AKI Programme - TVSCN

AKI Programme - TVSCN

National Acute Kidney Injury (AKI) Programme 02/07/2020 1 Acute Kidney Injury It is estimated that 1 in 5 emergency admissions into hospital are associated with AKI (Wang et al, 2012) Up to 100,000 deaths in secondary care are associated with AKI and 1/4 to 1/3 have the potential to be prevented (National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Adding Insult to Injury 2009) Not a specialty specific issue - the majority of cases arise and/or are managed in the community or across all specialities within secondary care (Selby et al, 2012). Estimated additional cost to NHS of 500 million (NHS Kidney Care) 02/07/2020

2 Acute Kidney Injury Acute Kidney Injury 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 Incidence of AKI is increasing AKI not requiring dialysis

Dialysis-requiring AKI Hsu CY et al. Kidney International (2007) 72, 208 Hsu RK et al. JASN 2013;24:37-42 * Per 100,000 person years * Per million person years Patients with AKI do not die from uraemia 41.1% 19.2% 17.1% 12.9% 3.1%

6.6% Selby NM et al. PLoS ONE 2012; 7(11): e48580 Bi-directional relationship of AKI and CKD 1million patients with baseline assessments of serum creatinine and proteinuria 233,803 hospitalised patients aged over 67 AKI increased risk of ESKD by 13 fold CKD and proteinuria increase risk of AKI Baseline renal function Rate ratio for hospital admission with AKI* eGFR >60

1.0 eGFR 45-59.9 2.3 eGFR 30-44.9 5.6 eGFR 15-29.9 13 *non-proteinuric group shown; similar pattern seen across all levels of proteinuria James MT et al. Lancet 2010; 376: 2096-2103

Ishani A et al. JASN 2009; 20: 223228 NCEPOD report published in 2009 Poor assessment of risk factors for AKI and acute illness Delays in recognising AKI Most patients with AKI are not cared for by nephrologists Post admission AKI avoidable in 21% Good care in <50% cases Study population Elderly population - median age of 83 Admitting specialty Conclusion Systematic failings in AKI

Failures in: Recognition and management of AKI Recognition and management of complications Referral and support Failures in recognition of the acutely ill NHS Outcomes Framework AKI Programme fits into Domain 5 Primary Aim The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. 02/07/2020 16 Design principles for the national AKI Programme

Global Social, primary and secondary care Multiprofessional with patients and across specialties Inclusive Measurement underpins evidence Simplify data flows Use to evidence change Strategy not tactics Programme Purpose The purpose of the National Programme is to deliver and implement a structure and tools within three years that will lead to a fall in the number of preventable episodes of AKI, and with that a reduction in deaths associated with AKI. It will lead work on the development of clinical tools, information and levers and prioritise patient empowerment. It will utilise commissioning pathways and other clinical networks. It will also establish local and national data collection and audit leading to further safety improvement and target research towards

areas that require elucidation. 02/07/2020 18 Programme Ambition This transformation will lead to well informed, proactive multi-professional teams, supporting patients, carers and the public. They will understand risk, prevention, recognition and recovery for their patients and for their organisations and be provided with appropriate tools and resources. Patients and their carers will understand their personal risk, be empowered to understand when to seek support and be provided with appropriate access. At organisational and national level agreed data will be collected and continuous national audit will be embedded into the learning process. Research and quality improvement for AKI will be established and robust. As AKI is a global health care issue, the NHS has the opportunity to lead on improving outcomes, providing systems and evidence for improvement in healthcare. 02/07/2020

19 Programme Objectives The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. It will aim to do this by: Ensuring that a variety of tools and interventions are developed and implemented to support the prevention, early detection, treatment and enhanced recovery of patients with AKI. Ensuring that patients who develop AKI are appropriately managed to reduce further deterioration, long term disability and death. Ensuring that appropriate education and training programmes are developed for all health professionals based on best available evidence. Ensuring that commissioners, health care professionals and managers are aware of the importance and risks of AKI and appropriate local strategies to reduce the burden of AKI are developed. 02/07/2020 20 Programme Objectives continued

Developing a national registry and audit for AKI leading to an improvement strategy on a national and local basis to reduce unwarranted variation in care. Involving patients and the public in understanding the risk of AKI and preventative measures through education and appropriate access to personal information. Supporting the development of a commissioning structure to allow local service configuration to provide quality care to individuals with AKI. Identifying the research agenda for AKI (including basic science, clinical care and service delivery). 02/07/2020 21 What it is not about Bad doctors or nurses AKI is a patient safety issue but 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 AKI National Programme Key deliverables Primary Care package Secondary Care package Measurement Commissioning Healthcare System Change Public Campaign AKI National Programme Key Milestones AKI Programme DETECTION WORKSTREAM September 2014 - April 2016 Sep-Mar 2014/15 Apr-15

