PRACTICUM SUMMARY REPORT
Name: Cal Doherty
Team Members: Nicola Trotter, Professor Peter Davey, Vicki Tully, Samira Bell
Project Title: Improving the Recognition of Post-operative Acute Kidney Injury.
University/Organization Name: University of Dundee
Health System Sponsor Name: Dr Samira Bell
Aim of project (1-2 sentences)
Our aim is to increase the number of patients returning to ward 9 for over one day post-surgery who
receive a serum creatinine measurement within 2 days of their urological surgery. Specifically, we want
the reliability of this measurement to be 95% or over in ward 9 by 30 July 2014.
Planned changes tested (2-3 sentences)
We will monitor patients undergoing urological surgery who return to ward 9 after their surgery and note whether
they receive a pre and postoperative creatinine in order to determine acute kidney injury rates. After obtaining
baseline data, we will discover where the problem lies in recognition of acute kidney injury and then increase rates
of pre and post-operative creatinine measurement via increasing staff knowledge and implementing new protocols
approved by the renal team. We will then measure the rates of the acute kidney injury in patients undergoing
urological surgery so the problem can be better understood and recognized and hence patient care can be
improved.
Predictions (2-3 sentences)
As a result of our study we hope to increase the number of patients receiving post-operative creatinine
measurements after they return to ward 9 postoperatively. This will lead to an overall improvement in detecting
acute kidney injury and hence will better patient care as these patients can be monitored by the renal team if need
be.
Results
Present your results with a graph(s).
1. Percentage of Patients who were Discharged on their First Post-op Day who Received Post-Operative Creatinine
Measurement on Ward 9. (Day 0= day of surgery).
2. Percentage of Patients who Returned to Ward 9 for 2 or more Days Post- op who Received a Creatinine
Measurement within 2 days of their Surgery. (Day 0= day of surgery).
3. Percentage of Patients, per Week, who Returned to Ward 9 for 1 or more Days Post-op who Received a Creatinine
Measurement within 2 days of their Surgery.
Summary of results (3-4 sentences):
Our presence on ward 9 and clinical engagement increased the percentage of patients returning to the ward who
received a post-operative creatinine. Through building relationships on the ward and sharing our data and
knowledge there was an increase from 27% of patients receiving post-op creatinine in our first week of collecting
data, to 87% in our last week on ward 9. This change seems to be most predominant in the patients who stay 2 or
more days after surgery as there was 9 consecutive days in which 100% of these patients received a post-operative
creatinine. However, as a set tool could not be emplaced at present, this shift was not sustained when the staff
members changed on the 27th of June. However, hopefully the shift in culture will branch down to other different
members of the team and a higher percentage of patients will receive a post-operative creatinine measurement.
Of the patients in which a pre and post-operative creatinine was recorded 19% (4/21) of patients developed postoperative acute kidney injury. This was calculated using the recommended definition of AKI (at least a 50%
increase in creatinine levels). This is a significant proportion of patients and thus highlights the need for further
monitoring and awareness of this condition.
Learning (4-5 sentences)
Comparison of questions, predictions, and analysis of data:
In our first PDSA cycle, we wanted to develop a data collection tool which would determine how many patients
who returned to ward 9 after their urological surgery for one or more day received a post-operative creatinine. We
predicted that a minority of patients would receive a post-operative creatinine based on concerns raised by a
previous NHS Tayside study. This was the case with only 27% of these patients receiving a post-operative
creatinine in our first week of data collection.
In PDSA cycle #2, we wanted to implement a tool in the post-operative form the surgeons fill in which would allow
for them to request for a post-operative serum creatinine to be carried out. We also wanted to raise awareness of
acute kidney injury through posters and leaflets. However, due to barriers around consent of requesting further
blood tests we could not implement a set tool. However, by engaging with the team and sharing our concerns
around this problem and raising awareness the percentage of patients receiving a post-operative creatinine rose to
87% in our final week. This showed a change of culture can occur by engaging with a clinical team and a change can
be implemented without devising a tool as such.
Impact on systems (3-4 sentences)
Discuss the project’s significance on the local system and any findings that may be generalizable to other systems:
Patients are still not protected from developing acute kidney injury following an urological operation, however the
recognition and detection of postoperative AKI has risen. This will allow for early detection of the condition and
thus will allow the renal team to monitor these patients in order to prevent them from further developing chronic
renal problems and co-morbidities.
The health care team (physicians, nurses, phlebotomists, medical technicians and medical students) will be
affected as there will be an increase in the number of bloods being taken on ward 9. However, they will benefit
from higher work satisfaction as they are providing better care and will be saving the NHS money in the long run as
these patients often go on to develop chronic complications. Other organizations can read this report and can
learn from the lack of understanding and recognition of post-operative AKI among health care professionals and
hopefully monitor their surgical patients' renal functions more carefully and raise awareness in their own areas of
work.
Conclusions (3-5 sentences)
Summarize the outcome of the project. Is this project sustainable? What are the requirements for sustainability?
There are many factors which contribute to the low percentage of patients receiving post-operative creatinine
measurements. By interacting with the urology team and presenting our data, the knowledge and comprehension
of the problem was altered. This lead to a change in culture and a significant increase in the number of postoperative creatinine measurements being taken. However, without a set tool or change in protocol it is unclear
whether this change will be sustained. It is difficult to know whether the provision of real-time feedback and
constant monitoring may be the main driver of this change.
Reflections/Discussions (5-7 sentences)
Discuss the factors that promoted the success of the project and that were barriers to success. What did you learn from
doing this project? What are your reflections on the role of the team?
A multidisciplinary team approach to improving the number of patients who receive a post-operative creatinine
may have improved the success of the project. We formed a strong relationship with the staff on the urology ward
but did not spend a lot of time engaging the urology consultants as they were often busy in theatre so we did not
see them on the ward. In hindsight, engaging all the stakeholders at the beginning may have reduced several
barriers we faced. Thus instead of focusing simply on the team on the ward we were in contact with on a daily
basis it is important to identify the full team and engage all members early on in the project.
Moreover, tackling a large project and then trying to scale the problem down in order to focus on a specific area is
challenging as it is difficult to know which route to follow and there is a sense of feeling that you should be tackling
all areas needing improved. Therefore, understanding the problem and defining a focused goal at the beginning of
the project would be beneficial.
By signing this document (electronic signature is acceptable), I attest that the information provided by the learners in
this project is accurate.
LEARNER(S):
Signature:
Nicola Trotter
Printed Name: NICOLA TROTTER
Area of Study: Medical Student
Signature:
Printed Name: Cal Doherty
Area of Study: Medical Student
Signature:
Printed Name:
CAL DOHERTY
Area of Study:
Printed Name:
Area of Study:
Signature:
Printed Name:
Signature:
Area of Study:
Printed Name:
Area of Study:
Signature:
FACULTY SPONSOR:
HEALTH SYSTEM SPONSOR (if different from faculty sponsor):
Signature:
Signature:
Printed Name: SAMIRA BELL
Printed Name: VICKI TULLY
Institution:
Institution:
AUTHORIZATION
Do the learners, faculty sponsor, and health system sponsor authorize this project for publication at www.ihi.org?
X☐ Yes
☐ No