Predict, prevent and manage AKI: A UK collaboration to detect a devastating condition

Our client

Western Sussex Hospitals NHS Foundation Trust (WSHNFT) became a Trust in 2009 after a merger of The Royal West Sussex and Worthing & Southlands Hospitals NHS trusts. It serves a population of around 450,000 covering most of West Sussex.

The Trust consists of three hospitals – St. Richard’s Hospital, Southlands Hospital and Worthing Hospital – along with a range of community hospitals and services, including Bognor War Memorial Hospital, Crawley Hospital, Health centres, GP surgeries and sexual health clinics.

WSHNFT provides a full range of major general hospital services, including:

• A full emergency service
• Planned and emergency services in surgery and medicine
• Women and children’s services
• Therapeutic, diagnostic and pharmaceutical services

The challenge

As many as 100,000 deaths in secondary care are associated with AKI each year, according to NHS England.¹ Many more patients go on to endure prolonged hospital admissions and to suffer from secondary chronic conditions. Now identified as one of two national clinical priorities for 2015-16, AKI is a chief concern for hospitals across the country.

Often caused by stress on the kidneys due to other illnesses or infection, or the side effects of some drugs, more than a third of AKI cases occur after admission to hospital, with the elderly especially at risk.²

It affects as many as one in five emergency admissions to hospital³ and costs the NHS as much as £620m per year; more than breast cancer or skin and lung cancer combined.⁴

National reports also indicate that the care of up 40 per cent of patients with AKI is inadequate, partly due to delayed recognition of the problem and that as many as 20 per cent of post-admission AKI incidents are both predictable and avoidable.⁵

Yet, despite a quality standard⁶ being released by the National Institute for Health and Care Excellence (NICE), and NHS England’s drive to significantly reduce premature mortality over the next five years,⁷ electronic alerts that can warn doctors and nurses of the condition arising have traditionally only been studied for patients who already have AKI. Until recently, little has been done in practice to predict which patients are at risk of developing the devastating condition. This is changing.

The solution

A national motivation to tackle the problem is now being met with practical action. Specialist healthcare technology provider Alcidion, working with clinical input from WSHFT, has developed a successful clinical and ICT solution to systematically identify and flag those developing, or those with, AKI and subsequently promote a swift clinical response that until now, has often been lacking.

The solution won national funding in May 2014 from the Department of Health and the Small Business Research Initiative (SBRI), so that it could be trialled at WSHFT, and in March 2015 won a second round of funding with the aim of scaling the AKI alerting technology more widely across the NHS.

Alcidion’s early warning system has been widely used by doctors, nurses and other clinical staff at WSHFT since 2012 to capture bedside observations digitally, automatically calculate National Early Warning Scores (NEWS) and alert clinicians to deteriorating patients who require immediate medical intervention.

The trust has now worked with Miya Assessments and Miya Observations (formerly knows as Patientrack) to embed a ground-breaking predictive scoring model, developed by its own specialist renal clinicians, into the early warning software platform. This allows for an AKI risk 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 and prevent conditions worsening.

The model, which is also combined with a national AKI staging algorithm, brings together various sources of data, including pathology results, to assess a patient’s creatinine level and information including a patient’s age, medical history and known co-morbidities, along with physiological information that is recorded at the bedside through Miya.

These elements combine to generate a score which is then displayed on the patient’s electronic chart and the hospital’s Miya alerting system. Patients identified with AKI are assigned a red flag so that appropriate care can be given immediately. Those at risk of developing AKI are marked with an amber flag so that care packages can be delivered, and patients who do not have the condition and are not judged to be at high risk are marked with a green flag.

The result

The result is intelligent real-time technology, designed to systemically improve the care of patients with or at risk of AKI. For the first time, clinicians can have complete visibility of the AKI status of every patient in the hospital and the system should allow healthcare professionals to recognise every identifiable AKI, improve the management of people with AKI, and prevent the preventable.

Wide ranging benefits are being identified as early intervention should help enable the prevention of morbidity and mortality associated with AKI, including secondary complications, such as chronic kidney disease. Additional benefits are also expected. Reduced lengths of stay, for example, will help to reduce further potential exposure to harm in the hospital environment and the technology could reduce the need for renal replacement therapies and escalation to intensive care.

Financial benefits for hospitals are also expected and not only as a result of reduced lengths of stay.

The solution can help to achieve commissioning for quality and innovation (CQUIN) targets around AKI, an incentive to reward good care of patients with the condition, which contribute to payments worth up to 2.5 per cent of a provider’s annual contract value.

Ultimately, 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.

The future

The solution will be developed as time goes on, feeding in new data, such as pharmacy and medication information. Although at present the Trust is using the national AKI staging algorithm⁸ and its own AKI predictive scoring model, the technology can be applied to any early warning score developed in the future.

“This technology should be of significant interest to NHS hospitals. Early intervention should help to prevent morbidity and mortality, including secondary complications such as chronic kidney disease. Even more can be achieved, including reduced lengths of stay and the potential for a reduction in renal replacement therapies and escalation to intensive care.”

– Dr Richard Venn, Consultant in Anaesthesia and Intensive Care at Western Sussex Hospitals NHS Foundation Trust

As more patients are cared for using the solution, potentially beyond Western Sussex, the AKI scoring model could also be refined based on richer data from larger samples, as well as potentially being adapted for different circumstances and demographics.

With such an emphasis now being placed on reducing deaths associated with AKI, the project embarked on in Western Sussex is highly relevant to many hospitals, something that a second round of Department of Health funding has reinforced. Several hospitals have already expressed a strong interest to add the AKI application into their own early warning system software through the Miya User Group.

“[The Miya solution] gives clinicians the ability to flag which patients are at risk of acute kidney injury almost from the moment they walk through the door, so that they can see which patients are at risk from the first set of observations.

Effectively it is an intelligent real-time technology that should systemically improve the care of patients. It will prevent and it will help to improve the management of people who come in with AKI.”

– Professor Lui Forni, Consultant in Intensive Care and Renal Medicine and Chair of the AKI Section of the European Society of Intensive Care Medicine

References:

1 NHS England Acute Kidney Injury Programme

2 Acute Kidney Injury Best Practice Guidance: Responding to AKI Warning Stage Test Results

3 Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients.

4 CG169 Acute kidney injury: NICE Guidance

5 Stewart J, Findlay G, Smith N et al. 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. London: NCEPOD, 2009;1-100.

6 NICE quality standards [QS76]

7 NHS England, The Forward View Into Action: Planning for 2015/16

8 See for example, NHS England Acute Kidney Injury (AKI) Algorithm