Title: Acute Kidney Outreach to Reduce Deterioration and Death (AKORDD) - A pilot study to look at enhancing patient care, improving patient outcomes and reducing NHS Costs
Funder: Department of Health (England)

Abstract: AKI has high impact but suboptimal care Acute Kidney Injury (AKI) affects about 18% of (non short stay) adult inpatients5 and a significant number of patients in the community, with 34-44% mortality amongst unselected inpatients.1;5;7;8 AKI is a very substantial cost to the NHS. We have a Quality, Innovation, Productivity and Prevention (QIPP) case study published by NHS Evidence (see appendix), looking at the marginal costs of AKI. In England, the marginal or excess costs due to AKI per se is hundreds of millions of pounds per year. The 2009 NCEPOD report highlighted unacceptable care of AKI patients.9 Non-specialists fail to recognise developing AKI, struggle to treat the condition effectively, and are slow to refer to specialists.7;9 70% of cases are not referred to Nephrologists.7;9 Earlier diagnosis and intervention is currently possible Earlier AKI diagnosis is already possible with existing systems We have produced Alerts for AKI based on rises in Creatinine, using our pathology software system.1 Our work on Alerts is the first published research on fully automated detection of Creatinine rises and AKI. Hypothesis Our hypothesis is that an AKI Outreach team, using the Alerts and delivering a standardised package of early advice and support to the clinical team, will reduce the mortality, morbidity and costs due to AKI. Audit data from ourselves and others suggests that marked improvements in patient care and outcomes are achievable. Using very conservative estimates in the QIPP we found that even quite modest amelioration of the impact of AKI would more than justify the cost of effective Outreach intervention. Research plan for AKORDD pilot study At this stage a quasi-experimental (Before and After) study is needed to pilot the combination of Alerts with a novel Outreach service. It will work alongside Critical Care Outreach. AKI patients are identified by the Alerts, and numbers will be considerably larger than those seen by Critical Care Outreach. We will determine the optimum Alert algorithm, and use it to detect AKI at two hospitals in a Before or Control phase. During the After phase, for one hospital and related primary care area an Outreach team will intervene, whilst patients in the second hospital/area will continue to receive standard care. The Outreach team will consist of a Research Fellow and Nurse, supervised closely by the lead investigator. For the intervention group we will contact Clinicians caring for patients with an Alert, advise on best management and may visit the patient if necessary. The composite primary end point will be death, need for renal replacement therapy (dialysis), or progression of AKI stage. We will also identify a range of secondary end points. Extensive qualitative research will evaluate the experiences of the Clinicians and patients with the Outreach pilot. A cost analysis will determine the feasibility of introducing an AKI outreach team. Outcome of a cluster trial and potential significance In our ageing population AKI is increasing.10 Associated morbidity, mortality and NHS costs can be prevented or reduced by improved recognition and more targeted care. The development of sophisticated Alert algorithms will detect large numbers of AKI patients at an earlier stage. Audit data and the QIPP suggest that an AKI Outreach team, using appropriate Alerts, is highly likely to achieve measurable reductions in the rates of death, dialysis and deterioration of AKI. However, a study is needed to resolve practical obstacles and to demonstrate feasibility. We will determine effect size and thus power of a subsequent Cluster randomised trial. This trial could lead to the rapid adoption of the Alert approach, AKI Outreach teams across the NHS, and improved patient outcomes.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: RENAL AND UROGENITAL