qi initiative: acute kidney injury (aki) care in acute oncology
TRANSCRIPT
The Christie NHS Foundation Trust
Patient First: Preventing Harm Improving care - Quality Improvement Theatre
Clinicians and QI staff - creating effective partnerships
Quality Improvement Initiative: Acute Kidney Injury (AKI) Care in Acute Oncology
Dr Tamer Al-Sayed MB ChB FRCP (London) MRCP (Nephrology) SCE (Acute Medicine) PGCE (PG Medical Education) GC (Medical Physiology & CV/Advanced Renal Specialisation)
Consultant in Acute & Renal Medicine Acute Kidney Injury Clinical Lead & Sepsis Co-Chair
Honorary Senior Lecturer, Department of Health & Medical Sciences, The University of Manchester
&Joanne Woolley, Clinical audit manager
The Christie NHS Foundation Trust
22-23 Nov 2016, London
The Christie NHS Foundation Trust
The partnership• Multiple National drivers: need for compliance with
best practice• Local clinical concerns: priority for improvement and
innovation• Clinical audit / QI team support for:
• Development of working group with Executive lead
• Use of AKI alert data collected for national purposes
• Data collection to support patient safety and quality monitoring
• Raising awareness, communicating progress
• Transfer to the electronic patient record and AKI dashboard
• Ongoing review and development
The Christie NHS Foundation Trust
Acute Kidney Injury (AKI) at The Christie
• The Christie NHS FT - comprehensive cancer centre• largest single site cancer centre in
Europe treating more than 44,000 patients a year
• 18 months ago, new Acute medicine role appointed“As a Consultant treating acutely unwell patients, I have worked with an expert team to develop guidelines for staff and patients in the treatment of acute kidney injury (AKI)” Dr Al-Sayed
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust
The Culture of Audit
• Feeds into clinical effectiveness and research committee
• Common goal – striving for excellence• One big team• Bidirectional interactions • Strong clinical governance leadership• Clinical audit a pivotal aspect of quality assurance• Proactive • Co-dependent
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The Christie Experience • Collaboration with UHSM & AKI working party • Clinical guidelines developed• Hotline triage tool • Audit tool • New fluid balance forms on OAU • Patient information leaflet• NHS Think Kidneys – Showcased work • Local teaching • Regional posters and presentations• NPSA award nomination• RCP Excellence in patient care submission • Development of e-learning tool
The Christie NHS Foundation Trust
NCEPOD & NICE
• For Better, for worse? – 2008 • Adding insult to injury – AKI 2009 • A time to intervene – 2012• Just say sepsis – 2015 • NICE AKI guidance 2012• NICE IV Fluid guidance 2013• NPSA June 2014 & August 2016
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Key performance indicators – facets of a care bundle
• Urine output• Urinalysis • Fluid balance
• Critical perfusion pressure • Oxygenation
• Treatment of sepsis – door to needle times • Discontinuing toxic medications• Hand over • Data recording – audit & governance
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Telephone triage for patients with suspected AKI
DIARRHOEA
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
• What chemotherapy is the patient on and when was the last treatment/tablet?• Are they receiving radiotherapy and when was their last treatment?• Number of recent episodes?
• How often do the bowels usually move? • How many stools a day is the patient passing or how much stoma output is there above normal amount? • Are stools/stoma output formed, loose or watery? Any faecal incontinence or urgency? Nocturnal movements?• Is there any abdominal pain e.g., cramping pains coming in waves?• For how many days has the patient had diarrhoea? Is it interfering with activities of daily living?• Are they able to eat and drink normally? Are they passing plenty of clear urine? • Do they have any other chemotherapy related toxicities, e.g. mouth ulcers, N/V, red hands/feet, stomatitis, mucositis?• Any recent antibiotics or recent hospital admissions?• Have they taken any laxatives or anti-sickness medication or any anti-diarrhoeal medication in the last 24 hours? What?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?Is the patient taking:
•NSAIDs e.g. Diclofenac, Ibuprofen•ACE inhibitors e.g. Ramipril, Lisinopril.
NB if patient taking any of the above drugs advise to omit until management plan agreed
Urgent review required or discuss with Acute Physician on MAU.