May- Sep 2015 Oct-15 Nov - Mar 2015/16 Test Primary Care Data in shadow form Implement Secondary Care AKI Warning Test Apr-16 Launch AKI Warning test to Primary Care Launch Primary Care education packages EDUCATION WORKSTREAM Develop Secondary Care

education packages Launch Secondary Care education packages including pilot testing Develop Primary Care education packages including pilot testing Test Education packages for Primary Care Refin e Primary Care Education packages Evaluation of Primary Care packages Launch Public/Patie nt Campaign INTERVENTION WORKSTREAM

RISK WORKSTREAM MEASUREMENT WORKSTREAM Develop Secondary Care package including Launch Secondary Care package development of tools and pilot testing Develop Secondary Care Risk Assessment tools Launch Secondary Care Risk Assessment Tools and pilot tools Develop Primary Care package including development of tools and pilot testin g Develop Primary Care Risk Assessment tools and pilot

testin g Design Quarterly Reports at CCG level for Primary Care CCG Level report on initia tion of Secondary Care AKI Warning Test HQIP Proposal Test Primary Care package and tools Refin e Primary Care package and tools Test Primary Care Risk Assessment tools and pilot testing Refin e Primary Care risk Launch Primary Care Risk Assessment tools Assessment tools

Launch Primary Care package Registry in place Commence Quarterly Reports at CCG Level based on shadow form results from Primary Care Data Costed Business Case National Audit Formal quarterly reports at CCG level re uptake in primary care Development of Primary care Commissioning levers and tools IMPLEMENTATION WORKSTREAM Development of Secondary Care Commissioning levers and tools Acute Kidney Injury Patient Pathway

Recovery Treatment Diagnosis At Risk + Event At Risk Group Well Group AKI National Programme AKI National Programme The Patient Characteristics Group is demonstrated with this diagram

Diagnosis At risk event Whole PopulationAt risk with anTreatment Recovery 02/07/2020 27 AKI Programme Board Members Richard Fluck, National Clinical Director Renal, NHS England Natasha McIntyre, South Derbyshire CCG and Co-Chair of the Implementation Workstream Kathryn Griffith, RCGP CKD Lead

Chas Newstead, Leeds Teaching Hospital Pathfinder Project and Co-Chair of the Implementation Workstream Ron Cullen, UK Renal Registry Director Chris Laing, Royal Free Hospital and CoChair Education Workstream Nick Selby, Consultant Nephrologist, Royal Derby Hospital and Co-Chair of the Detection Workstream Nitin Kolhe Royal Derby Hospital and Co-Chair of the Measurement Workstream Joan Russell, NHS England Head of Patient Safety

Charlie Tomson, North Bristol Trust and Chair of the Intervention Workstream Robert Hill, Consultant Clinical Biochemist, Chair of the Detection Workstream Fergus Caskey North Bristol Trust and Chair of the Measurement Workstream Karen Thomas, UK Renal Registry AKI Programme Manager Michael Wise, Lay Representative Mike Jones, County Durham & Darlington NHS Trust/Society for Acute Medicine Representative and Chair of the Education Workstream Andrew Lewington, Leeds NHS Trust and

Chair of the Risk Workstream Sarah Harding - GP NHS Leeds & East CCG and Co-Chair of the Risk Workstream Fiona Loud, Lay Representative and CoChair of the Risk Workstream Nesta Hawker, NHS England Pathfinder Project and Chair of the Implementation Workstream Dane Wiig, NHS England Comms Team Caroline Ashley, Royal Free Hospital and Chair Renal Pharmacists Group and Co-Chair Intervention Workstream Jonathon Hope, Lay Representative

Lorraine Oldridge, Public Health England Tom Blakeman, GP and Co-Chair of the Intervention Workstream Caroline Lecko, NHS England Patient Safety Lead Nutrition and Hydration, Chair of the Hydration Sub-Group Carol Peden, Academic Health Sciences Network Catriona Shaw, UK Renal Registry/Junior Drs David Milford, Paediatric Renal Physician, Birmingham Childrens Hospital

Ron Daniels, UK Sepsis Trust Fiona Thow, NHS Improving Quality 02/07/2020 28 NHS England Patient Safety Steering Group AKI National Programme Board Risk Education AKI Website SubGroup Detection Intervention

Algorithm SubGroup Software Implementation Sub-Group Best Practice in Ealert Group Expert Reference Group Hydration Sub-Group Implementation Measurement AKI Risk Workstream Priorities Identify at risk groups Gain an understanding of at risk communities from existing data stores

