Objectives and implementation

Overall objective

To deliver equitable, high quality acute kidney injury prevention and care to patients in London and referring regions, achieving this through a collaborative clinical network model, unconstrained by organisational or professional boundaries.

Specific objectives

  1. To reduce the incidence of acute kidney injury in London.
  2. To improve acute kidney injury outcomes in London.
  3. To improve holistic and supportive care for AKI patients and their families.
  4. To reduce the healthcare costs associated with this condition through more effective care and efficient use of available resources.
  5. To support innovation and research that will benefit AKI patients.

Process objectives and implementation

  1. A harmonised AKI pathway and guideline, based on National guidelines and available evidence, delivering equitable AKI care according to (where possible) defined clinical standards.
    1. A phase 1 pathway and guideline,launched on March 8th 2012 following consultation with Network membership at that point.
    2. The pathway and guidelines are a synthesis of existing National guidelines (UK Renal Association, Intensive Care Society, National Imaging Board, NCEPOD). They are designed to make such National guidelines accessible and facilitate their practical implementation at a local level across a sector. Please note that a written guideline on the interaction between critical care, nephrology and general ward areas (covered in the guideline) is an NCEPOD requirement and this necessitates, in London, regional collaboration.
    3. The purpose of guidelines is to describe appropriate care based on evidence or consensus, to reduce inappropriate variation in practice, to provide a rational basis for referral, to provide a focus for education, to promote efficient use of resources and to act as a focus for quality control and audit. The usual caveats regarding clinical guidelines apply; that is they are there to guide, rather than dictate, clinical decisions and do not replace the proper assessment of individual cases.
    4. Available clinical standards (e.g. Diagnostic ultrasound in <24 hours for nonrecovering AKI) are embedded in the guideline.
    5. We will take feedback from network members until March 8th 2013. We will then perform a complete update of the guideline, amending according to this feedback (where possible) and will perform a reconciliation with NICE Acute Kidney Injury (released 2013). Again trusts can adopt the guideline at this point if they wish. Thereafter we will update according to member feedback and new evidence on an annual basis.
    6. The guidelines are housed in the 'Clinical' section of the website and may be downloaded as the AKI Manual (PDF). Core guidelines are also available in the 'London AKI' mobile iphone/ipod application.
    7. We recommend trusts link to the URL of the website from their local guideline databases. Adoption by local guideline committees, and reformatting if necessary, can be undertaken London AKI Network hospital lead.
    8. London AKI Network provides a suite of educational materials housed within its website and an 'toolkit' to help hospital AKI leads implement the pathway. London AKI Network will ensure these materials are up to date and concordant with the guideline on an annual basis.
    9. London AKI Network will ensure that London AKI Network sponsored AKI audits are complementary to the guideline and that data and learning on implementation issues is shared. Network hospital leads and sector committees will address implementation issues and feed back to the board as necessary.
    10. 'Core' guidelines have been developed initially according to clinical priority, emphasising areas that require network collaboration. Other more specific guidelines will be developed according to emerging evidence or clinical need.
  2. Service redesign in AKI care
    1. In some instances it may require a redesign of existing services to deliver the pathway. London AKI Network will make the case for this through consultation with local clinicians, clinical directors MDs and commissioners.
  3. Collaborative AKI audit
    1. We have partnered initially with the London Specialist Commissioning Group (SCG) Audit and Information Unit (AAIU) on a core AKI audit for hospitals. This audit has a larger footprint including London, SE Coast and East of England. We have collaborated to ensure this audit and the London AKI Network initiative are complimentary and to avoid duplication of effort. The AAIU audit is supported by dedicated AAIU staff and online software. Requests to complete this go to Trust CEOs and Medical Directors.
    2. We are planning several other audits, including kidney unit transfer (timing and safety), AKI requiring dialysis in kidney units and critical care bed use for single organ kidney support. We will develop other audits through specific forums involving relevant professionals.
    3. We will not only audit process objectives, but hard AKI outcomes such as mortality, lengths of stay and need for long term renal replacement therapy (RRT) and share this data, driving equity.
    4. For key parts of the AKI pathway (such as transfer times to kidney unit) we will audit data prospectively in real time, resulting in immediate feedback.
    5. We will respond to audit data with pathway redesign, guidelines or education as appropriate and, where necessary, seek to address deficiencies in local resources that have been found to impact on care.
    6. Further information on these audits, other active projects and results are available here. In addition we will seek share audit data by presenting at London AKI Network, national and international meetings and events and, where possible, though publication in peer-reviewed journals. London AKI Network audits will also be presented to the Pan Thames Renal Audit Group (PTRAG).
  4. Improved AKI education
    1. The London AKI Network 'AKI Academy' is a range of educational resources which can be accessed here. These include online video learning, downloadable powerpoint presentations, self-assessment modules and AKI coursebook. This is designed to support a number of teaching styles and contexts. This resource will grow in time, incorporating sub-speciality areas and will be aimed at all healthcare professionals. Hospitals and AKI leads can access these resources for teaching and induction as they see fit, or may wish to develop their own materials (and in turn share these through the network).
    2. In addition we will be arranging not for profit AKI Academy events and courses for specific groups of healthcare professionals.
    3. The regional AKI committees will work with London's medical schools and nursing colleges to ensure undergraduate AKI education is in place. The AKI Academy will house material aimed at undergraduates.
    4. We will work to ensure national initiatives in AKI education (e.g. National competency frameworks) are implemented within London.
  5. Innovation and research
    1. London AKI Network will initiate and support innovation in AKI care.
    2. We will support network members as they lead on projects they have developed, supporting wider implementation in London.
    3. Some initiatives will be implemented on a pan-network scale, however in most cases innovations will be piloted at ward, hospital or sector level prior to wider adoption. We will also seek to implement successful initiatives originating outside of London. An early focus will be the use of AKI electronic alerting, which has been piloted in some centres within London and also at several sites Nationally. The network model will facilitate sector-wide, 'joined-up' solutions and more rapid implementation of these and other developments.
    4. We will use the network as a platform for collaborative, multi-centre research translational and clinical AKI research. We will work with London's three academic health science centres in this regard, seeking support from funding bodies, including London's NIHR Clinical Research Networks.