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VOMITING
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
•Frequency (number of episodes in last 24/48 hours) and nature of nausea with or without vomiting? •Assess bowel movements; Any symptoms that suggest constipation? Any diarrhoea?•What food and fluids have you been taking over last few days? •Any signs of dehydration e.g. decreased urine output, fever, thirst, dry mucous membranes etc.•What is the underlying cancer diagnosis? •What is the extent of the disease? – e.g. known metastases to brain, bone, liver etc.•What medication is the patient taking i.e. antiemetics and has there been any recent changes?•Increasing abdominal pain?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?Is the patient taking:
•NSAIDs eg Diclofenac, Ibuprofen•ACE inhibitors eg Ramipril, Lisinopril.NB if patient taking any of the above drugs advise to omit until management plan agreed
Review prescribed antiemetic medication;
Assess patient compliance
Phone / review the patient in 24 hours
As for grade 1
Advise to get GP review consider changing antiemetic including route of admin.
Phone / review the patient in 24 hours
If symptoms worsen or are associated with other toxicities consider admission.
Urgent review required or discuss with Acute Physician on MAU.
The Christie NHS Foundation Trust
Time Oral Intake Running Total
IV 1 IV 2/ Other Running Total
Total
Intake
07: 00
08: 00
09: 00
10: 00
11: 00
12: 00
13: 00
14: 00
15: 00
16: 00
17: 00
18: 00
19: 00
20: 00
21: 00
22: 00
23: 00
24: 00
01: 00
02: 00
03: 00
04: 00
05: 00
06: 00
TOTAL
INTAKE
Urine Running Total
Other Other Running Total
Total
Output
TOTAL
OUTPUT
Balance from
previous day:
Cumulative
balance:
Weight:
Balance from
previous day:
Cumulative
balance:
Weight:
BALANCE
Developed by Katerina Pearson, OAU Sister
The Christie NHS Foundation Trust
AKI alert and guidance on blood result
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Change in biochemical assay
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AKI alerts post change in algorithm• Initial audit identified need for change in algorithm to
improve accurate classification of AKI stage• Increased numbers identified; level 3 maintained
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AKI alerts: quality monitoring and improvement
• Adherence to care bundle and root cause analysis• Policy, guidance, education, awareness raising
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Assessing risk factors on admission
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Monitoring compliance with care bundle• Early increased compliance since pilot, eg.:
• Ultrasound KUB <24hours: up from 51% to 60%• Stop nephrotoxic medications: up from 54% to 63%• Urine dipstick and analysis: up from 54% to 67%
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Strong Leadership • Focus within The Christie:• Governance – clinical audit leadership and
steering • Clinical specialist leadership • Executive board membership• Embedding data collection into clinical
systems • Empowering staff to collect data• Assigning trainees with current projects •
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Sharing & Promoting Best Practice • Executive dissemination • Education – Presentations
• Non-medical prescribers
• Acute Oncology Masterclass for NW AON
• Morbidity & Mortality Grand Round
• Representation at the GM, Lancashire & South Cumbria Strategic Clinical Network
• National patient safety presentations• GP correspondence • Link with sepsis and IV fluid groups
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Practical Solutions – Real Problems
• Clinical audit will assure delivery and quality of this entire project through robust long term data collection & analysis
• AKI Dashboards – safety thermometer • EPR – AKI documentation• e-prescribing – medicines optimization • e-learning tools • AKI discharge summaries for GP & patients
The Christie NHS Foundation Trust
Simple is Effective Maximising the utility of clinical audit
A fully integrated team
Pioneering in Cancer Care in the UK Innovative & Expert real time cross disciplinary team
working beyond historical barriers
The power of a culture shift A new tradition
Medicines optimization Proactivity at the front door
Maximising patient outcomes
The Christie NHS Foundation Trust
References & Resources
• AKI toolkit 12 – RCP Oct 2015• AKI APP – RCPE • NICE AKI Guidance 2012• NCEPOD – Adding Insult to Injury 2009• NHS ‘Think Kidneys’ programme• Academy of Medical Royal Colleges • Royal College of Radiology – Contrast Nephropathy• Society of Intensive Care Medicine • Society for Acute Medicine • Royal College of Nursing • Royal Society of Medicine – Nephrology section • Renal Association/British Renal Society website