Involving care homes in Think Kidneys

Involving Care Homes in Think Kidneys

8 July 2015, Birmingham

Welcome

Programme for the day10:00 Welcome, housekeeping and plan for the day

10:10 Understanding the care home environment and setting the scene for change

10:40 The only way is Essex!

11:00 Think Kidneys National Programme – about acute kidney injury

11:30 Qs & As

11:55 Coffee break

12:05 How working with care homes could change the status quo – risk, prevention & care

12:15 Group work 1 – Learning about the care home environment – challenges and influences

13:00 Lunch

13:45 Getting it right for Nellie

14:15 Group work 2 – Resources, engagement and what’s needed

15:00 Qs & As and comments

15:15 Summary of the day and an action plan

Understanding the care home environment and setting the scene for change

Prof Julienne Meyer CBE

Promoting Quality of Life in Care Homes

My Home Life

www.myhomelife.org.uk

Professor Julienne Meyer CBE


So...what do we think about care

homes?

•Scandals?

•Poor quality?

•Money-grabbing?

•Undesirable?

•Less relevant?

•In decline?


Older people in care homes • 17, 678 care homes in UK

• 78% privately owned

• 405,000 older people (>65yr)

• Average age 85 years

• 80% cognitive impairment

• 40% depression

• 75% severely disabled

• Going into care later, sicker and more frail

• Median period (admission to death) is 15

months

Age UK (2015)


Workforce• ½ million employed in care

homes

• Care-assistants less than

living wage

• Lack of funding for training

• Paid less than those looking

after our rubbish

• 66% NVQ2 (4 or 5 GCSEs)

• 39% feel unappreciated by

public


“Islands of the old”

• Unsupported, isolated, mistrusted

• Feeding the system rather than

feeding residents!

• High levels of personal stress


Understand context, Value & respect• >3x number of care home beds, compared with NHS beds

• Caring for some of the most vulnerable citizens in society

• Making a significant contribution to care of frail older

people in our society. Projected to increase, not decrease.

• Care homes not paid the fair rate for care by LAs and

most care home staff on minimum wage (undervalued)

• <25% registered for nursing (mainly social care workforce)

• Residents going in later with more health problems

• Workforce needs healthcare training and/or better access

to health expertise


Common conditions(BUPA/CPA 2011)

• Neuro condition or mental disorder (75%)

– Dementia (44%),

– Stroke (20%),

– Depression (20%),

– Epilepsy (6%)

– Parkinson’s disease (5%)

• Heart disease (21%),

• Arthritis (18%),

• Diabetes (14%),

• Fractures (12%),

• Osteoporosis (9%),

• Lung or chest disease (8%)

• Cancer (7%).


Need for Formative Care

“For many residents, the optimum approach is that of end of life care, not conventional long-term

condition management.” BGS (2011)

• Dependent ‘dwindling’ older people not well served by the existing medical approaches.

• ‘Social watersheds’ may provide triggers for Formative Care

• Optimising of quality of life and experience (prime purpose)

• Target population (trajectory and social transitions)

• Little evidence at present (more research)

• Implementation of electronic care records and standardised assessment processes (helpful)

Bowman and Meyer, J (2014)


Examining Renal Patients’ Death Trajectories without Dialysis

• Trajectories for stage-5 CKD

– Predictable uraemic death

– Predictable death from other causes

– Unpredictable death

• Issues of concern

• Difficulties in managing the unknown

• Number of healthcare professionals involved

• Heavy symptom burden

• Lack of professional knowledge (hard for family)

• Pressures brought to bear on families caring

Noble et al (2010)


Quest for Quality• A health service suitable for the

specific needs of this population.

• The residents and their relatives

must be at the centre of decisions

about care.

• A multi-disciplinary approach.

• A partnership approach with care

homes and social care

professionals.