Identify events that mean AKI is more likely to happen Develop a matrix around the risk and the event Identify risk tools in use are they fit for purpose or are new ones commissioned 02/07/2020 Members Chair Andrew Lewington, Nephrologist, Leeds Teaching Hospital Co-Chair Fiona Loud, Lay Representative, British Kidney Patients Association Co-Chair Sarah Harding - GP David Wheeler, President, Renal Association Rob Parry, Nephrologist, Cornwall Annette Davies, Tutor Acute Care, University of Surrey Richard Healicon, NHS Improving Quality Miles Witham - Geriatrician Claire Beeson, Consultant Geriatrician Yvonne Higgins, Quality & Safety Manager NHS England

Rachel Lennon, Paediatric Nephrologist Coral Hulse, Nurse Consultant, Critical Care Outreach Service, Mid Cheshire Hospitals NHS Foundation Trust Paul Gardner - GP Liz Butterfield Community Pharmacist Rebecca Brown Community Pharmacist Helen Hobbs, Research Renal Nurse, Kent Kidney Research Group Berenice Lopez, Consultant Chemical Pathologist Alastair Santhouse, Consultant in Psychological Medicine, Guys Hospital Karen Thomas, AKI Programme Manager, UK Renal Registry Annette Lawrence, NHS Wolverhampton CCG Tom Blakeman, GP David Stephens, GP, Scotland 30 AKI Programme Board AKI Risk Workstream 02/07/2020

31 AKI Education Workstream Priorities Identify educational tools in use are they fit for purpose or are new ones commissioned Educational materials for health professionals particularly primary care on what AKI is and what steps to take including hospitalisation or not Educational materials for patients and carers on what AKI is and how to manage condition and any reoccurrences Endorsement of existing tools in use Develop a website Develop a publicity campaign to raise awareness

02/07/2020 Members Chair Mike Jones, County Durham & Darlington FT/RCGP Representative Co-Chair Chris Laing, Nephrologist, Royal Free Hospital Sue Shaw, Renal Service Pharmacist, Royal Derby Hospital Karen Thomas, AKI Programme Manager, UK Renal Registry Kathryn Griffith, RCGP CKD Lead Catriona Shaw, Clinical Fellow, UK Renal Registry/Junior Drs Nicky Wood, Outreach Sister, East Sussex Healthcare Claire Fraser, Nurse, County Durham & Darlington Michael Wise, Lay Representative Winnie Wade, Royal College of Physicians Michelle Timoney, Quality Improvement Lead Cheshire and Merseyside Strategic Clinical Networks Martin Christian, Childrens Services, Nottingham University Hospitals NHS Trust Pauline Pinkos Lay Representative 32

AKI Programme Board AKI Education Workstream AKI Website Sub-Group 02/07/2020 33 Education Workstream Core Education Workstream Group Michael Jones Michael Wise Cat Shaw Nicky Wood Michelle Timoney Chris Laing Sue Shaw Kathryn Griffith Claire Fraser Karen Thomas

Winnie Wade Martin Christian Formalised Education Publicity Campaign Education Workstream Stakeholders Patients Carers Patient Organisations General Public Media Social Media Patients Public Allied Health

Professionals Care Homes Drs GPs Acute Medicine clinicians General Surgeons Specialist Medicine clinicians Junior Drs Nurses Acute medicine nurses Community nurses Health visitors Midwives Mental Health Student Nurses Education Workstream Stakeholders

Nurses Allied Health Professionals Media Patients Public Educationalists Drs AKI Intervention Workstream Priorities Design a range of Care Bundles designed around such things as

medicines management, hydration etc Develop a decision tree for what action to be taken by healthcare professionals ie hydration, medicines management, tests and retesting, refer to specialists etc Consider good practice guidance around communicating AKI to GP with next steps, suggested follow ups, medicines review etc 02/07/2020 Members Chair Charlie Tomson, Nephrologist, North Bristol Trust Co-Chair Caroline Ashley, Chair Renal Pharmacists Group, Royal Free Hospital Co-Chair Tom Blakeman, GP Rukshana Shroff, Paediatric Nephrologist, GOSH Clair Huckaby, Pharmaceutical Adviser, Public Health, Dudley Metropolitan

Borough Council Bob Winter, National Clinical Director for Intensive Care, NHS England Suren Kanagasundaram, Nephrologist, Newcastle Caroline Lecko, Patient Safety Lead, NHS England Patsy Hargrave, Heart Failure Community Matron, Whittington Health NHS Leariann Alexander, Enhancing Quality Sister, Medway Trust Marlies Ostermann, Consultant in Critical Care and Nephrology, Guy's and St Thomas's Hospitals Jan Flint, Clinical Lead Renal Dietitian, Royal Free London NHS Foundation Trust & Chair of The Renal Nutrition Group of the BDA Sue Wilson, Critical Outreach Nurse, St Peters Hospital, Chertsey Karen Thomas, UK Renal Registry Rajib Pal - GP, Hall Green Health Jude Clarke Lay Representative Chris Mulgrew Nephrologist, Royal Devon & Exeter 37 AKI Programme Board

