The HSMR scoring system works by taking a hospital\u2019s crude\nmortality rate and adjusting it for a number of factors including population\nsize, age and poverty. From this it is\npossible to calculate two scores, the expected mortality rate for any given\nhospital and actual observed mortality rate. \nIt is the difference between expected and observed mortality that is\nimportant when considering HSMR. HSMR\nfor a given condition such as AKI, allows mortality rates between different\nhospitals and regions to be statistically compared and is used frequently as a\nmortality comparator between Trusts (see Dr Foster Intelligence). When comparing similar sized hospitals\n(regional peers) our AKI mortality is comparable and one of the better\nperformers, which is really reassuring that what we are doing as a Trust is\nhaving a positive impact on patient mortality. \nI believe that AKI e-alerting and the Trust response to AKI presence\nthrough the AKI bundle and staff intervention is key and has really made this\ndifference possible and something my Trust should be proud of! <\/p>\n\n\n\n
It is clear from this, that crude hospital AKI inpatient\nmortality is probably far too insensitive to be a useful improvement measure. It is influenced by too many patient and\nhospital factors! However, standardised\nHSMR is potentially a more robust measure of AKI mortality and may be something\nfor Trust\u2019s to look at more closely when trying to benchmark improvement. <\/p>\n\n\n\n
For other AKI outcomes, I believe that some refocus is\nneeded. For example, when looking at\nnon-elective inpatient mortality in my Trust. \nThis group of patients due to their emergency presentation are at least 4x\nat risk of AKI versus elective admissions, they are more likely to be medical\npatients with a large majority being over the age of 65years. Consistently 50-60% of these patients develop\nAKI in the community and present with it on hospital admission. They are an extremely heterogenous group with\nmany different causes of their AKI, with sepsis and hypovolaemia being most\noften to blame.<\/p>\n\n\n\n
So how do we refocus\nour outcome aims? <\/strong><\/p>\n\n\n\n Patients who develop AKI in the community (e.g.\nCommunity-Acquired AKI) before hospital admission are in my view a different\ncohort of patients to those who did not have AKI on admission but then developed\nit whilst in hospital (e.g. Hospital-Acquired AKI). Such groups could then be subdivided further\ninto non-elective and elective admissions. \nAll groups are important to tackle, but it is possible that those who\ndevelop AKI in hospital may have been more preventable than those who developed\nit in the community or potentially have more learning points to consider and\nintervene on. Who knows, this is just a\nhunch! It is important to investigate and consider whether this is indeed true,\nas it may involve different preventative strategies and approach for the community\nversus the hospital. One size does not\nalways fit all! Many Critical Care\nstudies in the past have failed when a strategy has been applied to the whole\ncritical care cohort rather than focusing down on specific subgroups of\npatients, where certain interventions are of benefit, making a true real\ndifference! If NCEPOD is to be believed, only 30% of all\nAKI cases in hospital were deemed preventable, with the vast majority of\npatients developing AKI due to severity of their disease process regardless of\nwhat preventative measures were employed. \nHowever, hospital AKI bundles may be more effective in those who have\nhospital-acquired rather than community-acquired AKI with such interventions\nimproving time taken for AKI resolution and peak severity. We may not be able to prevent AKI development\nin the majority, but our interventions could make a difference in bringing\nabout prompt resolution! Ultimately, it is\nhoped that such subgroup improvements could influence favourably overall\nmortality and length of stay. <\/p>\n\n\n\n There is still a lot of work to do in the face of increasing\nscrutiny from hospital management of AKI interventions and effectiveness versus\nthe cost of providing such resources. We\nconstantly need to justify why such initiatives are needed! AKI HSMR and focusing on AKI subgroup\noutcomes may indeed add to the growing evidence for AKI bundle use, providing\nmuch needed proof, that when employed with AKI e-alerts and other\ninterventions, AKI bundles do really make a difference to our patient\u2019s lives\nand hospital outcomes! <\/p>\n\n\n\n
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