The Festive Period for the Acute Medicine services in my area of the country (and indeed in others) has been frantic to levels that I cannot recall. More patients are being admitted to the acute medical beds and beyond, as the walls of the medical wards stretch to accommodate the beds within the surgical establishment. This so called boarding of patients is never satisfactory and indeed makes the whole system more inefficient and provides a poorer quality service.
For all those who believe that many patients are being admitted unnecessarily I should inform you of a small review that we have conducted; of the patients that have been admitted through the acute medical unit in which I work, approximately 35% have AKI as part of their overall diagnosis. Whether this is directly related to a dehydrating episode of diarrhoea and vomiting, related to sepsis, related to medication, or relates to the elderly patient who has become unable to maintain hydration, this is an increasing problem. We have to remember that the majority of patients presenting to hospital with AKI will not be seen by a nephrologist but we have to make sure that prompt and relevant treatment is given to avoid the need for nephrology intervention whenever possible.
Recognition of risk of developing AKI remains a very big issue. Studies have demonstrated the greatest risk factors and it is reassuring that many of these are recognised by the superb professionals with whom I work. Some medications that are usually very beneficial for patients can become less helpful as intercurrent illnesses supervene. Temporarily withholding the relevant medications, such as diuretics and ACE inhibitors, in the setting of AKI is now widespread practice. As the system gets increasingly stressed however such interventions may be missed and other inefficiencies also increase. The need to initiate, and respond to the results of, appropriate investigations is always emphasised in training and yet it is apparent that not all intravenous fluid prescriptions truly reflect the patients biochemical needs, or indeed that the fluid is always administered at the appropriate rate.
The UK wide introduction of e-alerts for AKI from Spring of this year will help with recognition of AKI. Action in response to such an alert is vital for patients and we have to make sure that no matter how hard pressed the system is, it is capable of providing quality patient centred care.
In the middle of the busiest time of year it is easy to forget some of the basics of care. Our job in the education workstream of the Think Kidneys programme is to ensure that all healthcare workers are well aware of the dangers of AKI and that prompt efficient measures become second nature and are taken to improve patient care, no matter how busy anyone actually is.
Mike Jones
Mike Jones is an acute physician working in University Hospital of North Durham. Having trained in Nephrology and worked as a consultant in that specialty, he was at the forefront of developing acute medicine as a new specialty.
Mike is chair of the SAC in acute medicine, and has been President of the Society for Acute Medicine. He is recently demitted Vice President of the Royal College of Physicians of Edinburgh. Mike remains active in education and training having developed the ACAT assessment tool and is responsible for the modified curricula for General Internal Medicine as well as Acute Medicine.
Mike is chair of the education workstream of the national AKI programme.