Explaining the barriers to and tensions in delivering effective

healthcare in UK care homes

• Older people are very complicated

• Trajectories are difficult to predict

• Don’t have the training

• Resources are tight

• Regulation is always present

• Roles and responsibilities aren’t clear

• Communication is a problem

Robbins et al (2013)


Provision of NHS generalist and specialist services to care homes in

England: review of surveys

• GP:Care Home ratio varies between 30:1 and 1:1

• Some GPs do weekly clinics, while others visited only on request

• Up to 8 different types of nurses provide in-reach services

• 25% of trusts report unequal access to physiotherapy and occupational

therapy

• 35% report unequal access to district nursing

Iliffe et al (2015)


Relationships, Expertise, Incentives, and Governance:

Supporting Care Home Residents’ Access to Health

Care: An Interview Study from England

Solutions have focused around:

– Remuneration – carrot

– Regulation – stick

– Parachuting in troops

– Generating social movements

Goodman et al (2015)


• Comprehensive assessment of new residents

• Recognise end of life & plan/support

• Structured 6 monthly multidimensional review (earlier if indicated)

• Including medication review

• Including risk assessments (e.g. falls, nutrition)

• Advance care plan for acute events/end of life

• Reliable systems to support telephone consultations and out of hours events

• Regular scheduled visits by GP/Specialist Nurse, Geriatrician to Review targeted residents

• Clarification of referral pathways and response times for specialist services

• Enhanced clinical interventions e.g. fluids, IVs, palliation

• Robust interagency, interdisciplinary governance


5 New Care Models

• Multispeciality community Providers

• Integrated primary and acute care

systems

• Urgent and emergency care

• Acute care collaboration

• Enhanced health in care homes

– NHS Wakefield CCG

– Newcastle Gateshead Alliance

– East and North Hertfordshire CCG

– Nottingham City CCG

– Sutton CCG

– Airedale NHS FT


MHL Mission

Promoting quality of

life for those living,

dying, visiting and

working in care

homes for older

people.


SupportAge UK, City University, Joseph Rowntree & Dementia UK

Other key organisations:

Relatives & Residents Association

National Care Forum

English Community Care Association

National Care Association

Registered Nursing Home Association

Care Forum Wales

Scottish Care

Independent Health & Care Providers

National Care Home R&D Forum


Phases of My Home Life

Phase One: Vision

(2005-7: HtA)

Phase 2: Dissemination

(2007-9: BUPA)

Phase 3: Implementation

(2009-13: JRF, DH, LA,

City Bridge etc)

Phase 4: Sustainability

(2013-19: Age UK, Henry Smith)


Began small, now social movement

Secret of success?

• Evidence-based

• Relationship-centred

• Appreciative

• Making a difference


New online tool

• Providers will also be able to

add flags to their individual

Provider Quality Profile (PQP) to

show they have adopted

recognised quality schemes

such as My Home Life, the new

NICE social care quality

standards and the Dementia

Care and Support Compact.

https://www.gov.uk/government/news/new-online-tool-to-search-and-

compare-local-care-providers


What we know residents, relatives and staff ‘want’ and

‘what works’ in LTCNeed shared evidence-

based and relationship-

centred vision that cuts

across:

– health & social care

– policy & practice

– regulation &

commissioning

– public & private

– NCHR&D (2007)


Relationship-centred Care

Security: to feel safe

Belonging: to feel part of things

Continuity: to experience links and

connections

Purpose: to have a goal(s) to aspire

to

Achievement: to make progress

towards these goals

Significance: to feel that you matter

as a person

Nolan et al (2006)

Positive relationships between residents,

relatives and staff and between care

homes and their local community and

wider health and social care system


MHL Leadership Support & Community

Development (LSCD) programme

Leadership and Support for care home managers to take forward quality improvement (4 day work shop, supported by action learning for one year)

Community Development for LAs/CCGs to work in better partnership with care homes (understand context, value & respect, resolve local issue)

Supportive network for care homes to share best practice and learn from each other (reduce ‘islands of the old’)


My Home Life:

Promoting quality of life in care homes

• Positive relationships (voice, choice

and control)

• Pivotal role of care home managers

(ongoing support)

