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Improving the Recognition of Post-operative Acute Kidney Injury. Baseline Data : Data Collected for patients undergoing urological surgical procedures.

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Presentation on theme: "Improving the Recognition of Post-operative Acute Kidney Injury. Baseline Data : Data Collected for patients undergoing urological surgical procedures."— Presentation transcript:

1 Improving the Recognition of Post-operative Acute Kidney Injury. Baseline Data : Data Collected for patients undergoing urological surgical procedures from 12 th - 16/5/2014 No.ProcedureDate of PACDate of pre-op ScrPre-op ScrSurgeryDischargeWardDate of post-op ScrPost-op ScrAKI 1TURBT +/- MMC22/4/142/4/149812/5/1419/5/ /590N 2Right extraperitoneal nephrectomyNo result12/5/ /5/14Ward 31913/5341N 3GA Cytoscopy +biopsies4/11/ /5/14 DSU--- 4TURBT9/4/1429/3/146412/5/1413/5/ Circumcision + HoLEP16/01/ /5/1415/5/ PDD Check cystoscopypostponed13/5/ BNI/HoLEP20/03/1417/03/149913/5/1414/5/14919/5 (GP)101N 8HoLEP28/4/1428/4/126813/5/1414/5/ Left FURSL2/04/144/03/14None13/5/1414/5/14DSU--- 10Rigid cystoscopy + EUA12/05/149/04/146114/5/ GA endoscopy + balloon dilatation of conduit diversion stoma. 7/05/145/02/ /5/ TURBT30/04/1414/03/146614/5/1415/5/ TURBT25/04/1412/03/148214/5/1415/5/141720/5 (GP)74N 14Change left ureteric stent12/03/1421/02/ /5/ Circumcision25/02/1413/11/136214/5/ Right FURSL2/04/14 15/5/ Exchange of bilateral stens + cystoscopy/Bx +/ TURBT 2/05/ /5/1419/5/14916/5139N 18Diagnostic Rt FURS +/- Bx +/- Lithotripsy TCINo result14/556 (14/5)15/5/14Transfer to RVDSU17/586Y 19 Lt FUR +/- Endoyelotomy +/- exchange of stent- TCI 10/03/ /5/ Postponed9 21Ureteroscopic Stone Extraction7/02/146/02/145116/5/1419/5/14916/5No result- 22Left ureteroscopy + lasertripsy7/04/ /5/1419/5/ TURBT18/04/ /5/1419/5/ GA cystoscopy + biopsy4/02/1423/01/ /5/1419/5/149---

2 Pre-assessment Clinic; Seen by nurse and pre- assessment form filled out – includes questions, examinations and investigations where indicated. Pre-assessment Clinic; Seen by nurse and pre- assessment form filled out – includes questions, examinations and investigations where indicated. Traffic light system. Anesthetist/ FY/nurse Surgery is agreed between the surgeon and patient. Initial section of pre-assessment form is filled out as well as a consent and waiting list form. Patient sent to pre-assessment clinic RED: Reviewed by anesthetist 0-10 days Urgent/drop- in/Booked appointment GREEN: Can be signed off by nurse AMBER: reviewed by FY doctor Booked Appointment; Seen within 10 days Booked Appointment; Seen within 10 days Drop-in (no appointment) Drop-in (no appointment) Urgent; Seen on same day or ASAP Urgent; Seen on same day or ASAP Assessment of Renal Function; Criteria for U&E’s >60 Diabetic Antihypertensive medication History of fluid loss ASA 3 or more Renal obstruction Obstructive urological surgery Major surgery Clinical signs of dehydration eGFR - <30 = red, = amber PMH – Chronic kidney disease Pre-assessment reviewed by anesthetist. Admitted for surgery; DSU/Ward 9 Admitted for surgery; DSU/Ward 9 Surgery Pre-assessment Clinic; Seen by nurse and pre- assessment form filled out – includes questions, examinations and investigations where indicated. 12 week old Blood results can be used. Pre-assessment Clinic; Seen by nurse and pre- assessment form filled out – includes questions, examinations and investigations where indicated. 12 week old Blood results can be used. Traffic light system. Anesthetist/ FY/nurse Surgery is agreed between the surgeon and patient. Initial section of pre-assessment form is filled out as well as a consent and waiting list form. Patient sent to pre-assessment clinic RED: Reviewed by anesthetist Start Time – Clock starts for 12 week target to surgery days Process Map 1 - Urology Ward 9 Pre-Surgery Urgent/drop- in/Booked appointment GREEN: Can be signed off by nurse AMBER: reviewed by FY doctor Booked Appointment; Seen within 10 days Booked Appointment; Seen within 10 days Drop-in (no appointment) Drop-in (no appointment) Urgent; Seen on same day or ASAP Urgent; Seen on same day or ASAP Assessment of Renal Function; Criteria for U&E’s >60 Diabetic Antihypertensive medication History of fluid loss ASA 3 or more Renal obstruction Obstructive urological surgery Major surgery Clinical signs of dehydration 12 week old U&E results can be used eGFR - <30 = red, = amber Chronic kidney disease is highlighted AKI risk is highlighted Assessment of Renal Function; Criteria for U&E’s >60 Diabetic Antihypertensive medication History of fluid loss ASA 3 or more Renal obstruction Obstructive urological surgery Major surgery Clinical signs of dehydration 12 week old U&E results can be used eGFR - <30 = red, = amber Chronic kidney disease is highlighted AKI risk is highlighted Pre-assessment reviewed by anesthetist. Admitted for surgery; DSU/Ward 9 Admitted for surgery; DSU/Ward 9 Surgery Form valid for 6 moths

