Acute Kidney Injury (AKI) is now attracting enormous amounts of discussion due to the fact that it accounts for 25 – 30% of inpatient mortality and costs an estimated one billion pound a year. Patients who develop AKI are likely to spend 2.5 times longer in hospital than patients who do not.
AKI is defined by a rise in serum creatinine, which is a blood measurement. It is an important indicator of renal health because it is an easily measured byproduct of muscle metabolism that is excreted unchanged by the kidneys. AKI is defined by a rise in serum creatinine of 26 µmol/l within 48 hours or, 50% increase in serum creatinine from baseline, known or presumed to have occurred within the last 7 days or, less than 0.5ml/kg/hr urine output for 6 hours.
National Confidential Inquiry into Patient Outcome and Death (NCEPOD) found in 2009 that there were systemic deficiencies in AKI prevention, recognition and treatment in hospital; only 50% of patients received ‘good’ care and 20% of deaths were predictable and avoidable. In an attempt to address this issue the National Institute for Care and Excellence (NICE) produced two specific guidelines relating to AKI and Fluid Management of patients in hospital.
A team at Papworth Hospital NHS Foundation Trust led by Dr Stephen Webb, Consultant Intensivist was set up to look into ways of implementing both NICE Guidelines into clinical practice and therefore reducing the potential harm to our cardio-thoracic patients. Regular audit highlighted a high incidence of AKI in the postoperative cardiac surgical population and also highlighted variable standards relating to fluid management in these patients, very often patients were referred to our ALERT Team for deteriorating renal function within 24 hours of Critical Care discharge.
Initially the team produced guidelines for fluid management for the postoperative cardiac surgical patient, which standardised practice across this group of patients. Next they produced revised Fluid Management Guidelines and an AKI Pathway to be used on all patients who develop an AKI in Papworth Hospital NHS Foundation Trust.
There is continued monthly prevalence audit on the incidence of AKI within the surgical group of patients. Specifically the incidence of creatinine rise, referrals to the ALERT Team for fluid management related issues or deteriorating renal function and all readmissions to Critical Care which are directly related to AKI.
We have also pledged as part of the Sign up to Safety Campaign to reduce the incidence of AKI by 10% by 2018 and ensure 50% of Cardiac Surgery and PPCI patients who develop AKI will be managed using the AKI Pathway and 100% of Cardiac Surgery and PPCI (Primary Percutaneous Coronary Intervention) patients will be assessed using the AKI Pathway.
Julie Quigley, Lead Advanced Nurse Practitioner, ALERT Team and Maire Gilhooly, Advanced Nurse Practitioner, Mallard Ward.