Predict, prevent and manage acute kidney injury: A UK collaboration

Professor Lui Forni, Dr Richard Venn, and Dr Luke Hodgson explore how Western Sussex Hospitals NHS Foundation Trust is using cutting-edge technology to tackle acute kidney injury

As many as 100,000 deaths in secondary care settings are associated with acute kidney injury (AKI) each year, according to NHS England. Many more patients go on to endure prolonged hospital admissions and to suffer from secondary chronic conditions. Now identified as one of two national clinical priorities for 2015-16, AKI is a chief concern for hospitals across the country.

Often caused by stress on the kidneys due to other illnesses or infection, or the side effects of some drugs, more than a third of AKI cases occur after admission to hospital, with the elderly especially at risk.

It affects as many as one in five emergency admissions to hospital and costs the NHS as much as £620m per year; more than breast cancer or skin and lung cancer combined.

National reports also indicate that the care of up 40% of patients with AKI is inadequate, partly due to delayed recognition of the problem, and that as many as 20% of post-admission AKI incidents are both predictable and avoidable.

Yet, despite a quality standard being released by the National Institute for Health and Care Excellence (NICE), and NHS England drives to significantly reduce premature mortality over the next five years, electronic alerts that can warn doctors and nurses of the condition arising, have traditionally been studied for patients who already have AKI. Until recently little has been done in practice to predict which patients are at risk of developing the devastating condition. This is changing.

Making prevention a reality

A national motivation to tackle the problem is now being met with practical action. Specialist healthcare technology provider, Patientrack, working with clinical input from Western Sussex Hospitals NHS Foundation Trust (WSHFT), has developed a successful clinical and ICT solution to systematically identify and flag those developing, or those with, AKI, and subsequently promote a swift clinical response that until now has often been lacking.

Until recently little has been done in practice to predict which patients are at risk of developing the devastating condition

The solution won national funding in May 2014 from the Department of Health and the Small Business Research Initiative (SBRI) so that it could be trialled at WSHFT, and in March 2015 won a second round of funding with the aim of scaling the AKI alerting technology more widely across the NHS.

Patientrack’s early warning system has been widely used by doctors, nurses and other clinical staff at WSHFT since 2012 in order to capture bedside observations digitally, automatically calculate National Early Warning Scores (NEWS), and alert clinicians to deteriorating patients who require immediate medical intervention.

The trust has now worked with Patientrack to embed a ground-breaking predictive scoring model, developed by its own specialist renal clinicians, into the early warning software platform so that an AKI risk score can be used to deliver real-time alerts to medical staff and advise on a best-practice checklist that they must follow to care for patients appropriately and prevent conditions worsening.

The model, which is also combined with a national AKI staging algorithm, brings together various sources of data, includes pathology results, to assess a patient’s creatinine level and information including a patient’s age, medical history and known co-morbidities, along with physiological information that is recorded at the bedside through Patientrack.

These elements combine to generate a score which is then displayed on the patient’s electronic chart and the hospital’s Patientrack alerting system. Patients identified with AKI are issued with a red flag so that appropriate care can be given immediately. Those at risk of developing AKI are marked with an amber flag so that care packages can be delivered and patients who do not have the condition and are not judged to be at high risk are marked with a green flag.

The result is an intelligent real-time technology designed to systemically improve the care of patients with, or at risk of, AKI. For the first time clinicians can have complete visibility of the AKI status of every patient in the hospital and the system should allow healthcare professionals to identify every identifiable AKI, improve the management of people with AKI, and prevent the preventable.

Wide-ranging benefits

Early intervention should help enable the prevention of morbidity and mortality associated with AKI, including secondary complications such as chronic kidney disease, but additional benefits are expected. Reduced lengths of stay, for example, will help to reduce further potential exposure to harm in the hospital environment and the technology could reduce the need for renal replacement therapies and escalation to intensive care.

For the first time clinicians can have complete visibility of the AKI status of every patient in the hospital and the system should allow healthcare professionals to identify every identifiable AKI, improve the management of people with AKI, and prevent the preventable

Financial benefits for hospitals are also expected and not only as a result of reduced lengths of stay.

The solution can help to achieve commissioning for quality and innovation (CQUIN) targets around AKI, an incentive to reward good care of patients with the condition, which contribute to payments worth up to 2.5% of a provider's annual contract value.

And, ultimately, the project is providing doctors and nurses with a more intelligent picture and a rapid, accurate assimilation of various sources of data in order to immediately highlight which patients need intervention to prevent the serious consequences of AKI.

Testing

To test the system, from late 2014 the AKI model is being trialled at the WSHT’s Worthing Hospital for a year to monitor the effectiveness of interventions and see how far harms associated with AKI can be reduced. Performance in these areas will be compared against those on admissions at the trust’s control site, St Richard’s Hospital in Chichester, as well as compared to historical levels at both sites. St Richards will then introduce the system and the project will undertake an additional year of analysis of the interventions' impact on readmissions.

Developing the solution

The system will be developed as time goes on, feeding in new data, such as pharmacy and medication information. And, although at present the trust is using the national AKI staging algorithm and its own AKI predictive scoring model, the technology can be applied to any early warning score developed in the future.

As more patients are cared for using the system, potentially beyond Western Sussex, the AKI scoring model could also be refined based on richer data from larger samples, as well as potentially being adapted for different circumstances and demographics.

Scaling up

With such an emphasis now being placed on reducing deaths associated with AKI, the project embarked on in Western Sussex is highly relevant to many hospitals, something that a second round of Department of Health funding has reinforced. Several hospitals have already expressed a strong interest to add the AKI application into their own early warning system software through the Patientrack Research User Group and, in addition, a standalone solution is now being made available for hospitals not using Patientrack.

Significant interest is anticipated from the NHS. Large capital investments have not been needed in Western Sussex, and cost-effective deployment could easily be achieved elsewhere. With such an urgency being placed on tackling AKI, any project that reveals a strategy to prevent the condition and improve management of patients with AKI could have an impact across the NHS and beyond.

Professor Lui Forni is a consultant in intensive care and renal medicine and chairman of the AKI section of the European Society of Intensive Care Medicine (ESICM); Dr Richard Venn is a consultant in anaesthesia and intensive care at Western Sussex Hospitals NHS Foundation Trust; Dr Luke Hodgson is an intensive care research registrar at Western Sussex Hospitals NHS Foundation Trust

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