Project: Managing Acute Kidney Injury Together for better health (MAKIT Better)
What are we trying to do?
We’re supporting and evaluating the improvement of care for acute kidney injury (AKI) in secondary care and at the interface between secondary and primary care. We’ll be supporting two quality improvement (QI) initiatives which aim to improve the identification of AKI and reduce the number of cases of AKI: one at Central Manchester University Hospitals NHS Foundation Trust, and one at Salford Royal NHS Foundation Trust. This project has a key focus on patient and carer experience, which will be used to inform the work.
QI work at Central Manchester University Hospitals NHS Foundation Trust
The QI work at the Trust has been designed around two specialist AKI nurses who form part of the renal team. The specialist nurses are responsible for supporting staff from all wards that provide care for people with AKI.
A QI programme was launched in 2013 in collaboration with Haelo (a quality improvement consultancy), employing a ‘systems’ approach in order to develop focussed and measurable goals and introduce improvement methods to support change (e.g. Plan, Do, Study, Act cycles). As part of this improvement work the Trust established targets associated with:
- Improved identification of AKI
- Reduction in progression from AKI stage one to stage two and three
- Reduction in length of stay associated with AKI.
The initial programme was completed in June 2014. During this time, the Trust achieved substantial reductions in length of stay associated with AKI. The renal team then conducted a factor analysis to identify the most important determinants of this reduction. They identified:
- Face-to-face contact with specialist nursing team
- Checklist for ward staff.
This analysis provided broad areas to continue to focus improvement work. However, it did not make clear what it was about interventions such as ‘education’ that made them successful. In addition, since the initial Haelo program came to an end, there has been a reduction in measurable improvements.
Therefore, the ongoing improvement work is focussed on how to sustain improvements. This will involve exploring the underlying factors associated with the success of the initial programme, the impact of changes on staff working practices and satisfaction levels, and the experience of patients receiving care for AKI.
QI work at Salford Royal NHS Foundation Trust
Each clinical area at the Trust has a designated AKI link nurse who takes the lead in developing and implementing interventions and processes that will help reduce the number of AKI cases. The AKI link nurse is also responsible for appropriately managing patients who are admitted with a diagnosis of AKI or who develop one whilst an inpatient.
Following an initial learning event in August 2015, the Trust had a three month “action period” during which time doctors, nurses and support workers tested new ideas such as:
- Posters and leaflets to raise awareness of AKI among the staff
- Information leaflets for patients and relatives
- Establishing processes for the timely analysis of urine and blood tests
- Ensuring fluid balance charts are documented rigorously for AKI patients
- Developing an AKI alert on the electronic patient record
- Developing an education programme and ongoing one-to-one teaching at ward level
- Developing an AKI resource pack for staff that includes tools and guidance.
A second learning session took place in October 2015 with the same teams to share their learning and discuss challenges. This was again followed by another three month action period to fine tune earlier ideas and start implementing those that made an impact on patient care. A third learning session will take place in March 2016 to review progress so far, start developing a change package (a more formal toolkit which includes ideas that have been tried and tested) and examine the reliability of QI activities and clinical interventions.
Why is it important?
We know that AKI increases mortality by up to 30% and that, in the UK, up to 100,000 deaths each year are associated with AKI. Up to 30% of these deaths could be prevented with the right care and treatment (NCEPOD, Adding Insult to Injury, 2009). AKI is common, harmful, costly and preventable and accounts for one in five emergency admissions into hospital.
AKI is not just an issue of kidney care, it can be a complicating factor of other areas of care and can emerge out of other issues: preventing this syndrome is key for saving the NHS money and improving patient care.
How will we do it?
This project has four elements:
- We will seek to understand the experience of care for patients who have an episode of care complicated by AKI
- We will evaluate the implementation of AKI assurance and QI initiatives
- We’ll look at the design of sustainable models of AKI care to support better coordination of hospital care and an improved interface with primary and community care
- We will investigate a platform for potential larger scale evaluation.
Who we are working with?