Thursday, 21 March 2013

Don't let them die of AKI

This year the global kidney community made acute kidney injury (AKI) the theme of World Kidney Day. This was a significant and important moment in raising the profile of such a common, harmful, and avoidable condition. At the Renal Association and forthcoming British Renal Society meeting AKI research is prominent and the NICE guideline on AKI is now out for consultation – what are you doing about it?

The day before World Kidney Day, in a prescient step, the Government appointed US patient safety expert Professor Donald Berwick to lead a newly created National Advisory Group on the Safety of Patients in England.

Berwick’s Group has been set up in the wake of the Mid Staffordshire NHS Foundation Trust Public Inquiry to make “zero-harm” a reality and take ‘serious and profound action’ to minimize patient harm. As his group of 14 US and UK experts sit down to take on this challenge  there will no doubt be a number of competing issues jostling for priority on their agenda. However, despite, being the cause of at least 12,000 avoidable deaths a year, an average of 32 a day, it is unlikely that AKI will be at the top of this group’s agenda. 

This would be a mistake and a missed opportunity. AKI is the “miner’s canary” of the quality of basic and safe care. It is the reliable biomedical counterpart to the “cultural barometer” called for by the Right Honourable Robert Francis QC’s in his second report on the Mid Staffordshire Trust failures of care.  It is the one single measure which will tell us if we are making improvements from the nadir of Mid-Staffordshire.

AKI is silent but deadly. It is estimated to affect up to one in five, or 20% of all emergency admissions to hospital, often as a result of primary illness such as pneumonia, diarrhoea or a heart attack.  That’s over half a million people a year in the UK  of whom somewhere between 62,000 and 210,000 people die with AKI, which is almost 200 times the number dying of a MRSA.

Up to a third of cases of AKI and thousands of deaths could be avoided through the provision of basic medical care, including reviewing medication, ensuring that patients are hydrated, treating infections promptly and ensuring consultant review within 12 hours. However, current care of patients is variable and often poor. The 2009 NCEPOD report Adding Insult to Injury highlighted failures of basic care of those with Acute Kidney Injury (AKI), with only half being found to be adequate.

In the age of the ‘Nicholson Challenge’, there is also a significant financial imperative to make AKI a political priority. AKI prolongs hospital stay by a multiplication factor of over 2.5 and costs the NHS £1.2 Billion. That’s the same cost as the whole of the chronic dialysis and kidney transplant programmes and greater than prostate, bowel and lung cancer combined. Estimates suggest AKI prevention could save the NHS between £130 to 186m a year, which would pay the full staff costs of a moderate sized district general hospital.

The challenge is how we can take a condition that is seen as a complex, specialist, renal issue and make it a mainstream health priority. The good news is that as a renal community, we are uniquely well positioned to make this happen, and in our experience with CKD, we have the roadmap.

Last year was the decade anniversary of the KDOQI CKD Guidelines, which were the first step in a ten year transformation of the political, public and policy profile of kidney disease. Whilst retaining the prioritisation on improvement in dialysis and transplantation, a wider focus was achieved, getting kidney disease understood within the wider-vascular agenda and making it an issue for all health care professionals. We transformed CKD beyond recognition lets now do the same for AKI.

What can we learn for AKI? NICE Guidelines for AKI, launched for consultation on World Kidney Day, and the prioritization of AKI in the Department of Health’s Cardiovascular Disease Outcomes Strategy are significant steps for raising awareness and influencing practice to tackle variations in care. 

However, they will not be enough alone. Indeed, the AKI guidelines are aimed at non-specialists in the NHS and it is worth remembering that we already have NICE Guidelines 50 on the recognition of acutely ill patients in hospital, which were published five years ago.Unfortunately, sometimes when an issue is everyone’s business, it quickly becomes no one’s business.

The last few months have been a tough time for the NHS. Not only have we just gone through the largest reorganisation since its inception in 1948 but at the same time the issue of how we in the NHS treat vulnerable patients, not only at Mid Staffs, has rightly come under scrutiny. AKI largely affects the vulnerable. The same people who often don’t get adequate hydration or nutrition in hospital. The same group for whom compassion, dignity and respect is often lacking.

AKI is the safety concern for the NHS and we will need broad engagement across specialties to drive improvements. But we will not achieve the transformational change required simply by commissioning alone. First and foremost, healthcare professionals across the NHS need to understand what the kidney does, why it is important, and how it can be protected. We will all need to ‘think kidney’ as a matter of course.

