Treat the Patient, Not the Test Result: A ‘Handy Guide’ for GPs responding to AKI Warning Stage Test Results

My brain hurt like a warehouse, it had no room to spare

I had to cram so many things to store everything in there

‘Five Years’ by David Bowie

Tom Blakeman & Charlie Tomson on behalf of the Responding to e-alerts in Primary Care Working Group

Does your brain hurt a lot?’ Are you interested in tackling harm associated with Acute Kidney Injury but also bothered about information overload and over diagnosis? If so, and if you have room to spare, then read more and join the debate – we’ve got five years!

Preventing avoidable deaths related to Acute Kidney Injury (AKI) is a global priority. [1] In England, the NHS Five Year Forward plan emphasises tackling AKI as a means to improving patient safety and health outcomes across the NHS.[2] The first major achievement of the Think Kidneys AKI Programme has been to get national agreement on a computerised algorithm that uses changes in serum creatinine measurements to allow detection of patients who may have AKI. This algorithm automatically identifies potential cases of AKI from laboratory data in real time and produces a test result (i.e. AKI stage 1, 2 or 3). The test result is named an ‘AKI Warning Stage’.

This major patient safety directive came into effect within all NHS Acute Trusts and Foundation Trusts in March, 2015. The next phase of AKI alerting involves direct communication of AKI Warning Stage Test Results to primary care. This reflects evidence that approximately 1 in 5 unplanned hospital admissions are associated with AKI, with almost two thirds of patients having developed it in the community.[3, 4]

AKI is a marker of the ‘sick patient.’ As such, the introduction of AKI Warning Stage Test Results offers the potential to support earlier detection and prompt management. However, this needs to be balanced against the potential for information burden for GPs and treatment burden for patients.[5]

Developing guidance on how AKI warning stage test results should be communicated to GPs, and how GPs should respond to them, is not straightforward. Unlike the hospital setting, blood tests in primary care are done much more selectively, but for a range of clinical indications. Baseline measurements may be fewer and less recent. Delays in getting samples from the patient to the lab mean that there is a higher risk of spurious hyperkalaemia, and a higher risk that the report will be available out of hours, requiring an out of hours doctor who doesn’t know the patient and has variable access to clinical information to act on the result. Phoning test results takes time and it can be difficult for the lab to ensure that information reaches the right individual and is acted on appropriately. Once the test result is communicated, the primary care team need to decide how quickly (if at all) to act on the test results, and what action to take.

Through Think Kidneys, we are developing a ‘Handy Guide’ for GPs and clinicians in primary care to help ensure that AKI Warning Stage Results are considered in a clinical context. That is, AKI is a clinical syndrome and it’s important to treat the patient, not the test result. As a starting point, we have used RAND methodology to achieve consensus, where possible, on the appropriate timing and method of communicating test results from the laboratory, and on the appropriate timing of a GP response to an alert.[6]

On 22^nd September, a group of ten clinicians spent 6 hours in a hotel meeting room in Leeds working through 652 lines on an Excel spreadsheet. The ten clinicians were: two clinical biochemists, one involved with Think Kidneys and one independent; two acute physicians with an interest in AKI; and six GPs. Of the GPs, two were involved with the Think Kidneys programme; three were involved in the RCGP over-diagnosis group,[7] representing urban, suburban and rural practice; and one was an inner-city GP with a major commitment to out of hours work. The process was chaired by Professor Stephen Campbell, who is an expert in using the RAND methodology to achieve professional clinical consensus.

Members of the Think Kidneys Primary Care Working Group developed a range of scenarios in order to help identify steps to be taken by both the Clinical Pathology Service and Primary Care in response to AKI Warning Stage results. The scenarios were written with a level of precision that reflected day-to-day clinical care. It was not possible to test all possible scenarios that might exist in every day practice. However, key variables to consider when responding to AKI Warning Stage Test Results, which we tested through the RAND process included:

What is the stage of AKI?
Is there a history of acute illness?
Does the patient have existing significant co-morbidities and risk factors?
AKI Warning Stage Test Results in the context of Chronic Health Failure
AKI Warning Stage Test Results in the context of Chronic Kidney Disease
Has there been a recent increase in dose of diuretics, ACE Inhibitors, Angiotensin Receptor Blockers or Aldosterone Antagonists?
Is Intrinsic Renal Disease suspected?
Is urinary tract obstruction suspected?
Are there any complicating factors?
Hyperkalaemia
Is there evidence of poor oral intake/urine output

We will know within a few weeks how much consensus we have achieved. We intend that the outputs from the clinical biochemistry section will influence national policy on communication of abnormal test results (e.g. which results should be phoned through). The outputs from the clinical scenarios will be used, along with other sources of information, to develop a ‘Handy Guide’ for primary care. In order to ensure that the guidance document fits with every day clinical practice, we plan to present and seek feedback from Clinical Commissioning Groups and Patient Safety Collaboratives. We then intend to publish the guide on the Think Kidneys Website and welcome comment – watch this space…

To sum up, does your brain still hurt? Have you still got room to spare? If so, we welcome your input to minimise information burden and maximise the potential for AKI Warning Stage Test Results to support safe and effective care. We’ve got five years…!

References

Mehta RL, Cerdá J, Burdmann EA, Tonelli M, García-García G, Jha V, Susantitaphong P, Rocco M, Vanholder R, Sever MS et al: International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. The Lancet, 385(9987):2616-2643.
England N: The Forward View into Action: Planning for 2015/16. In.: NHS England Publications; 2014.
Wang HE, Muntner P, Chertow GM, Warnock DG: Acute Kidney Injury and Mortality in Hospitalized Patients. American Journal of Nephrology 2012, 35(4):349-355.
Selby NM, Kolhe NV, McIntyre CW, Monaghan J, Lawson N, Elliott D, Packington R, Fluck RJ: Defining the Cause of Death in Hospitalised Patients with Acute Kidney Injury. PLoS ONE 2012, 7(11):e48580.
May C, Montori VM, Mair FS: We need minimally disruptive medicine. BMJ 2009, 339:b2803.
Fitch K BS, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonnell J, Vader JP, Kahan JP: The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica: RAND; 2001.
McCartney M, Treadwell J: The RCGP’s new standing group on overdiagnosis. BMJ 2014, 349.

Written by: Tom Blakeman

Tom is a GP and Clinical Senior Lecturer in Primary Care, as well as Lead for Kidney Health Programme, NIHR CLAHRC for Greater Manchester. He is interested in implementation research, with a focus on developing evidence-based interventions grounded in an understanding of routine clinical practice. Between...
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Written by: Charlie Tomson

Charlie is a consultant kidney specialist at Freeman Hospital, Newcastle on Tyne and was Chair of the Intervention workstream for the acute kidney injury national programme. Charlie trained at Cambridge, Oxford, Bath, Nottingham, Newcastle on Tyne, and Leicester, and held Consultant posts in London and Bristol...
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