• Consider our own attitudes, practices

and policies (reduce capacity to care)

• Stronger partnership working (agree a

vision & supportive ways of working)

• Negative press (impact on confidence)


Commissioning Relationship-Centred Care

• Essex CC has shifted its

commissioning approach from top-

down monitoring, inspection and

regulations to one that builds

relationships, invests in the

development of care home staff and

instils a shared vision for care and

support for older people

(www.myhomelifeessex.org.uk)


My Home Life Admiral Nurse

• Improved quality of care and well

being

• Increased staff knowledge, skills and

confidence

• Enhanced relationships between

residents, relatives and staff

• More with care home as option for

care


The future...•Vital part of care spectrum

•Demand increasing (40,000

beds needed in next ten years)

•Greater specialism

•Reducing pressure on NHS

•A sector that is emerging as

having the potential to deliver

quality for our frailest citizens in

community and in care homes


References• Age UK (2015) Later Life in the United Kingdom. London: Age UK

• BGS (2011) Quest for Quality British Geriatrics Society. British Geriatrics Society Joint Working Party Inquiry into the Quality of

Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement. BGS: London

• BUPA/CPA (2011) The Changing Role of Care Homes. Centre for Policy on Ageing: London.

• Noble H, Meyer J, Bridges J, Kelly D, Johnson B (2010) Examining renal patients' death trajectories without dialysis, End of Life Care,

4(2)26-34,

• Goodman C, Davies S L , Gordon A L , Meyer J, Dening T, Gladman JRF, Iliffe S, Zubair M, Bowman C, Victor C, Martin F C (2015)

Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents' Access to Health Care. An Interview Study

From England. Journal of the American Medical Directors Association 02/2015; DOI:10.1016/j.jamda.2015.01.072 ·

• Goodman, C; Davies, L; Gordon A L; Meyer, J; Dening, T; Gladman, JRF; Iliffe, S; Zubair, Bowman, C; Victor, C; Martin FC

(accepted) Supporting care home residents’ access to health care what works when in what circumstances: An interview study from

England JAMDA


Contact DetailsProfessor Julienne Meyer

My Home Life

City University London

Adult Years Division

School of Health Sciences

Northampton SquareEC1V 0HB, London, UK

Tel: +44 (0)20 7040 5776

Email: [email protected]

www.myhomelife.org.uk

www.city.ac.uk/dignityincare

www.city.ac.uk/bpop

The only way is Essex!

Kieran Attreed-James & Lesley Cruickshank

PROSPERPromoting Safer Provision of care for Elderly

Residents

Prosper

Promoting Safer Provision of Care for Elderly Residents

36

• Funded by The Health Foundation - Closing the Gap in Patient Safety

• First time a Social Care scheme has been chosen

• Essex County Council & UCLPartners working in partnership with Essex

Residential Care & Nursing homes

• Overarching aim to reduce the number of emergency hospital admissions

• Focus on Prevention - reducing the prevalence of falls, pressure ulcers

and Urinary Tract infections across care homes.

• 38 homes involved, with another 25 homes starting June 2015

Prosper Methodology

37

• Building staff capability through education in quality improvement methodologies – PDSA cycles (plan do study act) of small tests of change for continuous improvement

• Using data measurement over time to inform improvement cycles –moving homes away from feeling that data is only used for negative reasons

• Changing staff culture & behaviour on safety from being reactive to proactive & preventative

38

Outcome/Aim Primary Driver Secondary Driver

To achieve a 50%

reduction of UTI’s by

December 2015

Risk Identification

Risk Assessment

Reliable implementation of

Infection Prevention & Control procedures

Nutrition & Hydration

Education/Training

Understand UTI risk factors

Understand resident history, medical condition, cognitive impairment, invasive devices.

