A1(T)
AUDIT CYCLE TO IMPROVE THE CLINICAL ASSESSMENT OF PATIENTS WITH
ACUTE KIDNEY INJURY ON ADMISSION TO AN ACUTE ADMISSIONS UNIT
Nakoinz, S, Bhatty, U, Rolli, A, Nicholas, J, Carmichael, P
New Cross Hospital, Wolverhampton
PROBLEM: The aim of the audit was to review and improve the clinical assessment of patients
with evidence of Acute Kidney Injury or acutely worsened Chronic Renal Failure on admission to
an acute Admissions Unit (EAU).
PURPOSE: The NCEPOD report “Adding Insult to Injury” (2009)1 describes that a large
proportion of patients with Acute Kidney Injury are being mismanaged with respect to clinical
assessment, early diagnosis and management.
We aimed to review how well patients in our hospital are being assessed by the admitting doctors
and how standards can be improved.
DESIGN: During a 24-day period in September 2009, we collected data of all patients (medical
and surgical) admitted to the EAU with evidence of Acute Kidney Injury (AKI) or Acute on
Chronic Renal Failure (AoCRF). This was defined as a serum creatinine of >120μmol/l and a
previously normal value (AKI) or serum creatinine increase by 50% or more above historical
values (AoCRF). Here, we present the findings of those patients with creatinine values of
150μmol/l or more.
Of the identified patients, medical notes of the relevant admission were reviewed. The findings
were subsequently presented at a weekly educational meeting open to all medical doctors at the
hospital, and in the same meeting new guidelines on AKI for the Trust were launched. These were
published both as posters in the doctors’ office of the EAU as well as on the hospital-intranet.
In May 2010, the audit was repeated over a period of 14 days to see whether the new guidelines
had improved the previous findings.
FINDINGS: The initial audit found that 101 patients (7.5% of all admissions) had AKI or AoCRF
as defined above. In both audits, just under 4% of admitted patients had significant AKI or AoCRF
with creatinine values of 150μmol/l or more. These populations were very similar in both audits
with respect to demographics, severity and type of kidney failure, comorbidities and medication.
Clinical assessment was similarly unsatisfactory in both audits:
JVP
2009
2010
63%
64%
Skin
turgor
8%
12%
Postural
BP
2%
4%
Urine
dipstick
28%
33%
Renal
US
44%
36%
Myeloma
screen
20%
20%
Immunology
12%
12%
Referral
26%
42%
Investigations into the cause of the kidney failure were generally inadequate, and in over 40% no
impression of the kidney impairment was documented. Unfortunately, there was no difference
between the audit results apart from a tendency for more renal referrals in the second audit.
CONCLUSION: Clinical assessment and investigations of patients with evidence of AKI or
AoCRF on admission to EAU are inadequate. Frequently, AKI was neither appreciated nor
documented as a diagnosis.
Simple interventions such as a presentation in an educational meeting and readily accessible
clinical guidelines are insufficient measures to overcome these habits.
RELEVANCE: The findings suggest that the training of junior doctors regarding assessment and
appreciation of Acute Kidney Injury is insufficient and that this cannot be remedied by simple
interventions.
1
NCEPOD ‘Acute Kidney injury: Adding Insult to Injury’ (2009). www.ncepod.org.uk