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A new automated electronic alerting project at Western Sussex Hospitals NHS Foundation Trust aims to detect the risk of acute kidney injury early, promote intervention and save lives
Luke Hodgson MRCP MSc MBBS BSc
Intensive Care Research Registrar,
Western Sussex Hospitals NHS Foundation Trust, West Sussex, UK
Lui Forni MBBS BSc PhD MRCPI
Consultant in Intensive Care, Renal Physician and the Chair of the AKI section of the European Society of Intensive Care Medicine (ESICM)
Richard Venn MBBS FRCA MD FFICM
Consultant in Anaesthesia & Intensive Care
Western Sussex Hospitals NHS Foundation Trust, West Sussex, UK
It is estimated that as many as 100,000 deaths in secondary care are associated with acute kidney injury (AKI) each year, according to NHS England.1 Many more patients are likely to suffer further complications and prolonged hospital admissions, making the condition a priority for hospitals across the country.
Acute kidney injury can be caused by numerous things, such as stress on the kidneys due to other illnesses or infection, or the side effects of some drugs. More than a third of cases occur after admission to hospital and the elderly are especially at risk.2
Sudden damage to the kidney is a serious problem for many patients. It affects as many as one in five emergency admissions to hospital.3 Patients developing AKI suffer increased morbidity, mortality and have longer lengths of stay in hospital. With kidney disease costs on the rise, AKI alone costs the NHS as much as £620 million per year; more than breast cancer or skin and lung cancer combined.4
National reports also suggest that the care of up 40% of patients with AKI is inadequate, partly due to delayed recognition of the problem, with evidence also suggesting that as many as 20% of post-admission AKI incidents are both predictable and avoidable.5
An urgency has now been placed at a national level on tackling AKI. A quality standard6 has been recently released by the National Institute for Health and Care Excellence (NICE), building on the organisation’s 2013 guideline. At the same time, national directives are being driven forward by NHS England, which has identified tackling AKI as one of two clinical priorities for improving patient outcomes in 2015–2016, with the aim of substantially reducing premature mortality over the next five years.7
Yet despite efforts to improve safety and to identify patients in hospital who have contracted AKI, little has yet been done in practice to predict which patients are at risk of developing the devastating condition. There is a need to prevent damage before it occurs.
Prevention is now a key part of wider NHS plans. When it comes to tackling AKI, efforts to date have largely focused on highlighting those patients who already have it, many of whom are then already faced with an increased risk of dying in hospital.
As many as a third of AKI cases in hospital occur after admission, but electronic alerts designed to warn doctors and nurses of the condition arising, have only been studied for patients with established AKI, highlighting rises in creatinine after injury rather than identifying patients at risk of the condition. A rise in creatinine following an insult to the kidneys may take up to 24 hours to become apparent on a blood test. Now, this retrospective approach could soon become a thing of the past due to a pioneering electronic alerting project that is underway in Western Sussex.
Shifting the focus: preventable AKI should never occur
Clinicians at Western Sussex Hospitals NHS Foundation Trust (WSHT) have developed a successful clinical and ICT proof-of-concept solution to systematically identify and flag those developing, or those with, AKI. Importantly, this electronic warning project is also designed to automatically alert doctors and nurses to patients at risk of developing AKI and give medical professionals the opportunity to intervene early and deliver the right care to prevent AKI from becoming a problem wherever that is possible.
A collaboration with specialist healthcare IT company Patientrack has led to the development of the solution, which won national funding in May 2014 from the Department of Health and the Small Business Research Initiative (SBRI). Patientrack’s early warning system has been widely used by doctors, nurses and other clinical staff at the Trust since 2012 to capture bedside observations digitally, automatically calculate National Early Warning Scores (NEWS) and alert clinicians to deteriorating patients who require swift medical intervention.
By extending the use of Patientrack, which can be used to calculate any early warning score, the Trust is now putting into practice a predictive model developed by its pioneering multidisciplinary team of researchers to help improve the earlier identification of patients at risk of AKI.
The model is based on a new, locally developed scoring algorithm that brings together various pieces of information in order to identify patients already with AKI and those at risk. This data includes pathology results, to assess a patient’s creatinine level, of which even a slight rise could lead to serious consequences for the patient and is a crucial element in detecting AKI. This information is combined with the patient’s age, medical history and known co-morbidities such as chronic kidney disease, heart failure, liver disease and diabetes. Finally, Patientrack is used to record physiological information on the patient, such as respiratory rate and level of consciousness.
