Acute Kidney Injury toolkit

Embedding key elements of post-AKI care planning into routine practice

Why: Arranging timely review for all patients who have experienced AKI is recommended in international consensus guidance, and embedding this into routine practice can help ensure that all patients receive the individualised care that they need.

When: Determine the urgency of post-AKI care review. All patients warrant planned follow-up post-AKI, as many will remain at increased risk of poor health outcomes. It may be possible to redirect workflow to assist in timely delivery of this aspiration. To determine the urgency of review acknowledging the burden of general practice workload, consider:

1. Patient factors that should expedite review:

• Frailty or multi-morbidity. Kidney related care may be less urgent than other issues in such circumstances, for example anticipatory care planning may be prioritised when AKI episodes herald that frail, multi-morbid patients are failing.
• Pre-existing vascular disease or risk (CKD, diabetes, hypertension, heart failure)
• Polypharmacy
• Cognitive impairment
• Dependence upon a formal or informal carer
• Complex social needs

• Severe AKI (Stage 3 > Stage 2 > Stage 1)
• Renal function remains worse than patient’s pre-AKI baseline
• Significant illness caused AKI
• Patient required admission to critical care during admission complicated by AKI

How

1. Establish a practice protocol for post-AKI care.
2. Establish a proactive plan to support management of future episodes of acute illness
3. Consider utilising generic resources to support patient and carer involvement in care planning, to help embed post-AKI care planning into routine practice
4. Enrich Summary Care Records to support information exchange

A practice protocol may support care planning, including promotion of proactive holistic management and advanced care planning, in this high risk patient population.

• Does the patient have an existing care plan?
• If yes, does this need reviewing in light of recent episode of illness?
• If no, will the patient benefit from a care plan?

Members of the practice team to consider when embedding a protocol for identifying, coding, monitoring and managing this patient population include:

• GP lead
• Administration lead
• Practice pharmacist
• Community matron
• IT support - to help embed elements of AKI care into existing care plan documentation

Example of practice protocol developed by a practice based in Bury CCG:

Proactive follow-up for this high-risk patient population provides an opportunity to ensure involvement of patients and carers in decision making. Person-centred care planning includes supporting people to co-create individualised plans, visible to patients, carers and all sectors of healthcare. This will support better co-ordinated, safer healthcare and includes a need for:

• Shared understanding of the relevance of kidney health and AKI risk, in the context of chronic disease monitoring and medicines optimisation

• Plans for escalation of treatment in the event of acute illness

• Plans for modification of medication in the event of an acute illness

These priorities will vary according to individual need, incorporating: pre-existing co-morbidities; characteristics of the AKI associated illness; and the degree of kidney recovery

• Patient Capacity Assessment - This instrument aims to shift 'the focus from the medical condition of the person to their situation in life, identifies what the person values doing and being, explores how healthcare and other resources serve or limit this person, and recognises and cultivates opportunities to advance the person and their situation.'
• Social Prescribing – Taking into account individual’s health and social needs, consider the potential benefits of referring people to local, non-clinical services in the community
• Person Centred Care - RCGP resources to support the delivery of person-centred care
• NHS England toolkit for general practice supporting older people living with frailty
• Updated guidance on supporting routine frailty identification and frailty care through the GP Contract 2017/2018
• The House of Care – a framework for managing of long-term conditions
• Anticipatory Care Planning Toolkit
• RCGP Bright Idea - practice based development of questions to support anticipatory care planning

This section includes information on summary care records for each of the devolved nations:

Key Information Summary – Scotland

Best Practice Statement for Key Information summary (KIS) from the Scottish Government

Electronic Care Record - Northern Ireland

NI direct - resources to support understanding and use of Northern Ireland Electronic Care Record

Enriched Summary Care Records - England and Wales

• NHS Digital resources to support understanding and use of the Enriched Summary Care record in England and Wales
• Your Health and Care Records - NHS Choices resource to support understanding about health and care records