The second in our iSpyAKI blogs:
Working in Critical Care it is quite easy to get a skewed view on what AKI complications occur throughout the hospital, based on the type of patients that grace the critical care unit. Often, many that require Critical Care are admitted because of an AKI complication directly, requiring close monitoring and / or dialysis. It is safe to say, that often in the past, it felt that AKI complications such as hyperkalaemia and fluid overload were extremely common and because almost every critically ill patient seemed to have an associated AKI, that the ICU was managing a large proportion of the AKI patients in the hospital! How wrong was I?
From our monthly AKI audit, AKI complications (e.g. hyperkalaemia, acidosis, uraemia, acute pulmonary oedema) occurred on average 8% of the time, with hyperkalaemia being the most frequent complication (60% of these cases). Surprisingly, only 12% of patients required critical care involvement, with continuous renal replacement therapy / dialysis being used in only 5%. Most AKI in the hospital is diagnosed and managed on medical wards without any critical care involvement. The majority of AKI patients on the ward have no complications and are managed very well.
However, being in critical care, we often see the end result of patients whose AKI is severe and / or not responding to ward based management and who are deteriorating despite best efforts. Unfortunately, we also see a minority of patients in this group, where the AKI is now severe, but has been missed-not recognised, where the patient has been let down and badly managed either through a lack of recognition, lack of timely escalation and intervention or both. It is these cases that are extremely frustrating as the AKI on review, is often deemed preventable. I appreciate it is easy to sit in the ‘ivory tower’ of the ICU and criticise ward management, which may be unfair where wards are overstretched and under-resourced. However, accepting that these factors will contribute to some poorly managed AKI cases, the excuses often given for the rest, of why a patient has ended up in the state that they are in, is often inexcusable and appears on face value, to be failure of basic care and possibly common sense.
All Staff (doctors, nurses, allied health professionals, non-registered nursing staff) need to appreciate the importance of why and what they are doing basic observations for, they also need to know who to tell, how to escalate if problems arise and what interventions to do. This sounds obvious, but is not always the case, despite bundles and guidance. Often preventable AKI cases are associated with recurring themes such as failure to ensure someone is drinking / eating adequately, blindly prescribing NSAIDS without a U&E baseline in high risk patients, undertaking a trial without catheter before a bank holiday weekend and forgetting to reassess! Such themes almost always involve a failure of communication. Hyperkalaemia management is another AKI emergency that is widely taught but often poorly managed in the heat of the moment.
Improving the simple things that we do, applying common sense, would potentially save many patients from harm. However, if simple things aren’t working, this needs to be investigated why! Are staff trained and competent in the roles that they are expected to do? What I mean is: can every nurse or non-registered nurse including high turnover staff such as agency, complete a fluid balance chart to an expected standard? Do junior doctors and consultants honestly look at the fluid balance charts daily and construct, adapt their fluid plan? Do medical staff actually use and fill out an AKI bundle when faced with an AKI patient? Focusing down on these simple things, which with second thought isn’t so simple when involving staff behaviours and traditional culture, may actually change behaviour and make a difference. For common sense to prevail, basic training has to be spot on and resources must be used to ensure that all staff are consistent in their approach, so that these preventable AKI cases may become a thing of the past!