help you tell the

difference between a kitten and

food

Education

16.00 – Close and thanks for attending

Safe journey home


think kidneys primary care and commissions workshop 240315 master slide deck final

Healthcare