1. BACKGROUND Acute Kidney Injury (AKI) is common, with an incidence of one in five emergency admissions in the UK and up to 100,000 deaths each year in hospital. The NCEPOD report ‘Adding Insult to Injury’ 1 in 2009 demonstrated significant deficiencies in the care of these patients, stating 50% of patients received poor care and 30% of deaths were preventable. NICE guidance highlights the importance of early recognition of AKI and a national ‘Think Kidneys’ campaign has been developed. Our aim was to increase awareness and improve management of AKI in our hospital. METHODS A multidisciplinary working group was established, and an AKI e-alert for blood tests of kidney function was implemented. Baseline data was collected which identified that the incidence of AKI was 250 patients per month, with 2/3 of these patients being admitted with an AKI. Baseline measures for documentation of AKI and subsequent management were poor. A trust wide educational campaign entitled ‘UR’INE TROUBLE” was launched in November 2015, raising awareness amongst healthcare professionals. This involved giving a short 15 minute presentation introducing a simple AKI management bundle based on the word ‘URINE’ for easy recall, as shown in the poster opposite. This was then rolled out to all clinical staff by running AKI cafes and attending routine teaching sessions, as well as taking the training to the wards using a ‘tea trolley training method’, treating staff to coffee and cake whilst being trained, which was very popular! Cascade trainers were also used to increase speed of spread of the training. The following interventions were then tested on 2 pilot wards, using the Model for Improvement Plan Do Study Act Methodology: 1. An AKI bundle sticker to prompt compliance with delivery of the bundle, as well as improving documentation. 2. AKI safety magnet for ward white boards. 3. Documentation in the discharge summary was also poor, so an automated prompt was placed in all discharge summaries. L. Jordan, V. Selby, D. Skirrow, B. Walker, R. Penders, A. Taylor, J. Barnett REFERENCE: 1. NCEPOD, Adding insult to injury, 2009 RESULTS 526 staff were trained between November 2015 and March 2016 “It was a really interesting talk and raised my awareness” Royal United Hospitals Bath NHS Foundation Trust, UK A campaign to increase awareness and improve management of Acute Kidney Injury CONCLUSIONS We have demonstrated improvement in awareness of AKI and its management by implementing a simple AKI bundle of care through an innovative educational campaign which engaged staff who supported spread of the training by cascading the teaching in their area. The sticker and safety magnets have so far resulted in improved compliance with the AKI bundle by over 25% in all measures as shown and these are now being spread to other wards. Further projects have also commenced improving awareness on the wards of Intravenous Contrast administered in radiology, as well as amendments to hydration charts to increase focus on urine output. The improved documentation in discharge summaries of over 30% is also vital for long term improvement in the incidence of AKI and, as patients are also at increased risk of developing a subsequent AKI for the year following an event, an alert has been added to the discharge summary of all patients, to increase awareness of this in primary care further improving patient safety AKI BUNDLE STICKER AKI BUNDLE COMPLIANCE DISCHARGE SUMMARY INFORMATIONALERT ON DISCHARGE SUMMARY “This really is so important”