Retrospective Audit of Delayed Diagnosis of Hydronephrosis

in Acute Kidney Injury

John DreisbachRadiology ST3

West of Scotland Deanery

Acknowledgements:Srikanth Puttagunta

Grant BaxterColin Geddes

Background

• Acute Kidney Injury (AKI)– Definition

• Rapid deterioration of renal function

– Common in hospitalised patients• Prevalence ~5%

– Multitude of causes• Pre-renal, renal, post-renal (multiple often present)

– Poor outcomes• Independent risk factor for increased mortality

Background

• Acute Kidney Injury (AKI)– Definition

• Rapid deterioration of renal function

– Common in hospitalised patients• Prevalence ~5%

– Multitude of causes• Pre-renal, renal, post-renal (multiple often present)

– Poor outcomes• Independent risk factor for increased mortality

– POTENTIALLY REVERSIBLE

Background

• Obstructive Nephropathy and Hydronephrosis– Cause of AKI in 1-10%– Ultrasound – first line investigation in AKI to

diagnose or exclude hydronephrosis• (RCR, Renal Association and NICE guidelines)

Background

• Obstructive Nephropathy and Hydronephrosis– Cause of AKI in 1-10%– Ultrasound – first line investigation in AKI to

diagnose or exclude hydronephrosis• (RCR, Renal Association and NICE guidelines)

– REQUIRES PROMPT DIAGNOSIS• Protracted obstruction risks irreversible renal

damage• Readily treatable

Background

• NCEPOD– “Adding Insult to Injury”

2009• Investigated hundreds of cases

of death caused by AKI• Discovered failings A – Z in

clinical care of AKI

Background

• NCEPOD– “Adding Insult to Injury”

2009• Investigated hundreds of cases

of death caused by AKI• Discovered failings A – Z in

clinical care of AKI• Including: ‘omission or delay

of ultrasound, where clinically indicated, was a likely contributory factor to patient death in multiple cases’

Background

• Aims– Retrospectively audit delays in diagnosis of

hydronephrosis in patients with AKI at a local centre

Background

• Aims– Retrospectively audit delays in diagnosis of

hydronephrosis in patients with AKI at a local centre

– To the author’s knowledge, it is the first audit of its kind

• Other projects have only audited delayed ultrasound in UNSELECTED cases of AKI (the majority of which did NOT have hydronephrosis)

Standard, Indicator and Target

• Standard– Renal Association (UK) Guidelines (Acute Kidney

Injury, 2011):• ‘All patients presenting with AKI should have a

renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’.

Standard, Indicator and Target

• Standard– Renal Association (UK) Guidelines (Acute Kidney

Injury, 2011):• ‘All patients presenting with AKI should have a

renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’.

• Indicator– Time interval between first creatinine diagnostic of

AKI and verification of ultrasound report diagnosing hydronephrosis.

Standard, Indicator and Target

• Standard– Renal Association (UK) Guidelines (Acute Kidney

Injury, 2011):• ‘All patients presenting with AKI should have a

renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’.

• Indicator– Time interval between first creatinine diagnostic of

AKI and verification of ultrasound report diagnosing hydronephrosis.

• Target≥90% in ≤24 hours

Methodology

• Case Collection– Retrospective– Single centre (Western Infirmary, Glasgow)– 24 month period

• (1st of April 2011 to 31st of March 2013)

– Consecutive cases of hydronephrosis identified by examination of reports of all ultrasounds performed covering the kidneys

– Inclusion of cases with concurrent AKI• (Diagnosed biochemically (creatinine) as per KDIGO criteria)

Methodology

• Multitude of Ancillary Data Collected:– Demographics

• Age

• Sex

– AKI severity • Admission

• Deteriorations

– Pre-existing CKD– Specialty

• Admitting

• Requesting ultrasound

– Ultrasound request cards• Clinical information

– Key dates and times• Ultrasound ‘event creation’

(approximates to request time)

• Ultrasound scan

• Ultrasound report

• Verification of ultrasound report

– Cause of renal obstruction

Results

• Total ultrasound reports examined: 6,491

Results

• Total ultrasound reports examined: 6,491

• Number of cases reporting hydronephrosis: 162

Results

• Total ultrasound reports examined: 6,491

• Number of cases reporting hydronephrosis: 162

• Number of cases of hydronephrosis with concurrent AKI and meeting inclusion criteria: 50

Results

• Key Audit Measure

Results

• Delayed ultrasound in 24 patients– 33% (n = 8/24) progressed in AKI severity

before ultrasound– (c.f. only 1/26 of the non-delayed patients)

Results

x-axis = each patient; y-axis = time interval

Results

x-axis = each patient; y-axis = time interval

Results

• Adequacy of Request Card Information

• Only 38% of requests provided key information

Adequacy of Request Card Information     Item(s) of Information on Request Card Percentage Number     Card BOTH described AKI and queried hydronephrosis 38% 19Card did NOT BOTH describe AKI and query hydronephrosis 62% 31

Results

• Delays after Request and Adequacy of Request Card Information

• Chances of delayed ultrasound after request nearly 6 x higher (29% vs 5%) if inadequate clinical information on request card.

Delays by Request Card Information Adequacy    Delayed   NOT Delayed  Item(s) of Information on Request Card   Percentage Number Percentage Number           Card BOTH described AKI and queried hydronephrosis   5% 1 95% 18Card did NOT BOTH describe AKI and query hydronephrosis   29% 9 71% 22

Discussion/Conclusions

• First audit data of its kind – unique insight into the actual scale of the problems highlighted by NCEPOD

Discussion/Conclusions

• Audit identified poor local performance in promptly managing a time-critical condition

• Suggestion of potential harm caused by delays• The most time-consuming interval was between

AKI diagnosis and clinicians requesting ultrasound

• Delays between ultrasound request and scan strongly associated with inadequate clinical information provided to radiologists.

Interventions

• Achieved– Dissemination of results to local radiologists, renal physicians

and urologists• May 2013 ✔

– Presentation to local Radiology department• May 2013 ✔

– Presentation at local hospital meeting• November 2013 ✔

– Presentation at trust-wide Renal Consultant’s meeting• February 2014 ✔

– Multispecialty medical student teaching• (Renal, Urology and Radiology)• Winter 2013/2014 ✔• Included in routine teaching by Renal physicians ✔

Interventions

• Planned– Multispecialty junior doctor teaching

• (Renal, Urology and Radiology)

• Summer 2015 to coincide with new foundation doctors ✔– Complete Audit Cycle with 2 more years of data

• Summer 2015 ✔

References• 1. Waikar SS et al. The incidence and prognostic significance of acute kidney injury. Curr

Opin Nephrol Hypertens. May 2007. 16(3):227-36.

• 2. 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). A report by the National Confidential Enquiry into Patient Outcome and Death (2009).

• 3. Lewington A et al. Clinical Practice Guideline: Acute Kidney Injury. 2011. Renal Association.

• 4. iRefer: Referral Guideline U02: Renal failure. Royal College of Radiologists (RCR). Reviewed by author May 2015.

• 5. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Volume 2. Issue 1. March 2012.

• 6. Adam L et al. Renal Ultrasonography in the Evaluation of Acute Kidney Injury. Developing a Risk Stratification Framework. Arch Intern Med.2010;170(21):1900-1907.

• 7. Post TW et al. Diagnostic approach to the patient with acute or chronic kidney disease. Uptodate website. 2009. http://www.uptodate.com/online/content/topic.do?topicKey=renldis/19906&selectedTitle=2~150&source=search_result. Reviewed by author May 2013.

• 8. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. (Clinical guideline 169.) 2013.

Questions