Utilise Safety Handovers/Safety Huddles

Assess UTI risk on admission

Reassess regularly / when a change in condition

Communicate risk status to resident, staff and families

Incident Reporting / RCA

Reinforce the use of Infection prevention and control procedures

Reinforce hand washing techniques

Reinforce use of PPE

Introduce Nutrition and Hydration tool’s

Utilise DN’s, dietician and specialist nurse experience

Introduce visual cues to raise Staff awareness

Increase nutritional intake – shakes/grazing station

Staff education & training – IP&C, GULP tool

Resident & family/carer education

Utilise ‘How to guides’

Review and monitoring

Management of catheter & continence procedures

Infection control Champion

Audit checks ,monitoring of competency

39

40

Check for Urine Infection

If concerned call

the Community

Matron:

Check urine colour

Good

Good

Dark

Dark

If urine is dark –

give extra fluids.

Check for bowels

open

Are any of these symptoms

present?

Urgent need to pass

urine/ incontinent

when not usually

Confused

more than usual

when not usually

Feeling feverish and

unwell

Low tummy or

suprapubic pain

Prolonged contact with urine

can encourage urine infection.

Therefore, it is important to

ensure that Incontinence Pads

are changed in a timely way

Clients with urinary

catheters are likely to

have bacteria in their

urine – encourage fluids

If symptoms present

Safety Cross

41

Implementation

42

• Good Slipper guides at pre-assessment

• On spot debriefs• SBAR

• Prosper Champions

• Safety Cross

• Falls checklists

• Medication Reviews

43

• Engaging whole team

• 10 min power training

• Mirrors

44

• Focus on Hydration

• Jelly

• Doily’s

Results – One Year On

45

• Interim evaluation has reported a change in staff culture across all 38 homes participating to date.

• Improved data recording, capturing information previously not recorded – Falls, UTI’s, pressure ulcers, hospital admissions

• Homes are using data to inform proactive approaches to prevention

• No statistical significant change at this stage –challenges in collecting historical data

By Products

46

• Integrated working between Health, Social Care and Care Homes

• Training

• Linking projects

• Community of Practice/Network meetings

• Consistent approach across CCG boundaries

• Influencing future commissioning

Prosper

47

Contact details;

Lesley Cruickshank

Prosper Project lead

[email protected]

07557 081571

Kieran Attreed-James

[email protected]

07557168059

mailto:[email protected]

mailto:[email protected]

Acute Kidney Injury (AKI)

Keeping kidneys healthy:

The AKI programme boardDr Richard Fluck

[email protected]

National Clinical Director (Renal) NHS England

What do they do?Public understanding of the kidneys

IPSOS Mori poll 2014 general population

51% knew kidneys make urine

8% thought the kidneys pumped blood

12% were aware of role on medicines processing

– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al

The challenge

Risks to the kidney

68% alcohol53% dehydration22% medications1% smoking

– Poster SP196 DO PEOPLE ‘THINK KIDNEYS’? A STUDY OF KNOWLEDGE LEVELS IN THE GENERAL POPULATION Selby et al

21.01.2015The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 50


What is acute kidney injury?

Acute kidney injury (AKI) is a

rapid deterioration of renal

function, resulting in inability

to maintain fluid, electrolyte

and acid-base balance. It

normally occurs in the

context of other serious

illness (e.g. sepsis) on a

background of risk.


Why is it important?Associated with other serious illness

“Force multiplier” for poor outcomes

Potential to improve care

Reduce avoidable harm -death and morbidity

Reduce cost

Important marker of illness

1911-1986

AKI Harmful? Who is most at risk?



‘40000 excess deaths pa’ (Kerr et al April 2014)

‘Think Kidneys’ objectives

Develop and implement tools and interventions for prevention, detection, treatment and enhanced recovery

Promote effective management of AKI

Provide evidence-based education and training programmes

Highlight importance of AKI to commissioners, health care professionals and managers

The NHS campaign to improve the care of people at risk of or with, acute kidney injury | 57

‘Think Kidneys’ AKI Programme

The NHS campaign to improve the care of people at risk of or with, acute kidney injury| 58

Strategy

Who is at risk?

When do people sustain AKI?

How should patients with AKI be managed?

What do people need to know?