There has been a lot of nurse and health-care assistant bashing but culture is set from the boardroom. As General Slim once said “there aren’t any bad soldiers only poor officers.” In my experience nearly everyone in the NHS gets up in the morning to do a good job. So let’s move away from blaming whole segments of the health care professions but at the same time acknowledge that the system isn’t the Commissioning Board, the new PFI trust buildings, the rules and regulations – it’s you and I, it’s the staff of the NHS and yes we need to up our game as multiprofessional teams and help address these failures.

Let’s start with AKI. Let’s use the Academy of Medical Royal Colleges multiprofessional skills and competencies framework on all our wards.  If you haven’t introduced eAlerts for AKI in your hospital what on earth are you waiting for?  If AKI isn’t a board priority in your hospital, if it’s not in the quality accounts, why not?  But most of all, what can you personally do to help stop people dying of AKI?

My message to the kidney community as I step down from the role of Renal Tsar for the country is thank you for all your support, together we are doing a good job for patients and families with CKD.  Now is the time to turn our attention to AKI.

Friday, 8 March 2013

Kidney the Heart of a New CVD Strategy

Living well for longer needs good kidney function. Many will have seen the press coverage of the Lancet article on “UKhealth performance: findings of the global burden of disease study 2010” earlier in the week. It concluded that although life expectancy in the UK has increased by 4.2 years, in the twenty years from 1990-2010 the UK’s position in the league table of other developed countries remains poor and is significantly below the average in Europe, North America and Australia. It calls for an integrated and strategic response to improve public health, prevention, early intervention and treatment.

The same morning the Lancet article appeared, the Secretary of State for health launched a call to action to reduce avoidable premature mortality. Stopping smoking is probably the most important thing a healthcare professional can advise and help with, and certainly outweighs anything else an individual smoker can do for their health. Smoking takes 16 years off life expectancy, causes kidney disease and accelerates the loss of kidney function. Smokers are less likely to be suitable for transplantation.

The call to action illustrates the problem- for instance the all cause mortality for women in England is placed 15th out of 17 European countries. Last year, 37,000 people died of circulatory diseases - that includes kidney disease. Those living in the most deprived areas are more than two times more likely to die prematurely when compared to the least deprived 20% of our nation. Kidney disease has an earlier onset, is more severe and has worse outcomes in deprived populations. What can we do? Answer: Everything we can- more prevention, earlier diagnosis, better treatment, more choice, improved dignity and care. England would have 29,000 fewer deaths per year if it had the same mortality rates as Switzerland.

The “reforms” of the Health and Social Care Act will be in place by 1st April this year. Not only is that April fools day, it is also Easter Monday. Despite that the  various bits of the health  jigsaw -  in the NHS Commissioning Board, Public Health England, Local Government and the Local NHS need to fit together and unite behind the goal of reducing avoidable premature morbidity and mortality.

Okay, what does that mean? Well, look at the Cardiovascular Disease Outcome Strategy, it has identified 10 actions covering:

  • Manage CVD as a single family of diseases
  • Improve prevention and risk management
  • Improving and enhancing case finding in primary care
  • Better identification of very high risk families /  individuals
  • Better early management in secondary intervention in the community 
  • Improve acute care- this includes avoiding acute kidney injury
  • Improve care for patients living with CVD
  • Improve end of life care for patients
  • Improve intelligence, monitoring and  research and support commissioning

Health care professionals, commissioners, carers and families, patients, health and well-being boards and the public all have a part to play in this strategy that recognises the importance of kidney disease, as both the vascular disease and a vascular risk factor or amplifier.

During the development of the strategy what I regularly heard was:

 “Treat me as a person and not a single condition”

 “Get the various bits of the NHS that look after me to pool their expertise and share information about my care”

“Don’t miss opportunities to improve my treatment and care, because you’re only interested in the heart…diabetes… or the kidney”

“Prevention is definitely better than living with a long-term condition that can’t be cured”

“Look after me safely when I am sick- protect my kidneys”

“We live in the 21st Century – use information to drive better understanding and improvement”

Jeremy Hunt cannot make these things happen. David Nicholson cannot make these things happen. The kidney community- that is you can play its part to make all these things happen. The only place quality is actually delivered in the NHS is in the interactions between patients and health care staff  face to face, by telephone, by renal patient view  and other means at all of our disposal