1. Retrospective Audit of Delayed Diagnosis of Hydronephrosis in Acute Kidney Injury John Dreisbach Radiology ST3 West of Scotland Deanery Acknowledgements: Srikanth Puttagunta Grant Baxter Colin Geddes

2. Background Acute Kidney Injury (AKI) –Definition Rapid deterioration of renal function –Common in hospitalised patients Prevalence ~5% –Multitude of causes Pre-renal, renal, post-renal (multiple often present) –Poor outcomes Independent risk factor for increased mortality

3. Background Acute Kidney Injury (AKI) –Definition Rapid deterioration of renal function –Common in hospitalised patients Prevalence ~5% –Multitude of causes Pre-renal, renal, post-renal (multiple often present) –Poor outcomes Independent risk factor for increased mortality –POTENTIALLY REVERSIBLE

4. Background Obstructive Nephropathy and Hydronephrosis –Cause of AKI in 1-10% –Ultrasound – first line investigation in AKI to diagnose or exclude hydronephrosis (RCR, Renal Association and NICE guidelines)

5. Background Obstructive Nephropathy and Hydronephrosis –Cause of AKI in 1-10% –Ultrasound – first line investigation in AKI to diagnose or exclude hydronephrosis (RCR, Renal Association and NICE guidelines) –REQUIRES PROMPT DIAGNOSIS Protracted obstruction risks irreversible renal damage Readily treatable

6. Background NCEPOD –“Adding Insult to Injury” 2009 Investigated hundreds of cases of death caused by AKI Discovered failings A – Z in clinical care of AKI

7. Background NCEPOD –“Adding Insult to Injury” 2009 Investigated hundreds of cases of death caused by AKI Discovered failings A – Z in clinical care of AKI Including: ‘omission or delay of ultrasound, where clinically indicated, was a likely contributory factor to patient death in multiple cases’

8. Background Aims –Retrospectively audit delays in diagnosis of hydronephrosis in patients with AKI at a local centre

9. Background Aims –Retrospectively audit delays in diagnosis of hydronephrosis in patients with AKI at a local centre –To the author’s knowledge, it is the first audit of its kind Other projects have only audited delayed ultrasound in UNSELECTED cases of AKI (the majority of which did NOT have hydronephrosis)

10. Standard, Indicator and Target Standard –Renal Association (UK) Guidelines (Acute Kidney Injury, 2011): ‘All patients presenting with AKI should have a renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’.

11. Standard, Indicator and Target Standard –Renal Association (UK) Guidelines (Acute Kidney Injury, 2011): ‘All patients presenting with AKI should have a renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’. Indicator –Time interval between first creatinine diagnostic of AKI and verification of ultrasound report diagnosing hydronephrosis.

12. Standard, Indicator and Target Standard –Renal Association (UK) Guidelines (Acute Kidney Injury, 2011): ‘All patients presenting with AKI should have a renal tract ultrasound within 24 hours (if renal tract obstruction is suspected)’. Indicator –Time interval between first creatinine diagnostic of AKI and verification of ultrasound report diagnosing hydronephrosis. Target ≥90% in ≤24 hours

13. Methodology Case Collection –Retrospective –Single centre (Western Infirmary, Glasgow) –24 month period (1 st of April 2011 to 31 st of March 2013) –Consecutive cases of hydronephrosis identified by examination of reports of all ultrasounds performed covering the kidneys –Inclusion of cases with concurrent AKI (Diagnosed biochemically (creatinine) as per KDIGO criteria)

14. Methodology Multitude of Ancillary Data Collected: –Demographics Age Sex –AKI severity Admission Deteriorations –Pre-existing CKD –Specialty Admitting Requesting ultrasound –Ultrasound request cards Clinical information –Key dates and times Ultrasound ‘event creation’ (approximates to request time) Ultrasound scan Ultrasound report Verification of ultrasound report –Cause of renal obstruction

15. Results Total ultrasound reports examined: 6,491

16. Results Total ultrasound reports examined: 6,491 Number of cases reporting hydronephrosis: 162

17. Results Total ultrasound reports examined: 6,491 Number of cases reporting hydronephrosis: 162 Number of cases of hydronephrosis with concurrent AKI and meeting inclusion criteria: 50

18. Results Key Audit Measure

19. Results Delayed ultrasound in 24 patients –33% (n = 8/24) progressed in AKI severity before ultrasound –(c.f. only 1/26 of the non-delayed patients)

20. Results x-axis = each patient; y-axis = time interval

21. Results x-axis = each patient; y-axis = time interval

22. Results Adequacy of Request Card Information Only 38% of requests provided key information Adequacy of Request Card Information Item(s) of Information on Request CardPercentageNumber Card BOTH described AKI and queried hydronephrosis38%19 Card did NOT BOTH describe AKI and query hydronephrosis62%31

23. Results Delays after Request and Adequacy of Request Card Information Chances of delayed ultrasound after request nearly 6 x higher (29% vs 5%) if inadequate clinical information on request card. Delays by Request Card Information Adequacy Delayed NOT Delayed Item(s) of Information on Request Card PercentageNumberPercentageNumber Card BOTH described AKI and queried hydronephrosis 5%195%18 Card did NOT BOTH describe AKI and query hydronephrosis 29%971%22

24. Discussion/Conclusions First audit data of its kind – unique insight into the actual scale of the problems highlighted by NCEPOD

25. Discussion/Conclusions Audit identified poor local performance in promptly managing a time-critical condition Suggestion of potential harm caused by delays The most time-consuming interval was between AKI diagnosis and clinicians requesting ultrasound Delays between ultrasound request and scan strongly associated with inadequate clinical information provided to radiologists.

26. Interventions Achieved –Dissemination of results to local radiologists, renal physicians and urologists May 2013 ✔ –Presentation to local Radiology department May 2013 ✔ –Presentation at local hospital meeting November 2013 ✔ –Presentation at trust-wide Renal Consultant’s meeting February 2014 ✔ –Multispecialty medical student teaching (Renal, Urology and Radiology) Winter 2013/2014 ✔ Included in routine teaching by Renal physicians ✔

27. Interventions Planned –Multispecialty junior doctor teaching (Renal, Urology and Radiology) Summer 2015 to coincide with new foundation doctors ✔ –Complete Audit Cycle with 2 more years of data Summer 2015 ✔

28. References 1. Waikar SS et al. The incidence and prognostic significance of acute kidney injury. Curr Opin Nephrol Hypertens. May 2007. 16(3):227-36. 2. Adding Insult to Injury. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure). A report by the National Confidential Enquiry into Patient Outcome and Death (2009). 3. Lewington A et al. Clinical Practice Guideline: Acute Kidney Injury. 2011. Renal Association. 4. iRefer: Referral Guideline U02: Renal failure. Royal College of Radiologists (RCR). Reviewed by author May 2015. 5. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Volume 2. Issue 1. March 2012. 6. Adam L et al. Renal Ultrasonography in the Evaluation of Acute Kidney Injury. Developing a Risk Stratification Framework. Arch Intern Med.2010;170(21):1900-1907. 7. Post TW et al. Diagnostic approach to the patient with acute or chronic kidney disease. Uptodate website. 2009. http://www.uptodate.com/online/content/topic.do?topicKey=renldis/19906&selectedTitle=2~150 &source=search_result. Reviewed by author May 2013. http://www.uptodate.com/online/content/topic.do?topicKey=renldis/19906&selectedTitle=2~150 &source=search_result 8. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. (Clinical guideline 169.) 2013.

29. Questions