Transcript Renal Referrals at UHB - West Midlands Renal Network

Renal Referrals at UHB
Mark Jesky
Research Registrar
Background
• Renal referrals received from virtually all hospital
specialties
• Increased emphasis in recognising acute kidney
injury (AKI) and managing appropriately
– Awareness of even mild AKI associated with increased
hospital stay and mortality
• Traditionally, referrals recorded on ad-hoc basis
– Auditing activity difficult
A Brave New Dawn
• From September 2010 referrals made on PICS health
informatics system
Audit Questions
• Referral demographics
• For AKI referrals
–
–
–
–
AKI stage at referral
AKI stage at peak creatinine during admission
Length of stay by AKI stage
Survival
• discharge
• 90 days
– Renal survival
– Renal Follow-up
Demographics
• From mid September 2010 – mid July 2011
• 623 episodes captured
– (1 person may have more than one event)
Number /day (inc weekend)
Number /day (exc weekend)
Total No. Referrals
623
573
No. Days
314
225
Referrals / day
2.0
2.5
Referral by Day
140
120
100
80
60
40
20
0
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Referral by time of day
62.4%
180
160
140
41.7%
120
100
80
60
40
20
0
0000 - 0559
0600 - 0759
0800 - 0959
1000 - 1159
1200 - 1359
1400 - 1559
1600 - 1759
1800 - 1959
2000 - 2159
2200 - 0559
Type of Referral by PICS
300
250
200
150
100
50
0
Acute Kidney Injury
Chronic Kidney Disease
On Haemodialysis
Transplant
Other
Referral by Directorate
300
250
200
150
100
50
0
AKI data
• 332 AKI episodes
– 310 episodes excluding solid organ transplantation
• AKI classification
Stage
Serum Creatinine criteria
Urine Output Criteria
1
Increase in serum creatinine of ≥26.4 µmol/L or < 0.5 ml/kg/ hr for more
increase to 150-200% from baseline
than 6 hours
2
Increase in serum creatinine to more than 200300% from baseline
< 0.5 ml/kg/hr for more
than 12 hours
3
Increase in serum creatinine to more than
300% from baseline or ≥354 µmol/L with an
acute increase of at ≥44 µmol/L
< 0.3 ml/kg/hr for 24 hours
or anuria for 12 hours
AKI data
• 332 AKI episodes
– 310 episodes excluding solid organ transplantation
• 24 duplicate referrals (21 single admission, 3 two admissions)
• 3 triplicate referrals (1 single admission, 2 two admissions)
Stage
Serum Creatinine criteria
Urine Output Criteria
increase to 150-200% from baseline
< 0.5 ml/kg/ hr for more
than 6 hours
2
Increase in serum creatinine to more than 200300% from baseline
< 0.5 ml/kg/hr for more
than 12 hours
3
Increase in serum creatinine to more than
300% from baseline or ≥354 µmol/L with an
acute increase of at ≥44 µmol/L
< 0.3 ml/kg/hr for 24 hours
or anuria for 12 hours
1
• AKI classification
Increase in serum creatinine of ≥26.4 µmol/L or
AKI stage
(duplicates from same admission removed)
At Referral
At Worst
AKI unclassified
81
(28.4%)
31
(10.9%)
1
78
(27.4%)
83
(29.1%)
2
27
(9.5%)
28
(9.8%)
3
84
(29.5%)
141
(49.5%)
unknown
15
(5.3%)
2
(0.7%)
Outcomes by AKI stage
(duplicates from same admission removed)
Length of Stay - Length of Stay All
alive to
discharge
days
days
Median (IQR)
Median (IQR)
AKI unclassified
13 (6.5-21)
12 (6.75-21)
1
18 (11-42.5)
16 (9.5-35)
2
21.5 (10-44)
25 (11-49.5)
3
17 (10-37.75)
19 (10-44)
Outcomes by AKI stage
(duplicates removed)
Died in
Hospital
90 day
mortality
n (%)
n (%)
AKI unclassified 31
3
(9.7%)
4
(12.9%)
1
83
16
(19.3%)
24
(29.2%)
2
28
6
(21.4%)
10
(28.9%)
3
136
39
(28.7%)
51
(37.5%)
n
Renal Survival
• 51/285 required in-patient renal replacement
therapy (RRT)
– 17.9%
• 10 required on-going RRT post discharge
Renal Follow-up
• From last (UHB) renal function on PICS
• Alive and eGFR <30
– 62 / 285 (21.8%)
– Of these 62,
• 38 (61.3%) under renal follow up
• 24 (38.7%) not under follow up
– 1 self discharge, 1 decreased mobility, 2 DNA
Summary
• Electronic referrals good way to capture data
• Typically over 14 referrals a week
• AKI associated with increased length of stay
– Similar AKI 1-3
• Significant mortality (in hospital and beyond)
• Not all patients being adequately followed up
Recommendations
• Increase awareness of increased LOS,
mortality associated with all stages of AKI
– Ensure prompt referral
• Appropriate individuals need to be followed
up in renal clinics
– Documentation of follow-up in notes
– Ensure no loss to renal follow up
Acknowledgements
• Dr Rachel Plant
• Dr Peter Hewins