What is wrong with AKI care?

When LAKIN launched in 2012 we identified the following problems with AKI care in London.

"NCEPOD 'Adding Insult to Injury' and local audits have identified several problems that require strategic and collaborative solutions"

  1. There are deficiencies in basic AKI management in general ward and acute areas. This is is in part reflective of generalised failures in management of the acute illness (identified in NCEPOD 'An Acute Problem'). There are, however, failings in the treatment of isolated acute kidney disease in otherwise stable patients (with, for example urinary tract obstruction or acute glomerulonephritis). Problems have been identified across the care pathway including aspects of prevention, recognition, diagnostics, therapy, timely referral to specialists and aftercare.
  2. Nephrology services have become centralised, while AKI remains widely spread. Nephrology outreach services have often not been configured around delivering specialist advice to acute areas but around, for example, outreach chronic kidney disease programmes. Accessing nephrology advice can be difficult, and there is some evidence of variation in the expectations made of non-specialist teams.
  3. The optimal care pathway has not been previously defined or harmonised across sectors. As the pathway involves interaction between tertiary nephrology services, critical care units and local hospital wards within a sector, such pathways must be agreed regionally and there has previously been no mechanism to address this.
  4. There is evidence of inequity. The availability of acute dialysis, diagnostic imaging, nephrology advice or interventional radiology (for relief of urinary tract obstruction) varies greatly across sites.
  5. Emergency transfer from ward areas to the renal unit for diagnostics and treatment may be delayed. This may prevent timely therapy for more mild AKI that requires disease-specific therapy.
  6. While the majority of patients with AKI may be managed in general wards, the minority of patients with severe AKI should be able to access high dependency or kidney unit care rapidly. Such facilities provide 24/7 multidisciplinary specialist care. The mortality risk for severe AKI (AKI 3) exceeds that for acute myocardial infarction (which is normally managed in coronary care units). Given this mortality risk, kidney unit or general high-dependency care would seem warranted for many of these patients.
  7. Step-down and transfer of AKI patients from ITU to kidney units for ongoing dialysis is often delayed, resulting in inappropriate use of critical care beds for single-organ support. The critical care environment, with many patients sedated and ventilated, will not be appropriate for many ambulant, rehabilitating patients having isolated kidney support. In addition critical care beds are costly, there are inevitable capacity issues, and these beds may be needed for other patients.
  8. There has been no clear or standardised audit strategy for AKI and how a sector performs collaboratively in AKI care, indeed standards to audit against have been lacking.
  9. Though national guidelines on AKI (e.g. Renal Association, National Imaging Board) are now available, these have often not been effectively operationalised within NHS Trusts.
  10. There appears to be an educational deficit as regards this condition that affects all disciplines at all levels.
  11. NCEPOD 'Adding Insult to Injury', has increased awareness and led to a response in many hospitals. We have some evidence, however, of uncoordinated initiatives at both at sector and hospital level. Not only may this be counterproductive, but leads to an unecessary duplication of effort. It is essential that guideline implementation, education, audit and changes in practice are 'joined-up' and mutually supportive. It also desirable that learning, best-practice and expertise are shared where possible.
  12. We lack data on the epidemiology of this condition in London, the resources available, the resources required for more effective care and how these resources should be shared.

References

Adding Insult to Injury. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure). National Confidential Enquiry into Patient Outcome and Death (NCEPOD). 2009.