When• When do people sustain AKI?

• How is early diagnosis supported?

• 60% of AKI arises in the community

• A trigger event e.g. infection, sickness, cardiac event

How

• How should AKI be managed? How does that look in primary and secondary care?

• Prevention

• Treatment

• Recovery

What

• What do people need to know?

• Education for the public

• Education for patients and carers

• Education for professionals

Risk

VulnerabilityA fixed set of characteristics – e.g. age, co-morbidities including

CKDs, drugs

TriggerAn event that might precipitate AKI, e.g. surgery, sepsis

ResponseMitigating the risk e.g. sick days rules, monitoring

28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 63

Sick day rules

Teaching

Large group

E-learning

Ward based

Educational Toolkit

Method by which NHS can rapidly alert the healthcare system to

patient safety risks, or to provide guidance on preventing harm

What are NHS patient safety alerts?

Level 3:

Directive: requires specific action(s) within timeframe

Level 2:

Specific resource and information sharing

Level 1:

Warning of emerging risk

| 67The NHS campaign to improve the care of people at risk of or with, acute kidney injury


Care bundles and response


Influencing the System: Levers

Safety collaboratives: AHSN/SCNSign up for safetyHealth Foundation

Forward view: into action 2015/16NHS England is proposing to introduce new national CQUIN indicators to tackle sepsis and acute kidney injury; and a new quality premium indicator to tackle resistance to antibiotics.

‘AKI warning stage’

Patient management

system

Alert Response

Local systems

Message

Master patient index

Other data systems

AKI Registry

RegionalNational Research

QI

Measurement

The pathway and commissioning levers

Risk assessment

• CQUIN in test in SDH

Improved diagnosis

• Safety alert NHS England

Treatment

• NICE guidance

• Care bundles

Recovery

• National CQUIN

Secondary care

Primary care

The ask for you

28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 72

2/3 of AKI starts in the community

How do we help you understand the vulnerability of your clients?

What education do you need?

What interventions can we support you with?

What are the practicalities

Summary

AKI is

Common

• 1 in 5 of all emergency admissions

• 2/3 starts in the community

It is costly

• It increases the risk of death and harm

• It costs resources

It is treatable

• Education• Early detection

• Better intervention

Karen ThomasThink Kidneys Programme ManagerUK Renal [email protected]

Teresa WallaceThink Kidneys Programme CoordinatorUK Renal [email protected]

The chairs and co-chairs of all the workstreams in ‘Think Kidneys’

Joan RussellHead of Patient SafetyNHS [email protected]

Ron CullenDirectorUK Renal [email protected]

www.linkedin.com/company/think-kidneys

www.twitter.com/ThinkKidneys

www.facebook.com/thinkkidneys

www.youtube.com/user/thinkkidneys

www.slideshare.net/ThinkKidneys

www.thinkkidneys.nhs.uk

Acknowledgements


Questions for the speakers

Working with Care Homes to Change the Status Quo

Mike JonesConsultant Acute Physician

Richard John Parfitt

Born 1948

Smoked 1966-2014

Excess alcohol (and other substances)

Three myocardial infarctions (quadruple bypass 1997, stent 2011 and 2014)

But still performing

Ageing population

432,000 in care homes

The largest number of practices visiting one care home was 30.

Some GPs did weekly clinics, while others visited only on request.

Up to eight different types of nurses providing in-reach services, with multiple different nurses often providing in-reach to the same home.

Risk, Prevention and Care

Drugs

Prescribing in care homes is a particular area of concern.

