Acute kidney injury; improving thecommunication from secondary toprimary care

Clemency Nye, Suzanna Lake

To cite: Nye C, Lake S. Acutekidney injury; improving thecommunication fromsecondary to primary care.BMJ Quality ImprovementReports 2017;6:u211147.w6661. doi:10.1136/bmjquality.u211147.w6661

Gloucestershire NHSFoundation Trust

ABSTRACTAcute kidney injury (AKI) is a common but preventableevent in secondary care. It is known to be associatedwith poorer outcomes for the patient’s future health.Patients therefore require specific after-care in thecommunity following an AKI, both in the short andlong term. However, information about an inpatient AKIis often not communicated to primary care atdischarge. Only 11.0% of discharge summariescontained full information about an AKI (includingstage of AKI, changes to medications and follow-uprequired) in August 2015.We aimed to improve communication about AKI on

discharge summaries via implementation of a series ofinterventions between June 2015 and March 2016. Aspecific section was added to the discharge summarysoftware to prompt inclusion of information regardingAKI. An automatic warning message was added later asan additional prompt. A programme of education wasprovided for the junior doctors. A ward-basedcampaign was rolled out using the animated character‘Ned the Nephron,’ using posters, emails and screensavers. We also introduced an AKI warning sticker fordrug charts, which reminds the discharging doctor thatthe patient has had an AKI during the admission.Our primary outcome was the percentage of

discharge summaries that had the AKI sectioncompleted, as this contained all the desiredinformation, including stage of AKI and frequency offollow up blood tests in primary care. Monthly datacollections showed that this gradually increased from4.7% in September 2015 to 35.0% in January 2016.We expect further increases with the recentintroduction of the drug chart sticker.

PROBLEMThis project was conducted across GloucesterRoyal Hospital and Cheltenham GeneralHospital, two district general hospitals with acombined total of over 1000 inpatient beds.The project was undertaken by a core teamof foundation 2 doctors, with support fromthe renal team and the Gloucester Safetyand Quality Improvement Academy.The problem was that information about

an inpatient AKI was inconsistently and infre-quently being communicated to primary care

at discharge. Only 11.0% of discharge sum-maries audited in the trust in August 2015contained full information about an AKI(including stage, changes to medications andfollow-up required). Discharge summariesare completed by junior doctors – work withthis target group suggested that this low com-pletion rate was due to a combination of lackof awareness of the long-term significance ofAKI and role of primary care in AKI preven-tion, and time pressures when completingdischarge paperwork.The aim of the project was to increase the

proportion of discharge summaries acrossboth hospital sites which contained completeinformation about an inpatient AKI to 30%by April 2016.

BACKGROUNDAcute kidney injury (AKI) is a common butpreventable event in secondary care. It isknown to be associated with both short-termand long-term adverse outcomes for thepatient.1 Long term outcomes can includeincreased risk of repeat AKI, higher risk ofdevelopment of chronic kidney disease andgreater chance of progression to end-stagerenal failure,2 higher risk of future cardiovas-cular and cerebrovascular events,3 andincreased all-cause mortality at 10 years.4

The crucial role of the primary care phys-ician is increasingly being recognised in AKI,particularly in the prevention of future AKIevents.5 Up to 30% of AKI events are pre-ventable,6 although the contribution madeby optimal management in primary care hasyet to be quantified. In order for primarycare to play an effective role in AKI preven-tion, the general practitioner must be pro-vided with the relevant information fromsecondary care following a patient’s AKI.Patients also require specific after-care in thecommunity following an AKI, both in theshort and long term. This usually comprisesfollow up blood tests to ensure stable renal

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function in the short term, and longer term ongoingassessment of prescribed medications. In addition, theprimary care physician must take into account thepatient’s increased risk in all the above areas in theirfuture management.

