1. Renal Referrals at UHB Mark Jesky Research Registrar

2. Background Renal referrals received from virtually all hospital specialties Increased emphasis in recognising acute kidney injury (AKI) and managing appropriately – Awareness of even mild AKI associated with increased hospital stay and mortality Traditionally, referrals recorded on ad-hoc basis – Auditing activity difficult

3. A Brave New Dawn From September 2010 referrals made on PICS health informatics system

4. Audit Questions Referral demographics For AKI referrals – AKI stage at referral – AKI stage at peak creatinine during admission – Length of stay by AKI stage – Survival discharge 90 days – Renal survival – Renal Follow-up

5. Demographics From mid September 2010 – mid July 2011 623 episodes captured – (1 person may have more than one event) Total No. ReferralsNo. DaysReferrals / day Number /day (inc weekend)6233142.0 Number /day (exc weekend)5732252.5

6. Referral by Day

7. Referral by time of day 41.7% 62.4%

8. Type of Referral by PICS

9. Referral by Directorate

10. AKI data 332 AKI episodes – 310 episodes excluding solid organ transplantation AKI classification StageSerum Creatinine criteriaUrine Output Criteria 1Increase in serum creatinine of ≥26.4 µmol/L or increase to 150-200% from baseline < 0.5 ml/kg/ hr for more than 6 hours 2Increase in serum creatinine to more than 200- 300% from baseline < 0.5 ml/kg/hr for more than 12 hours 3Increase in serum creatinine to more than 300% from baseline or ≥354 µmol/L with an acute increase of at ≥44 µmol/L < 0.3 ml/kg/hr for 24 hours or anuria for 12 hours

11. AKI data 332 AKI episodes – 310 episodes excluding solid organ transplantation 24 duplicate referrals (21 single admission, 3 two admissions) 3 triplicate referrals (1 single admission, 2 two admissions) AKI classification StageSerum Creatinine criteriaUrine Output Criteria 1Increase in serum creatinine of ≥26.4 µmol/L or increase to 150-200% from baseline < 0.5 ml/kg/ hr for more than 6 hours 2Increase in serum creatinine to more than 200- 300% from baseline < 0.5 ml/kg/hr for more than 12 hours 3Increase in serum creatinine to more than 300% from baseline or ≥354 µmol/L with an acute increase of at ≥44 µmol/L < 0.3 ml/kg/hr for 24 hours or anuria for 12 hours

12. AKI stage (duplicates from same admission removed) At ReferralAt Worst AKI unclassified81 (28.4%) 31 (10.9%) 178 (27.4%) 83 (29.1%) 227 (9.5%) 28 (9.8%) 384 (29.5%) 141 (49.5%) unknown15 (5.3%) 2 (0.7%)

13. Outcomes by AKI stage (duplicates from same admission removed) Length of Stay - All days Median (IQR) Length of Stay - alive to discharge days Median (IQR) AKI unclassified13 (6.5-21)12 (6.75-21) 118 (11-42.5)16 (9.5-35) 221.5 (10-44)25 (11-49.5) 317 (10-37.75)19 (10-44)

14. Outcomes by AKI stage (duplicates removed) n Died in Hospital n (%) 90 day mortality n (%) AKI unclassified313 (9.7%) 4 (12.9%) 18316 (19.3%) 24 (29.2%) 2286 (21.4%) 10 (28.9%) 313639 (28.7%) 51 (37.5%)

15. Renal Survival 51/285 required in-patient renal replacement therapy (RRT) – 17.9% 10 required on-going RRT post discharge

16. Renal Follow-up From last (UHB) renal function on PICS Alive and eGFR <30 – 62 / 285 (21.8%) – Of these 62, 38 (61.3%) under renal follow up 24 (38.7%) not under follow up – 1 self discharge, 1 decreased mobility, 2 DNA

17. Summary Electronic referrals good way to capture data Typically over 14 referrals a week AKI associated with increased length of stay – Similar AKI 1-3 Significant mortality (in hospital and beyond) Not all patients being adequately followed up

18. Recommendations Increase awareness of increased LOS, mortality associated with all stages of AKI – Ensure prompt referral Appropriate individuals need to be followed up in renal clinics – Documentation of follow-up in notes – Ensure no loss to renal follow up

19. Acknowledgements Dr Rachel Plant Dr Peter Hewins