The Care Home Use of Medicines study:

256 residents across 55 homes

69.5% of residents to be subject to one or more error

mean of 1.9 errors per participant

Risk Factors

Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria

Age >75 years

Heart failure

Liver disease

Cardiovascular disease (previous MI, stroke, PVD)

Diabetes mellitus

Recent use of nephrotoxins, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers

Risk Factors

Chronic Kidney Disease - eGFR <60 ml/min/1.73 m2 and/or history of proteinuria

Age >75 years

Heart failure

Liver disease

Cardiovascular disease (previous MI, stroke, PVD)

Diabetes mellitus

Recent use of ‘nephrotoxins’, e.g. non-steroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, diuretics

Acute Risks

Hypotension

Sepsis

Dehydration

Diarrhoea

Decreased intake (acute illness, cognitive impairment)

High urinary output (Cf CKD, Diabetes)

Prevention

Identify patients at risk

Optimise volume status especially when losing excess (diarrhoea, heat etc)

Treat infection promptly

Avoid nephrotoxins if better alternatives

NSAIDs + ACEI bad combination

Review medications,e.g. adjust drug doses, withhold antihypertensives if hypotensive

Summary

Care home residents are a special case. They represent the most frail, most dependent, most vulnerable members of our society

Prevailing models of care and routine practice have been demonstrated to be inadequate to meet their needs.

How should we modify the system to diminish the risk from AKI?

Group work 1 – Nesta Hawker

Learning from you about the care and nursing home environment – challenges and influences

1. What motivates / influences change in clinical/care

practice?

2. What are the greatest challenges you face in care

homes?

30 mins + 15 mins feedback

Lunch

1.00pm to 1.45pm

Dr Rajib Pal

Think Kidneys!How to get it wrong for Marjory and right for

Nellie!

AKI in Care Homes

Background

GP partner in Birmingham

GP Trainer/Appraiser

Honorary Clinical Lecturer, University of Birmingham

NICE Acute Kidney Injury, GDG member

Think Kidneys Intervention work-stream member

NHS England: working group member of discharge standards

Macmillan GP Facilitator

Who is here ?

Care Home managers

Nurses

Health care Assistants

Doctors

Pharmacists

Others

Disease

Causes of AKI

Exposures Susceptibilities

Sepsis Dehydration or volume depletion

Critical illness Advanced age

Circulatory shock Female gender

Burns Black race

Trauma CKD

Cardiac surgery especially bypass Chronic heart, lung or liver disease

Major surgery Diabetes mellitus

Nephrotoxic drugs Cancer

Radiocontrast agents Anaemia

Poisonous plants and animals

The story of Marjory’s kidneysWhat can we do to harm them?

Marjory aged 83 Group1

Marjory lives in a R/HWhat can she do to damage her kidneys?

Marjory aged 83 Group 2

Lives in a N/HHas dementia, heart disease, diabetesWhat can you do to damage her kidneys?


Lives in a R/HShe feels unwell with urinary symptoms and feverWhat can you and she do to damage her kidneys?


Lives in a N/H“tummy bug”What can you do to damage her kidneys?


Lives in a N/HOff her food/drink10 different tablets

Lithium/Ramipril/ Spironolactone/Metformin/ Ibuprofen

What can you do to damage her kidneys?

The story of Marjory’s kidneys

How to damage Marjory’s kidneys

Group 1: R/H: Age 83 what can she do?

Group 2: N/H: dementia, heart disease, diabetes

Group 3: R/H: Unwell and UTI

Group 4: N/H and “tummy bug”

Group 5: R/H: “off food/drink”, on lots of tablets

Get older!!

Pick and eat wild mushrooms

Get fat and diabetic

Eat salt and get hypertension

Eat liquorice and raise BP

Take OTC aspirin-paracetamol combination and get

analgesic nephropathy

Take OTC ibuprofen and have 3x risk AKI

Smoke and have renal arterial disease

Take too much alcohol and raise her BP

Develop renal stones with high protein diet or spinach,

nuts and rhubarb increasing oxalate levels

Take large quantities of osmotic laxatives

Marjory Aged 83 Group1

Marjory Aged 83 Group 2

Do not check BPUnhealthy and fatty dietFluid restrictDo not register with GPDo not access GP/OOHNo blood testsMiss off tablets


Do not speak to her

Ask her NOT to drink fluids

Give her ibuprofen

Do not inform GP/OOH

Tell her that she will be fine after a few days


Not drinking risks pre renal damage

Delayed treatment risks pyelonephritis

Risk of glomerular damage with penicillins and sulphonamides

Risk of tubular damage with aminoglycosides

Risk of post renal damge with crystals in urine with high dose sulphonamides

Risks of AKI with NSAID used as analgesics

Risk of toxicity with nitrofuratoin eGFR<60


Fluid restrict herGive ibuprofenGive her extra medsDo not inform seniorDo not inform GP/OOHDo not isolate


Do no talk to her

Keep her isolated

Do not encourage her to eat/drink

Do not ask her how she is feeling?

