Title: Applying Systems Thinking to enhance recovery after acute kidney injury
Funder: Department of Health and Social Care

Abstract: Kidneys are essential for our health. They have a number of vital roles. These include filtering our blood and getting rid of waste and excess water by converting it into urine. _x000D_ _x000D_ “Acute Kidney Injury” (AKI) refers to a circumstance when the kidneys suddenly stop working properly within hours or a few days. There are many reasons why AKI can occur. The most common cause is when our body becomes short of salt and water, such as when people become dehydrated from diarrhoea and vomiting. AKI is common, harmful and costly. It affects 1 in 7 people admitted to hospital unexpectedly. It is more common among people who are frail or who live with multiple health problems such as diabetes and heart failure. _x000D_ _x000D_ We have shown that AKI remains an important and overlooked health problem for people even after they recover and go home from hospital. One in 5 people will need to be admitted to hospital again as an emergency within a month and 1 in 3 people within three months. If someone has had AKI they are also more likely to develop lasting kidney damage known as chronic kidney disease (CKD). Over the past 10 years, tackling the harm related to AKI has been a major priority for the NHS. However, most research and quality improvement activities have taken place in hospitals. Research is now needed on how to ensure high quality person-centred care for people affected by AKI following discharge from hospital. _x000D_ _x000D_ As a starting point, we have already used robust research methods to develop national standards to improve care for people affected by AKI. These include: (1) Helping people understand how to keep their kidneys healthy when they become unwell; (2) Supporting people with their medicines, such as restarting important drugs for people with heart failure; (3) Ensuring a timely review by a clinician; and (4) Carrying out tests at the right time to ensure that we are quick to identify people with recurrent or lasting kidney problems. _x000D_ _x000D_ Through the establishment of a Kidney Patient Involvement Network working group, the UK Standards for Public Involvement will provide a structure to ensure patient voice and experience are central to all stages of the study: _x000D_ First, we will analyse large numbers of medical records to assess the current state of care for people leaving hospital following AKI. We will check whether care is being delivered according to national standards, try to work out why care sometimes fails to meet these standards, and identify areas where we can improve future care. _x000D_ _x000D_ Second, we will talk with people to learn from their experiences of care following AKI. With people’s permission, we will review their medical records and interview others involved in their care, such as their GP, nurse, pharmacist or member of hospital staff. Where appropriate, we will also talk with family members who provide support. _x000D_ _x000D_ Third, we will hold workshops with patients and care providers, where we will discuss findings from our analyses of the interviews and medical records. Through shared learning, we will develop practical recommendations to improve the quality of post-discharge care._x000D_ _x000D_ In partnership with patient and professional representatives, our research will: (1) strengthen national guidelines; (2) help improve resources that support person-centred care; (3) develop reliable ways of measuring high quality care for people leaving hospital after AKI; and (4) guide quality improvement across the health service.

Lay abstract: Background_x000D_ Acute kidney injury (AKI) is a common, harmful and costly clinical syndrome, characterised by sudden worsening in kidney function. It affects around half a million people in England each year, contributing to 7 in 100 unplanned hospital admissions. Older frail people living with multimorbidity are especially vulnerable to AKI._x000D_ _x000D_ People discharged from hospital following AKI experience high rates of unplanned readmissions (1 in 5 within 30 days) and poor long-term health outcomes (1 in 5 sustain AKI again, 1 in 6 develop chronic kidney disease, and 1 in 4 sustain a major cardiovascular event). There is uncertainty around how patient, clinician and system factors contribute to these outcomes and, critically, how they can best be targeted to benefit patients._x000D_ _x000D_ Aim and objectives_x000D_ We aim to understand and target improvements in the quality of post-discharge care following AKI. Our objectives are to:_x000D_ 1a. Determine the extent of variations in post-discharge care of people with AKI according to recommended evidence-based practice._x000D_ 1b. Identify patient and general practice characteristics associated with the implementation of post-discharge recommended care processes after AKI._x000D_ 2a. Understand patient, carer and healthcare staff experience of post-discharge AKI care pathways._x000D_ 2b. Identify patient, professional and organisational factors that support or inhibit the implementation of person-centred, evidence-based post-discharge AKI care._x000D_ 3. Integrate findings to develop practical recommendations for improvement at patient, clinician and organisational levels of care._x000D_ _x000D_ Methods_x000D_ Work Package 1 (WP1; M1-24): Population-based cohort study using linked electronic health records from the Clinical Practice Research Datalink, Hospital Episode Statistics and ONS mortality records. We will identify patients with AKI-related hospitalisation and apply earlier-developed indicators of evidence-based, person-centred care. We will examine how patient and organisational factors explain variations in processes and outcomes of care._x000D_ _x000D_ WP2 (M6-30): Qualitative case studies in four integrated care systems with purposeful sampling of organisations, patients and care providers. We will interview 24 patients, shortly after discharge and 3-6 months later, 12 carers, and 36 healthcare providers, as well as analyse local policies and protocols. We will use Systems Thinking as a sensitising framework, contrasting ‘work-as-imagined’ with ‘work-as-done’ in analysing how patients, clinicians, practice teams and organisations manage post-discharge AKI care. _x000D_ _x000D_ WP3 (M1-30): Structured deliberations in participatory workshops involving patients and healthcare providers across the primary-specialist care interface. We will integrate WP1&2 findings and define and iteratively refine an ideal care pathway. We will develop an improvement strategy that explicitly consider impacts on affordability, practicability, effectiveness, acceptability, safety and equity._x000D_ _x000D_ Anticipated impact and dissemination_x000D_ This study will produce a coherent logic model for service improvement which includes practical recommendations and a set of indicators based on routinely collected data for assessing progress. Our findings will articulate the patient voice in strengthening systems of care. Our strong partnerships with the UK Kidney Association and the Kidney Patient Involvement Network will enable the translation of our work into national policy and improvement programme

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: RENAL AND UROGENITAL