AKI mortality -the coding of these patients Countess of Chester Hospital NHS Foundation Trust

Team Details Dr Tim Webster, Consultant Physician Sarah Balogh, Clinical Information Analyst Michael Jones, Coding Team Leader Michael Spry, Clinical Improvement & Assurance Manager Mr Ian Harvey, Medical Director Email: michaelspry@nhs.net

What was your original project Aim and has this changed? AIM: To improve the accuracy of mortality data for AKI at the Countess. To remove the “it’s the data not us” argument from mortality conversations And fix the “FCE”

Driver Diagram

Measures and Data Identified as an outlier for renal failure deaths 46 deaths in 12 months

Reviewed from admission to death Checked against audit standards 46 case notes Reviewed from admission to death Checked against audit standards

Summary of results Standard Aim Compliance EWSs score 100% 78% Urine dip requested 58% MSSU requested 42% Fluid balance requested Nephrotoxics stopped 74% Anti-hypertensives stopped Catheter decision documented 36% Urgent Renal USS 31% Daily U&E requested 49% Senior review 87% Appropriate referral 69% AKI staged 0%

Time from U&E taken to patient seen This represnts 80%of patients being seen within 4hr of a sample being taken. 9999 represents those on which the time was not documented on the clerking.

Was AKI diagnosed on first documentation 82% of case not which had an abnormal U&E documented, were also concluded to have AKI on the first clerking.

Coding As previously discussed, this was a specific factor highlighted in the Keogh report. Ratios can be improved or worsened without any change in the number of lives saved. It is important to examine the data and consider whether it is a true reflection of the hospital performance. Firstly, we look at how many of these cases had AKI appear on the death certificate and where. For 29% of the cases, AKI was not listed anywhere on the death certificate. The next two highest scores were seen equally, for 1a and part 2.

Why is this? 1 = no AKI 9 = resolved to normal 6 = ‘end of life’ Represents 35% of the cases So why is this? We have already seen that there were a number of points that could be improved upon with regard to management…but 26% were not felt to contribute to the cause of death. Although 46 case notes were pulled: 1 did not have AKI9 resolved to normal limits 6 were patient with significant co-morbidites and were soon managed palliatively

In relation to death certificates? ‘End of life’: Resolved: And in relation to the death certifcates? For the end of life patients; one had AKI listed as part 1a, two were listed in part 2 and 3 were not present. For those which resolved, 8 did not have AKI on the death certificate, and one was listed under part 2 to have ‘CKD’.

Coding: conclusions Not appearing on death certificate 11 of 13 appropriately so 16 of 46 did not die from AKI So in coding conclusions: 11 out of the 13 that did not appear as AKI on the death certificate had either resolved/ the patient was palliated for other reasons. 16 of the 46 cases did not did as a result of their AKI; one of which had no renal impairment.

The FCE….. A Finished Consultant Episode is the time a patient spends in the continuous care of one consultant using hospital site or care home bed(s) of one health care provider or, in the case of shared care, in the care of two or more consultants. Where care is provided by two or more consultants within the same episode, one consultant will take overriding responsibility for the patient and only one consultant episode is recorded.

What we’ve tried Casenote review of all TW patients coded with AKI in 3 months = 0 Casenote review of all AKI deaths coded over 3 months. Only 3 cases identified. All appropriate.

Endless meetings to try and alter the way FCEs are identified through meditech- unable to unpick this problem Pilot of block coding all FCEs together on MAU to ensure no part of MAU spell is missed - no change in outcome achieved as FCE2 still remains on MAU.

Need FCE 2 on base ward following MAU stay to achieve accurate coding – how this can be achieved remains an issue

Other Related Work Clinical improvements in AKI ongoing through separate AQ/CQUIN working party Live coding pilot within stroke department is showing significant benefits - ?could translate into other areas

Key Achievements & Lessons Learnt Proud of persevering with ‘dry’ topic, complex – better understanding of coding issues and improved communication with coding department Live coding on one COE ward as a pilot – daily coding to go through casenotes to ensure agree with coding and have a co-morbidity checklist. Re-enforced use of diagnosis at PTWR, and coders now attending specialty meetings to re-enforce coding. What would you do differently – unpicking of clinical and administrative complexity of mortality – difficult to focus on both IT issues have been very frustrating – creating our own process constraints effecting our performance Live coding due to roll out – reduced FCEs, improved coding – clearer indication of focus Team regularly meeting to keep momentum More focused brief – avoid duplication of clinical aspects e.g. multiple projects looking at AKI

What should AQuA do differently Collaborative working could have been very useful Timescale seems to have lost some momentum Initial focus on choosing a project could have been helpful – some difference of opinion between team and AQuA around the value of ‘coding/FCEs’ as a project- this could have been raised earlier