Continue all medication

Do not inform senior/GP/OOH

SAD MAN: Drugs to be aware of if patient is hypotensive and unwell

SAD

MAN

SAD MAN

Sulphonylureas e.g. gliclazide

ACE and ARB e.g. ramipril/losartan

Diuretics e.g. furosemide

Metformin

Aldosterone antagonists e.g. spironolactone

NSAID e.g. ibuprofen, naproxen

CKD and NSAID: renal risk

NSAID impact kidney function in at least 8 ways ( R Fluck)

Prostaglandins are important to maintain perfusion within the kidney

Block of prostaglandins reduces renal blood flow with fluid retention, increased creatinine and potassium

Acute use reversible fall in GFR

Chronic use linked with hypertension and CKD progression

RECOMMEND annual U and E and BP with NSAID

RECOMMEND avoid NSAID with ACE/ARB and diuretic combination

Potential causes of AKI in Marjory





Burns Black race

Trauma CKD






Real Primary CareGetting it right for Nellie age 84 (1)

R/H

Exercise and healthy diet, fluid intake

Non-smoker

Alcohol Xmas

Regular medication

BP/cholesterol ok

Seen by GP every 6 months

Nellie aged 84 (2)

Dementia, Diabetes, Heart Disease

N/H

Caring environment

Regular medication

Healthy diet/fluids

GP ward rounds

Good BP control/lipids ok/HbA1c ok

Lives in R/H

Suspected UTI

Encourage fluids

GP informed (or OOH)

Antibiotics

MSU sent

Script/meds collected same day, Rx started

Feels much better 48 hrs

Nellie aged 84 (3)

Lives in N/H

“tummy bug”

Encourage fluids

Light diet

Advice from GP

Sick day rules

Likely viral gastroenteritis

Settled after 72 hours

Nellie aged 84 (4)

Lives in a N/H

Off her food/drinks

10 different tablets

Lithium/Ramipril/Spironolactone/Metformin/Ibuprofen

Speak to her

Encourage fluids/food

Inform senior/GP/OOH

Depression

Reviewed and treated

Nellie aged 84 (5)

AKI - Acute Kidney Injury

AKI Stage Serum creatinine Urine output

Stage 1 Increase of more than or equal to

26.5 umol/l or increase of 150-200%

from baseline

Less than 0.5ml/kg/h for

more than 6 hours

Stage 2 Increase of 200-300% from baseline

i.e. 2-3 fold


more than 12 hours

Stage 3 Increase to more than 300% i.e.3 fold

increase from baseline or more than

354 umol/l


more than 24 hours. Or

anuria for 12 hours

Causes of AKI





Burns Black race

Trauma CKD






119

The primary aim ofThink Kidneys is to ensure

avoidable harm relatedto acute kidney injury is

prevented in all care settings

Thank you

Group work 2 with Nesta Hawker

1. What resources do care home staff need to help them

manage acute kidney injury?

2. How do we engage and educate staff?

3. What do you need from the Think Kidneys programme?

30m + 15m feedback

Open mic session……

What else does Think Kidneys need to know?

08/07/2015

08/07/2015 123

The clever (academic) approach

Build a blender with rubber blades.Install a kitten detector

The simple (implementation) approach

Don’t stick a kitten in a blenderDon’t press the start button if you see a

kitten in the blender

What you might need

A chart to help you tell the difference between a kitten and food

Education

I love my cat

Summary of the day

Next steps

Thank you

Safe journey home