AKI Intervention Workstream 02/07/2020 38 AKI Implementation Workstream Priorities Develop commissioning tools service specifications, CQUINs, enhanced service agreements Provide evidence that tools work Collect baseline data from the pilot projects 02/07/2020

Members Chair Nesta Hawker, CRG Accountable Commissioner Co-Chair Chas Newstead, CRG Chair Co-Chair Lynn Woods, Southern Derbyshire CCG Richard Fluck, National Clinical Director Michelle Timoney, Representing Cheshire Wirral and Warrington Specialised Commissioning Rosie Kaur, Liverpool CCG Fiona Loud, Patient Representative Ron Daniels, Chair UK Sepsis Trust Karen Thomas, UK Renal Registry Ron Cullen, UK Renal Registry Caroline Huff, NHS Hastings & Rother CCG Liz Kanwar, Salford Royal Lynn Woods, Southern Derbyshire CCG Manish Sinha, Paediatric Nephrologist, Guys and St Thomas Sam Doddridge, Salford Royal Samantha Glynn-Atkins, Salford CCG Sheila McCorkindale, Salford CCG

39 AKI Programme Board AKI Implementation Workstream 02/07/2020 40 AKI Measurement Workstream Priorities Demographic information demonstrating the size of the AKI problem need to define national AKI message content Establish data items and linkage for Registry Demographic information demonstrating size of at risk group

Measure adherence of acute sector to care bundles Consider downstream consequences for AKI 02/07/2020 Members Chair Fergus Caskey, Consultant Nephrologist, North Bristol NHS Trust, Medical Director, UK Renal Registry Co-Chair Nitin Kolhe, Nephrologist, Royal Derby Hospital Ron Cullen, Director, UK Renal Registry George Swinnerton, UK Renal Registry Robert Hill, Chair of the AKI Detection Workstream James Hollinshead, Public Health England James Medcalf, University Hospitals Leicester Nick Selby, Nephrologist, Royal Derby Hospital Denny & Bud Abbott, Lay representatives Jeremy Thorp, HSCIC Karen Thomas, AKI Programme Manager

Kay Tyerman, Paediatric Nephrologist, Leeds 41 AKI Programme Board AKI Measurement Workstream 02/07/2020 42 AKI Detection Workstream Priorities Algorithm agreed and in place Education re algorithm Communicating with LIMS providers Messaging for primary care

and the impact 02/07/2020 Members Chair Robert Hill, Consultant Clinical Biochemist, Sheffield Teaching Hospital Co-Chair Nick Selby, Nephrologist, Royal Derby Hospital Ali Cheema, Consultant Acute Medicine, Sheffield Teaching Hospital Anne Dawnay, Consultant Biochemist, UCL Hospitals Mike Bosomworth, Consultant Clinical Scientist, Leeds Hospital Simon Higgs, Clinical Effectiveness Manager, Western Sussex Hospital Debbie Higgs, Consultant Nurse Critical Care, East Kent Hospitals David Milford, Paediatric Nephrologist, Birmingham Childrens Hospital Gifford Batstone, Specialist Pathology Adviser, NHS England Finlay MacKenzie, University Hospital, Birmingham Karen Thomas, UK Renal Registry Nick Palmer, Lay Representative Erika Denton, Consultant of Radiology, Norfolk and Norwich University Hospital Daniel Lasserson, GP Fergus Caskey, Consultant Nephrologist, North Bristol NHS Trust, Medical Director,

UK Renal Registry Nitin Kolhe, Nephrologist, Royal Derby Hospital Chris Thompson, University Hospital North Staffs Trevor Hine, Royal Liverpool & Broadgreen 43 AKI Programme Board AKI Detection Workstream Algorithm Sub-group Software Implementation Task group Best Practice in E-Alert Messaging Sub-group

AKI Detection Workstream Expert Reference Group 02/07/2020 44 AKI Programme Board AKI Hydration Sub-group 02/07/2020 45 What have we achieved so far?

Established a Programme Board Recruited a Programme Manager Established 6 workstreams Identified workstream priorities Issued an NHS England Patient Safety Alert for the Detection of AKI in secondary care settings Contributed to an entry into NHS Choices for Acute Kidney Injury Commenced work on a programme website Ran a launch event for key stakeholders Summary The NHS England AKI programme is well established It will deliver change in 2-3 years A national system of measurement will be commenced in summer 2014 As part of the NHS England Patient Safety group it will make the NHS the safest healthcare system in the world. AKI Programme

How to find out more Karen Thomas, AKI Programme Manager [email protected] Teresa Wallace, AKI Programme Coordinator [email protected]hs.uk 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] 02/07/2020 www.england.nhs.uk/AKIProgramme Follow us on Twitter : @ActKidneyInjury 48

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