Soublik, P, Hickinbotham, L, Kawar, b northern General Hospital, Sheffield Introduction

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How can we improve the management of Acute Kidney Injury: data from a teaching hospital setting
Soublik, P, Hickinbotham, l, Kawar, B

Northern General Hospital, Sheffield
Introduction: Acute kidney injury (AKI) is a common problem that affects patients admitted under any speciality. In 2009, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of patients that died in hospital with AKI. One of the recommendations was that improvements to undergraduate and postgraduate training could be a mechanism for reducing the incidence of predictable and avoidable AKI.
We undertook a service assessment to elucidate where the educational needs should best be directed and what factors are lacking in providing high quality care for patients with AKI. This would be helpful when formulating educational and service improvement strategies.
Method: We prospectively reviewed the case notes and blood results of all patients who were referred to the on-call nephrology service over a 2 month period with AKI in a teaching hospital with an onsite renal department. A questionnaire was devised and information was obtained on patient age, sex, co-morbidities, timing of AKI, source of referral, adequacy of investigations and treatment, and outcomes.
Results: We acquired data on 70 patients (49 males). The average age of patients was 71.5 ± 12.8 years. Key findings included:

  • 54% had AKI on admission and the remaining 46% acquired AKI in hospital.

  • 53% were referred from the medical specialities and 41% were referred from the surgical specialities. The rest were from critical care.

  • 32% of medical referrals and 59% of surgical referrals developed AKI during admission. This was statistically significant (p<0.05) with χ2 test.

  • Urinanalysis was performed in 57% of cases and renal tract imaging in 64%.

  • In 70% of medical referrals and 52% of surgical referrals, management was deemed adequate. There was no significant difference between the 2 groups.

  • Overall, 61% of patients recovered on the base ward, 24% died, 6% referred to ITU and 9% transferred to the renal ward.

Conclusion: Whilst delay in the recognition of AKI was not a problem, there was room for improvement in the investigation and management of AKI and was similar for patients referred from medical or surgical specialties. However, there was a higher rate of patients who developed AKI during admission under surgical than under medical teams. This may be multifactorial and may be related to differences in the nature of the patients and course of management between the two disciplines. Nonetheless, surgical patients may be at higher risk of developing AKI. Therefore, we recommend:

  • Education of junior doctors, particularly those on surgical firms as part of the Foundation programme. Awareness of the use of anti-hypertensives, especially ACE inhibitors, fluid balance and avoidance of NSAIDs, may reduce the development of peri- and postoperative AKI.

  • Development of a Care Pathway for AKI would enable junior doctors and nursing staff, particularly on surgical wards, to commence physiological monitoring early and identify possible nephrotoxins when prescribing or dispensing.

  • A renal outreach services may help to optimise the care of established or incipient AKI and help educating nursing and medical staff.

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