Transcript A Before and After Study to evaluate Acute Kidney Injury

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.
Declaration
I have attended unpaid advisory boards and
user groups run by Sunquest International.
Alert studies
OBSERVATIONAL AUDIT
17th Sept to 17th Dec 2008
463 first Alerts in adults in study period
61%
176 Alerts from dialysis patients
52 repeat Alerts for same patient
21 Alerts from patients already on dialysis
23%
7%
3%
Thomas, Sitch and Dowswell Nephrol Dial Transplant 2011
15TH
BEFORE STUDY
OBSERVATIONAL
May to 12th June 2009
4 weeks
AFTER STUDY –
SERVICE EVALUATION
12TH June to 31st July 2009
7 weeks
411 first Alerts in adults in study period
66%
144 Alerts from dialysis patients
20 repeat Alerts for same patient
15 Alerts from patients already on dialysis
23%
3%
2%
Small numbers of Alerts with/in:
CKD – no clear ACKD; Children under 16 years
Alerts with suppressed low Creatinine; Poor data
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 Alerts
Included in service
evaluation
Results of service evaluation
262 potential calls
253 patients 1st episode of AKI
Eligible for survival analysis
≥ 2nd AKI episodes in 9 patients
Excluded from survival analysis
After study: Outcome of Outreach
• Call successful in 89.7% (median 14.6h)
– fully successful
– partial success
– referred and seen as a result of call
235
225
8
2
• No call / call unsuccessful in 10.3%
27
– Patient deceased by time of call
– Insufficient time
– Could not contact / Call declined
12
8
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 recommendations
Drugs stopped as potentially
contributing to AKI
ACE inhibitor / ARB
Aspirin
Diuretic (non K sparing)
NSAID
Other hypotensive
K sparing diuretic
Aminoglycoside
Aciclovir
Other (incl. NSAID gel, CNI)
Drugs stopped / reduced to
avoid adverse events
60
30
21
19
18
13
4
3
7
LMW heparin
Metformin
Hartmann’s
Reduced opiate dose
19
10
2
8
Drugs recommended to be avoided
Avoid contrast
6
Avoid NSAID
2
Total of :
222 drug recommendations made
In 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
Carl Richardson
Cathy Hatton
Harry Nair
Joanne Walker
Karen Harris
Lynette Groombridge
Roger Adkins
Sharon Deakin
Steven Ting
Trudy Manji
Annette Dodds
Carol Willis
Clive Allen
Indranil Dasgupta
Jyoti Baharani
Lisa Tebbit
Lynn Ivison
Sarah Powers
Steve Smith
Tami Stevenson
Vijay Suresh