BASELINE MEASUREMENTOur primary outcome was the percentage of dischargesummaries that had the specific AKI section completed,as this contained all the desired information, includingstage of AKI, changes to medications and frequency offollow up blood tests in primary care. The AKI sectionwas introduced in May 2015, and therefore the baselineuse of the AKI section prior to this was 0%.The first data collection occurred in August 2015. A

list of patients who had an AKI during August and weredischarged during the same month was compiled bycross-referencing between a list of patients flagged forAKI by the pathology IT system and a hospital dischargedatabase. 149 patient discharges in total were audited.10.7% contained complete information about the AKI(all three points as above.) 31.6% contained incompleteinformation (1 or 2 points of information.) 57.7% of dis-charge summaries had no mention at all about the AKI.We repeated data collection each month for a total ofsix months.

DESIGNWe questioned a number of junior doctors at differentstages of training about the reasons why they did notalways complete the AKI section of the dischargesummary and their ideas for improvement. We then ana-lysed the problem using a driver diagram. Our primarydrivers were: junior doctor education and engagement,the design of the discharge summary software itself andremembering that the patient has previously had an AKIduring the admission when completing the summary.We therefore designed our interventions to target thesethree areas.In order to improve junior doctor engagement, we

held two teaching sessions for the F1 and F2 doctors,who were completing the majority of discharge summar-ies. We aimed to emphasise the significance of AKI andthe importance of follow-up following an AKI in theseteaching sessions. We also targeted the wider hospitalcommunity via a trust-wide email, ward posters andarticle in the trust newsletter Outline. We created an ani-mated character, ’Ned the Nephron,’ which was used totie the campaign together and create a talking point.We worked closely with the IT department to improve

the design of the discharge summary software. A specificbox for information relating to AKI, with drop-downfields for easy completion, was added to the software.This box was then gradually amended over the course ofthe project following feedback from junior doctorsabout its’ usability. Finally, an automated pop-up

reminder message was added, to prompt doctors to com-plete the AKI section before completing the summary.Remembering that the patient has had an AKI was a

problem because patients were often being dischargedsome time after the AKI event or after transfer betweenwards, and it was difficult for doctors to recall the AKI,particularly if the AKI had been present on admission.We therefore created an AKI drug chart sticker whichwas added to the front of the drug chart when an AKIwas recognised, and served as an ongoing reminder ofthe AKI.

STRATEGYPDSA 1: introduction of AKI section on dischargesummaryThe dedicated AKI section on the discharge summarysoftware was introduced in May 2015. The first data col-lection cycle was in August 2015. Each cycle of data col-lection analysed between 130 and 220 patientdischarges. Results from August showed a 10.7% compli-ance with use of the AKI section, in patients known tohave had an AKI during their admission. This revealedthe need for further promotion and explanation of theAKI section to its users.

PDSA 2: junior doctor educationTwo teaching sessions were run for junior doctors inOctober 2015. We focused on the importance of goodcommunication to primary care about inpatient AKIs,and the need for long-term follow up care after an AKI.Data was collected at the end of November. The propor-tion of completed AKI sections was 11.1%, which was nosignificant improvement compared to the 10.7% seen inAugust. We therefore considered a more direct approachto reminding doctors about the AKI section.

PDSA 3: changes to discharge summary softwareIn December 2015, an automated reminder message wasadded to the discharge summary software, to serve as anadditional prompt to junior doctors. Data collection atthe end of December showed an increase in proportionof AKI sections completed to 29.5%. This suggested thatthe reminder was an effective method of increasingcompliance.

PDSA 4: introduction of drug chart stickersWe began to introduce the AKI drug chart stickers towards in January 2015. The compliance increased to35% at the end of January 2015.

RESULTSMonthly data collections showed that the use of the AKIsection of the discharge summary (in patients who hadhad an AKI) gradually increased from 10.7% in August2015 to 35.0% in January 2016. This was a markedimprovement. On an informal basis, the degree ofawareness of AKI and the need for effective communica-tion to primary care improved among the junior doctor

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population. There is, however, the potential for furtherimprovement, and for additional work on this subject, inparticular examining how the information communi-cated from secondary care about an AKI is received andacted upon in primary care, and whether optimal followup improves patient outcomes.

