A Before and After Study to evaluate Acute Kidney Injury Outreach

– preliminary results and two-year followup of a Complex Multifactorial Intervention

Mark Thomas, Cathy Hatton, Carol Willis and Jyoti Baharani.

DeclarationI have attended unpaid advisory boards and user groups run by Sunquest International.

Alert studies

OBSERVATIONAL AUDIT17th Sept to 17th Dec

2008

BEFORE STUDY OBSERVATIONAL

15TH May to 12th June 2009

4 weeks

AFTER STUDY –SERVICE EVALUATION12TH June to 31st July

20097 weeks

463 first Alerts in adults in study period61%

176 Alerts from dialysis patients 23%

52 repeat Alerts for same patient 7% 21 Alerts from patients already on dialysis

3%

411 first Alerts in adults in study period66%

144 Alerts from dialysis patients 23%

20 repeat Alerts for same patient 3% 15 Alerts from patients already on dialysis

2%Small numbers of Alerts with/in: CKD – no clear ACKD; Children under 16 years Alerts with suppressed low Creatinine; Poor data

Thomas, Sitch and Dowswell Nephrol Dial Transplant 2011

BEFORE AND AFTER STUDY• Alert messaging system set up on ICE Laboratory Information System

– Sunquest Information Systems Inc.• AKI Alerts

– Creatinine rises of ≥ 75% from the last value notified to a messaging inbox• Before phase: ‘Usual care’ 158 patients

– Alerts collected without intervention– Referrals received as usual

• After phase: 253 patients– Alerts reviewed early morning and late afternoon, five days a week – A Nephrology nurse or doctor discussed patient with

any available primary clinician– Case details and recommendations recorded using standard proforma

and faxed (when possible)

According to National Research Ethics Service procedures, the project was classified as a service evaluation by the Heart of England NHS Trust Research and Development office and did not require separate ethical approval.

After study – service evaluation

AFTER STUDY –SERVICE EVALUATION

12TH June to 31st July 2009

262 eligible AlertsIncluded in service

evaluation

253 patients 1st episode of AKIEligible for survival analysis

≥ 2nd AKI episodes in 9 patientsExcluded from survival analysis

Results of service evaluation262 potential calls

After study: Outcome of Outreach• Call successful in 89.7% (median 14.6h) 235

– fully successful 225– partial success 8– referred and seen as a result of call 2

• No call / call unsuccessful in 10.3% 27– Patient deceased by time of call 12– Insufficient time 8– Could not contact / Call declined 7

• Median of 3 recommendations (for all 262 Alerts)

Non Drug recommendations• ‘Investigational’ recommendations 306

– including urine dipstick, recheck of U&E, other

• Volume status related recommendations 151– including clinical reassessment; catheterisation– including advice on fluid prescription

• Care pathway recommendations 45– medical review, admission, appropriate transfer

• General medical recommendations 38– typically about underlying conditions

• Escalation / palliative care recommendations 16

Drug recommendationsDrugs stopped as potentially contributing to AKIACE inhibitor / ARB 60Aspirin 30Diuretic (non K sparing) 21NSAID 19Other hypotensive 18K sparing diuretic 13Aminoglycoside 4Aciclovir 3Other (incl. NSAID gel, CNI)7

Drugs stopped / reduced to avoid adverse events

LMW heparin19

Metformin 10Hartmann’s 2Reduced opiate dose 8

Drugs recommended to be avoidedAvoid contrast 6Avoid NSAID 2

Total of : 222 drug recommendations madeIn addition to: 64 similar actions taken by primary team before call

Conclusions• A modest time input (15-20 hr per week) resulted

in large scale changes to care of AKI patients• Consistent 6-8% absolute survival benefit appeared

rapidly and was maintained• Further work needed on peak creatinine, dialysis

usage, multivariate adjustment of survival analysis• Further studies of the Alert + Outreach approach

are clearly warranted

Thanks to colleagues

Angela Price Annette Dodds Carl Richardson Carol Willis Cathy Hatton Clive AllenHarry Nair Indranil Dasgupta Joanne Walker Jyoti Baharani Karen Harris Lisa Tebbit Lynette Groombridge Lynn Ivison Roger Adkins Sarah PowersSharon Deakin Steve Smith Steven Ting Tami StevensonTrudy Manji Vijay Suresh