3 GP Referral Treatment decided 6 Weeks Treatment given 12 weeks Pre-Assessment Clinic 18 Weeks 3 months From pre-op Scr to surgery; Upto 12 weeks + 3 months = ~6 months (this does not include periods of unavailability where the 12 week clock can be stopped) Due to form being valid for 6 months, bloods could potentially be used upto 9 months ago Process Map 2 - Simplified Pre-Surgery Process Map Highlighting potential time lapse between pre-op Scr - Surgery

4 Process Map 3 - Urology Ward 9 Post- Surgery Post-Surgery; DSU Ward 9 (daycase) Ward 9 (1 day) Ward 9 (>1 day) Other ward Post-Surgery; DSU Ward 9 (daycase) Ward 9 (1 day) Ward 9 (>1 day) Other ward 1. DSU; Nurse led-ward Routine post-op obs. Follow recommendations from surgeon and anesthetist Same day discharge No routine post- operative U&E’s 1. DSU; Nurse led-ward Routine post-op obs. Follow recommendations from surgeon and anesthetist Same day discharge No routine post- operative U&E’s 3. Ward 9; Routine post-op obs. Follow recommendations from surgeon and anesthetist Same next day discharge No routine post-operative U&E’s 3. Ward 9; Routine post-op obs. Follow recommendations from surgeon and anesthetist Same next day discharge No routine post-operative U&E’s 4. Ward 9 ; Routine post-op obs. Follow recommendations from surgeon and anesthetist Routine U&E’s; Major surgery TURP 4. Ward 9 ; Routine post-op obs. Follow recommendations from surgeon and anesthetist Routine U&E’s; Major surgery TURP Day 0 Day 1 >1Day Surgery 2. Ward 9; Routine post-op obs. Follow recommendations from surgeon and anesthetist Same day No routine post-operative U&E’s 2. Ward 9; Routine post-op obs. Follow recommendations from surgeon and anesthetist Same day No routine post-operative U&E’s Day 0 Other Ward

5 Process Map 4 - Phlebotomist Service on Ward 9 Phlebotomist takes bloods of patients who are in their beds Phlebotomist checks which bay the patients are in or if discharged Phlebotomist collects labels from ward 9 (begins between 10am- 12am Phlebotomist has a set run of wards Starts 8 a.m. Labels are printed for these blood requests for each ward FY requests patients’ bloods to be taken the night before Phlebotomist sends bloods to lab via the ward portal system Phlebotomist carries out a sweep of the ward to pick up any patients missed Portal System/ Porter/end of run If urgent Phlebotomist sends for Porter to bring bloods to lab Phlebotomist waits till the end of the run and sends bloods to lab Phlebotomist moves onto next ward Results return within 2-3hours

6 DISCHARGE Transport Pharmacy Catheter (TURBT + TURP) Fish Bone Diagram 1 - Factors of Discharge Time on Ward 9 Patient passes urine Removal 6 a.m Time for pharmacist to collect medication Medication available Pharmacist agreeing on discharge Time when ward assistant calls Ambulance waiting times Relative available U.S. scan of bladder Bed Availability Number of discharges vs. new patients Moved to day room Busy ward

7 Process Map 5 - AKI guidelines for post-op AKI Stage 1 Stage 2 or 3 Stage 1 Stage 2 or 3 Repeat sample in 2 -3 days to ensure it has returned to baseline. Discussed with renal registrar on call and refer to AKI guidance. Stage 1Stage 2 or 3 Compare pre and post-op Scr Levels

8 Process Map 6 - Collecting data Start – day 0 Request, from the ward assistant that an extra surgical list for the following day is printed off After 3pm Retrieve surgical list from folder after its printed 5mins per patient Access ICE and Clinical Portal to access relevant information (see table). More specific information on data collection in word document <5mins per patient Retrieve any missing data the following few days (e.g. Discharge date, post-op Scr). Day of discharge can either be accessed via clinical portal or the discharge book on ward 9. 2mins per patient Data input into table No.No. Procedure Date of PAC Date of pre-op Scr Pre-op Scr Surg ery Disch arge W ar d Date of post-op Scr Post-op Scr AKIAKI


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