Renal teams supporting AKI in the critically ill patient

Review of London kidney teams’ response to COVID-19, March-June 2020

Summary of key themes

  1. Training of ITU teams – develop shared resources and experience across London in the training and education of renal and intensive care teams to support renal replacement therapy for critically ill patients.
  2. Consider having a named renal consultant present in ITU for peak surge periods to improve communications and support teamwork and shared learning.
  3. Continue to share the diverse approaches across London to help meet the needs of patients with specific RRT requirements (such as PD where coagulopathy renders vascular access very difficult).
  4. We achieved good outcomes in some kidney patients using innovative solutions.  How do we evaluate these for use in the future?
  5. Intermittent haemodialysis was an option for ongoing HD care in place of CRRT.
  6. Kidney teams can collaborate with critical care teams to minimise risk of acute kidney injury and avoid starting renal replacement therapy sooner than is necessary or beneficial.

Next steps

  • Use the London Networks to develop a pan-London ITU/Renal nurse group to support a sustainable training model to maintain skills. Potential to involve industry in the delivery of this.
  • Share learning between ITU and renal networks and ensure closer collaboration and joint planning for second surges
  • Collate outcome (PD, CRRT, IHD in AKI) and histopathology data, and share analysis and findings to inform future planning

Summary of discussions

What worked well?

  • Collaboration between Nephrologists and Intensivists was vital to meet the unpredicted demand for RRT on ICU
  • Different units found different solutions (e.g. IHD, APD, making fluids for CVVHD) all of which had merit and drawbacks
  • The practical expertise of the technicians was vital in planning and delivering and expanding RRT at pace in ICU. The use of portable RO units was an essential part of this
  • Sector level critical care and renal collaborations were vital for active movement of patients and provision of care
  • Pan London collection of data and sharing of wider information was also essential, not least to allow the movement of patients between sectors when needed
  • Local efforts by renal teams to establish alternatives to filtration within their own trusts were essential
  • Accelerated training nursing plans in working with ITU colleagues enabled teams to deliver IHD
  • ITU teams found that having a named renal consultant shared learning and improved communication and teamwork
  • There was fantastic work from Renal technicians to get necessary work done to facilitate RRT expansion

Key challenges

  • Working at such a pace for a sustained period was challenging
  • There were different levels of network functioning and functional groups depending on purpose: clarity on each of these roles only emerged after some weeks and with some avoidable duplication of effort
  • Managing the practicalities of installing water, rapidly expanding PD, sustaining workforce, and providing training
  • Burden on staff, especially dialysis nurses, to provide renal support in ITU whilst also maintaining staffing for ICHD units

What could we do better?

  • Improve decision-making and communication with patients and families regarding treatment escalation plans
  • Capitalise on the opportunity to continue the improved management of AKI through structured and ongoing closer collaboration between renal and ITU teams
  • Clearer transfer protocols covering escalation of patients in non-renal centres