LESSONS AND LIMITATIONSLessons learnedWe have learnt that changing the behaviour of a popula-tion is a difficult process, and requires multipleapproaches, and the involvement of a number of differ-ent key teams within the hospital. One of the main chal-lenges we faced was being limited by the informationsystems software available within the trust, as the dis-charge summary software was unwieldy and difficult touse, and could not communicate with the pathologysoftware.It was interesting to note that a simple strategy of edu-

cation for junior doctors was unsuccessful. We spoke to anumber of junior doctors from different specialties andat different stages of training to try to understand thereasons behind this. We found that, although they hadlearnt some new information from the teaching, particu-larly regarding the effect of an AKI episode on apatient’s long-term outcomes, they felt that they werealready under pressure and could not easily take on anew requirement. It was also hard for them to associatefilling in the AKI section with better patient outcomes,

because the intended benefits to patients were long-termand happened outside of secondary care, and thus therewas no visible benefit for them to appreciate.

LimitationsIt was not possible to examine every discharge summarygenerated in the hospitals, so we randomly selected asample to study from databases with which we were pro-vided. We would like to have access to a wider sample inorder to be sure that our random sample was representa-tive of the whole population. In order to be sure thatour findings are not the result of chance, we would alsoneed to analyse more data and employ statistical tests.

Balancing measuresWe did not test any balancing measures, but it wouldhave been useful to examine measures such as length oftime to complete discharge summary and junior doctorlevels of satisfaction with the process. We could alsowork with general practitioners to assess whether theyhave found the information useful in their practice, andto what extent the additional recommendations e.g.follow up blood tests, have added to their workloads.

SustainabilityWe have tried to make our changes sustainable in anumber of ways. Firstly, we have ongoing support fromthe renal team and patient safety team, who remaininvested in the project. The new cohort of foundation 1

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doctors in August 2016 have been thoroughly educatedin the use of the AKI section. We have also given adviceon the design of an AKI section in a new dischargesummary software, which is due to be launched in thetrust within the next year.

GeneralisabilityWe feel that our project could be extended to otherNHS trusts, as all hospitals have to generate dischargesummaries to communicate from secondary to primarycare, and communication about inpatient AKI events is

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being increasingly recognised as important. The projectwas run with similar results in two hospitals with differ-ent ranges of specialties and different catchment popu-lations. The main difference between our trust andother trusts will be the computer software available,which may be more or less advanced in other trusts, orintegrated with other software, such as pathology report-ing software, to varying degrees.

Cost effectivenessThe burden of AKI is estimated to cost the NHS over £1billion per year, or around 1% of the total NHS budget7.Good follow up care in the community after an AKI ishoped to reduce future AKIs and reduce re-admissionrates. This should lead to cost savings for the trust. Theproject was also part of a national CQUIN, and thereforeimproving the information on discharge summaries wasassociated with a direct financial reward to the trust.

CONCLUSIONThe problem of effective communication from second-ary to primary care is common throughout hospitaltrusts. This is particularly the case for the subject of AKI,especially with recent focus on the importance of therole of primary care in AKI.5 We believe that our inter-ventions could be easily implemented in other hospitals.The series of interventions introduced led to a signifi-

cant improvement in practice, and further improvementis expected with ongoing changes. Further data collec-tion will be undertaken in late 2016, to assess the sustain-ability of the change.

Acknowledgements Additional core team member – Sophie BoydDr Preetham Bodanna – renal consultant and project mentorGloucester Safety and Quality Improvement Academy – particularly Andrew

Seaton (Director of Patient Safety), Jan Joseph and Alexandra PurcellIsrar Baig – renal pharmacist

Declaration of interests Nothing to declare.

Ethical approval Ethics review was not sought because the study met criteriafor exemption from such review, according to an institutional policy, as thework was deemed an improvement activity.

Open Access This is an open-access article distributed under the terms ofthe Creative Commons Attribution Non-commercial License, which permitsuse, distribution, and reproduction in any medium, provided the original workis properly cited, the use is non commercial and is otherwise in compliancewith the license. See:• http://creativecommons.org/licenses/by-nc/2.0/• http://creativecommons.org/licenses/by-nc/2.0/legalcode

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