17 March 2015

Driving up Quality using a CQUIN

Preetham BoddanaConsultant Nephrologist ,GHNHSFT AKI Celebration and Sharing Event

Gloucestershire Hospitals

The scale of the problem

• AKI is common • AKI is associated with

considerable harm • AKI causes significant

costs • The course and

development of AKI is modifiable

AKI Opportunities

• AKI is not primarily a renal issue– Renal leadership can help to establish this

tenant– Local groups can reiterate this and implement

best practice– CQUINS can incentivize

• Prevention will reduce:– Proportion requiring RRT– Long term conditions (LTC) burden

• CVD• CKD

• Timely investigation and treatment will:– Improve individual patient experiences and

outcomes

Introduction of a pathway to identify and manage patients at risk of

AKI @GRH

 

•Identification of AKI

•Implement the Care Bundle

• Measure progress

For further information including management of grade 3 AKI, refer to the AKI protocol available on the trust intranet.

Acute Kidney Injury Management Guidelines

AKI FLAG

Medication Review

Early Warning Score

Repeat Creatinine

Fluid Balance Review

Senior Review

AKI Care Bundle in

Gloucestershire Hospitals

PDSA Testing Ramps for: AKI Care Bundle

A P

S D

APS

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D SP A

Impro

vement

measu

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thro

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month

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Cycle 1A: Design and complete local testing of sticker on - Ward 7b

Cycle 1B: Develop E-learning for AKI to support launch of form

Cycle 2B: Spread sticker to wider Trusts through Safety Cafes and induction

Cycle 2A: Development of Sticker wider testing

Process Change PDSA

AKI Learning

Safety Café

Briefings

E-Learning module for

junior doctors on AKI

AKI covered during

induction to trust

Briefings on fluid balance

to nurses during

handover

AKI-CQuIN (2012-2013)

Programme = £880,000

Target 1• 30%

compliant with Care bundle by September 2012

Target 2 • 45%

Compliant with Care bundle by December 2012

Target 3 • 60%

Complaint with care bundle by March 2013

AKI-CQuIN(2013-2014)

Programme = £1.5 m

Target 1• Complete Root

Cause analysis on AKI patients each month

Target 2 • 75% Compliant

with Care bundle by March 2014

Patient's NumberRequestor's Location CREAT eGFRRequesting Clinician

1126824 WARD 4A TOWER BLOCK GRH 152 DR A.D. MONRO1061253 WARD 7B TOWER BLOCK GRH 593 <15DR T.M. PICKETT1146516 EMERGENCY DEPT GRH 142 MR S.E. MCCABE

457196 WARD 7B TOWER BLOCK GRH 613 <15DR T.M. PICKETT707695 WINDRUSH WARD CIRENCESTER 136 DR R. WELDING967638 ACUTE CARE UNIT A GRH 1090 <15DR J. BARKER277771 WARD 7B TOWER BLOCK GRH 348 <15DR T.M. PICKETT

27962 WARD 7B TOWER BLOCK GRH 163 DR J. MORIARTY695417 WARD 7B TOWER BLOCK GRH 1013 <15DR M. POTLURI435727 WARD 7B TOWER BLOCK GRH 489 <15DR S.M. JENKIN668454 WARD 4A TOWER BLOCK GRH 274 DR A.D. MONRO258645 CARDIOLOGY WARD 1 GRH 180 DR B. NUTA223956 WARD 3B TOWER BLOCK GRH 180 MR C.E. AYLOTT200033 WARD 7B TOWER BLOCK GRH 592 <15DR P.V. BODDANA

1644901 EMERGENCY DEPT GRH 201 MR S.E. MCCABE1122850 EMERGENCY DEPT GRH 503 <15MR N. NON SPECIFIED CONSULTANT

484531 WARD 7B TOWER BLOCK GRH 264 MR N. NON SPECIFIED CONSULTANT110462 DEPT OF CRITICAL CARE GRH 811 <15MR N. NON SPECIFIED CONSULTANT276461 WARD 4A TOWER BLOCK GRH 338 DR S. KULKARNI875623 WARD 7B TOWER BLOCK GRH 935 <15DR M. POTLURI842562 CHILDRENS INPATIENTS GRH 28 >90DR W. QAYUM570210 WARD 9B TOWER BLOCK GRH 127 DR I.P. DONALD433842 EMERGENCY DEPT GRH 273 MR N. NON SPECIFIED CONSULTANT

20649 WARD 3A TOWER BLOCK GRH 208 MR R.E.W. CLOSE447622 EMERGENCY DEPT GRH 147 DR V. STACEY142749 WARD 3A TOWER BLOCK GRH 214 MR W.T. MASON309781 WARD 2A TOWER BLOCK GRH 177 DR T. MAHAJAN

1079038 WARD 4A TOWER BLOCK GRH 133 DR A.D. MONRO1121484 CARDIOLOGY WARD 1 GRH 405 <15DR S.M. JENKIN1078866 WARD 5A TOWER BLOCK GRH 175 MR D.F. HEWIN

750965 WARD 7B TOWER BLOCK GRH 310 <15DR M. POTLURI38958 WARD 7A TOWER BLOCK GRH 105 DR C. HOLLYWOOD83036 EMERGENCY DEPT GRH 82 MR N. NON SPECIFIED CONSULTANT

936990 DEPT OF CRITICAL CARE GRH 346 DR S.J. TWIGG264815 EMERGENCY DEPT GRH 201 MR S.E. MCCABE277792 WARD 7B TOWER BLOCK GRH 372 <15DR J. MORIARTY

27586 CCU WARD GRH 197 DR S.M. SIEDLECKA36157 EMERGENCY DEPT GRH 99 MR N. NON SPECIFIED CONSULTANT

142353 WARD 2B TOWER BLOCK GRH 127 MR H. WHEATLEY782772 WARD 7B TOWER BLOCK GRH 474 <15MR N. NON SPECIFIED CONSULTANT

Goal Primary Drivers Secondary Drivers Action Improve compliance and reliability of the AKI care bundle for patients who identified on the pathology system As at risk of AKI – Targets 75% Trust wide

- Audit of randomly identified patients from Pathology system

Improve the use of the care bundle sticker

Maintain knowledge of clinical staff

Monitor E-learning compliance of medical staff – AS from Sept Provide 5 minute briefing at F1 & F2 training – IB Oct Establish November Communication event – AKI Walkabout, Posters, Dispensing units, Screen saver etc Arrange teaching on F1 & F2 education programme (October)

Measure real time use of AKI stickers

Establish weekly audits of sticker use and feedback to Divisions and clinical staff – LD\PB & Medics Oct Provide real time performance information to wards and junior doctors

Complete 3 root cause analysis of stage 2-3 AKI and evaluate problems

Two trainees identified and set up, LD - Sept

Review results of monthly

Email results of audit each month to all medical staff and ward managers – AS August To include more specific detail and sent to Clinical Governance leads Feedback results through Foundation leads – Marie Wheeler, Adam Rye, Richard Hopkins

Improve the awareness in ward areas amongst the clinical team when a patient is at risk of AKI

Re-design and test the sticker to included a mini sticker for the prescription chart or clinical notes

Discuss the design with the printers – AS October Alter the wording on the pathology screen to say “must complete AKI sticker”

“Head of Marginal Gains” What can we (NHS) learn from British Cycling Success in Olympics?

We need to improve further - 95% reliability

AKI CQuIN Team @GRH