P28
THE MISSING LINK: HOSPITAL DISCHARGE LETTERS FOLLOWING ACUTE
KIDNEY INJURY
Allen JC, Harrison LEA, Bisset L
Department of Renal Medicine, Nottingham University Hospitals
INTRODUCTION: Acute kidney injury (AKI) is a common problem causing significant morbidity.
Patients affected are at greater risk of developing chronic kidney disease in the future. Discharge
letters are a vital part of the communication between secondary and primary care as it is one of the
main standardised mechanisms of informing GPs that an episode of AKI has occurred. A discharge
summary should provide the GP with relevant information and advice regarding the AKI episode to
ensure appropriate monitoring of the patient, safe reintroduction of medications and to guide future
management and monitoring.
METHODS: We reviewed discharge letters of 50 patients referred to the renal team with AKI
between February and April 2013. Patients were identified from the renal referrals database and were
either cases discussed with, reviewed by or taken over by the renal team. Data collection included
patient demographics, cause of AKI, biochemical parameters, and information relayed to the GP
regarding renal diagnosis, blood results, medications and ongoing management. Exclusion criteria
comprised patients who were already under the care of the renal team, referred by other Trusts,
dialysis dependent on discharge, discharged to other healthcare facilities or those who died during
admission.
RESULTS: Discharge letters of 50 patients were reviewed (age 68±14 years, 64% male), most of
which were for emergency admissions (14% elective, 86% emergency). Median duration of hospital
stay was 14 days (range 2-158 days). AKI stage 3 was the commonest stage for referral, (46% stage
3, 18% stage 2 and 36% stage 1) with the main causes of AKI being dehydration/ hypovolaemia
(24%), multifactorial (18%) and nephrotoxics (12%).
Only 84% of discharge letters included a diagnosis of AKI, with 83% of these recorded in the patient
problem list summary and 17% recorded in the free text section. AKI stage was included in less than
10%. Less than half of the letters (42%) included a formal diagnosis of the cause of AKI, and advice
provided by the renal team was referenced in around one third. Of the 5 patients who received
haemodialysis, 4 had dialysis treatment details included in their discharge letter. In terms of
biochemistry, 48% included admission/peak creatinine or eGFR but only 22% included discharge
creatinine or eGFR. 56% of patients had medication discontinued due to their AKI, yet of these only
43% had advice about restarting drugs. 44% of letters recommended GP renal follow-up, but less than
half of these provided a time and task specific plan.
CONCLUSION: This review has highlighted shortcomings in the information relayed to GPs
following AKI. Although most discharge letters informed GPs that AKI had occurred, a significant
proportion did not include relevant information about severity, diagnosis and biochemical parameters.
The majority of patients had drugs stopped without clear advice on how or when to restart them, and
GP follow-up requests were often non-specific.
We recommend the implementation of a simple standardised AKI dataset in discharge letters to
ensure adequate information is relayed to GPs. This would comprise part of trustwide AKI guidelines
and include AKI stage and cause, changes in medication, and admission, peak and discharge
biochemistry (creatinine and eGFR). Requests for GP follow-up should include clear instructions
regarding reintroduction of medications, along with time and task specific management
recommendations. A plan to assess the impact of this following introduction of this would be
valuable.