Tuesday, 15 June 2010

Confused doctors and vulnerable patients

I came across this phrase whilst examining a PhD on quality improvement in healthcare. It was used in the context of confusing guidelines and lack of clear responsibilities in the implementation of the well established evidence base for venous thrombo embolism (VTE) prophylaxis in Australia.

The phrase “confused doctors – vulnerable patients” rang true to me for acute kidney injury (AKI) where the terminology is still poorly defined and often confusing. To compound things, many healthcare professionals are a little afraid of the kidney. Chas Newstead (Consultant Renal Physician, St James’ Leeds), recently introduced me to the term “reno phobia” meaning fear of encountering kidney disease. This may be one of the reasons a “slightly” raised serum creatinine isn’t always picked up and acted upon in the acutely unwell. Talk of fractional excretion of sodium, Henderson-Hasselbalch equation or anion gap can induce hypotension tachycardia in many who have been through medical school by surfacing deep seated, disturbing memories of undergraduate renal physiology.

The parallels between AKI and VTE run even deeper. Both are common, harmful and treatable. Both are very frequent in hospitalised patients. Both usually occur as a consequence of another underlying or superimposed illness. Both require a system-wide response focussed on assessing risk, early detection and prompt treatment. It’s just over a year since the NCEPOD report into AKI “adding insult to injury” highlighted the deficiencies in care. Only 50% received good care. In one fifth of those with hospital acquired AKI it was both predictable and avoidable. In the foreword, Tom Treasure (NCEPOD Chairman) recounts a story of a medical student presenting a case “from the hospital IT system, she had downloaded and tabulated the blood results and had devised a colour code for those falling outside the normal range. What caught my eye was a run of 3-4 days of blood results, urea and creatinine, printed in red. “Oh, that’s the weak end” she sagely remarked”.

Tom points out that despite all our technological advances and improvements in treatments and operations we are losing sight of the basics. One of the key things we must do is to demystify AKI, in its early stages it signifies the patient is sicker than might originally have been thought. Early AKI demands good basic medical care - attention to fluid balance, careful consideration of what drugs to continue and which to stop and review of management of the underlying acute problem. Senior review of all acute admissions to hospital within 12 hours should help improve the quality of care for AKI.