These elements combine to generate a score which is then displayed on the patient’s electronic chart and the hospital’s alerting system. Patients identified with AKI are issued with a red flag so that appropriate care can be given immediately. Similarly, care packages can be delivered for those at risk of developing AKI, who are marked with an amber flag. Whilst those who do not have the condition and are not judged to be at high risk are identified with a green flag.
The Trust has worked with Patientrack to embed the AKI algorithm into the early warning software platform, which allows the AKI score to be used to deliver real time alerts to medical staff and advise on a best practice checklist that they must follow to care for patients appropriately.
Effectively Patientrack, combined with the Trust’s risk scoring model, now provides an intelligent real time, always-on technology that should systemically improve the care of patients with or at risk of AKI. The system should allow healthcare professionals to identify every identifiable AKI, improve the management of people with AKI and prevent the preventable.
Benefits of using the system: testing anticipated outcomes
A wide range of benefits are anticipated from the project.
Early intervention should help enable the prevention of morbidity and mortality, including secondary complications such as chronic kidney disease. But more can be achieved. Reduced lengths of stay for patients who avoid kidney damage as a result of AKI, for example, will help to reduce further potential exposure to harm in the hospital environment. The project will also analyse whether the technology can help to reduce the need for renal replacement therapies and escalation to intensive care with its potential for associated morbidity, mortality and psychological harm. The technology could also be applied to help identify a number of other conditions in the future.
The Trust could also reap financial benefits. An incentive to reward the good care of patients with acute kidney injury is planned for introduction in 2015/16 by NHS England8 under the commissioning for quality and innovation (CQUIN) payment framework. This will contribute to payments worth up to 2.5% of a provider’s annual contract value.
The AKI model will be used at the Trust’s Worthing Hospital for a year to see how far harm associated with AKI can be reduced and the effectiveness of interventions. Performance in these areas will be compared against those on admissions at the Trust’s control site, St Richard’s Hospital in Chichester, as well as compared to historical levels at both sites. St Richards will then introduce the system and the project will undertake an additional year of analysis of the interventions’ impact on readmissions.
This testing period will be used to identify any barriers to implementation and assess how staff react to the new system. However, wider use of the Patientrack system has already been very well received at the Trust. Given priorities placed on improving AKI management and the very real impact this can have on saving lives and improving care, there is every reason to believe that medical professionals will welcome this innovative use of technology to bring together useful information in one place.
Such information would not otherwise be as easily available to busy clinicians, who would have to search through patient histories and bring data together manually in order to have any chance of making similar assessments. The project is providing doctors and nurses with a more intelligent picture and a rapid, accurate assimilation of various sources of data in order to immediately highlight which patients need intervention to prevent the serious consequences of AKI.
Developing the solution
It is also anticipated that the solution will be developed into the future. New data, such as pharmacy and medication information, could be added to the warning score. And, although at present the trust is using the national AKI staging algorithm9 and its own locally developed AKI predictive scoring model as its risk scoring algorithms, the technology can in fact be applied to any situation in which data can be combined to create an early warning score, and alert the relevant healthcare professional.
As more patients are cared for using the system, and as the potential for expansion of the solution beyond Western Sussex becomes a reality, it may also be that the scoring model is refined based on richer data from larger samples, or adapted for different circumstances and demographics.
The future: a solution for the NHS?
It is now the responsibility of every hospital to identify patients with AKI. The Trust’s work on the algorithm, with the support of Patientrack, has allowed Western Sussex to go beyond that by highlighting patients at risk. With such an emphasis now being placed on reducing deaths associated with AKI, the project we have embarked on in Western Sussex is likely to be highly relevant to many other hospitals.
Several hospitals have already expressed a strong interest to add the AKI application into their own early warning system software through the Patientrack Research User Group.
And the AKI solution is gaining recognition at a national level. Patientrack with Western Sussex were one of 14 winners of a £3.6 million prize fund intended to address the life-changing effects of kidney failure. The competition – funded by the Department of Health through the Small Business Research Initiative, and managed by the National Institute for Health Research Devices for Dignity Healthcare Technology Cooperative (NIHR Devices for Dignity HTC) – looked for innovative solutions that could use technology to help improve diagnosis and care. This money will enable the project to move forward.
The Trust and Patientrack expect significant interest from the NHS. Owing to the use of existing technology, large capital investments have not been needed in Western Sussex and wider adoption at other trusts would also be achieved cost effectively. Now, with such an urgency being placed on tackling AKI, any project that reveals a strategy to reduce AKI and improve management of patients with AKI could have ramifications across the entire NHS and even beyond into the international healthcare environment.