The role of acute kidney injury (AKI) specialist nurse was set up as part of a bespoke service within Walsall Healthcare NHS Trust, acting as a ‘spoke’ for renal services in the area. The hub service offers dialysis, and provides chronic kidney disease (CKD) and renal clinic outreach both locally and via the hospital, which is located 6 miles away. Locally, the service was previously provided by two consultants who provided nephrology and acute medical cover, and offered AKI advice and support to ward doctors.
The service expansion, which included the addition of my role, was developed in order to provide support for all patients diagnosed with stage 3 AKI within 12 hours of diagnosis. The service provides intervention, advice, guidance and follow-up, and facilitates early discharge with appropriate follow-up, either in the community or in the outpatient clinic setting. The follow-up service includes patient review, identification of reversible causes, a medicines review, appropriate prescribing of ongoing medication to avoid further complication from kidney injury or CKD. Appropriate referrals would be made at this visit, including investigations required, for biopsy, dialysis education, dialysis access formation or conservative management.
The referral systems in place include an email option, direct referral via the patient record database, and a laboratory-generated notification indicating all AKIs identified via the clinical chemistry results database, which generates a list of patients with AKI stage 1 (mild), stage 2 (moderate) and stage 3 (severe) daily. There is also a bleep and telephone contact option.
At the point of my appointment to the AKI specialist nurse post, about 50% of all AKIs were being seen. Since my appointment, over 80% of all AKIs are being seen. This has resulted in a greater number of patients having appropriate follow-up, management, in-hospital care and post-discharge follow-up, which aligns with the ‘getting it right first time’ agenda. It also encourages the development of champions in many of the ward areas, which in turn encourages best practice.
The AKI role was developed to expedite time from diagnosis to treatment of AKIs and ensure correct and appropriate intervention, reduce the length of stay following AKI diagnosis by providing a weekly ‘hot’ clinic service, and to support the role with audit data. These aims have now been achieved.
Education
Alongside these intervention and support services an education programme for other health professionals has been developed, largely generated from observation of my role in practice. Consequently, I now hold both clinical and formal teaching sessions with fourth-year medical students, nurses, pharmacists and FY1 doctors. I also provide more informal, and often ad hoc, sessions in the clinical area, either at the request of the manager of the area, or in response to identified gaps in knowledge.
The rolling programme of education is aimed at qualified nurses who are new to the trust or are from overseas, as well as those wanting a refresher. The programme includes courses on:
- The deteriorating patient
- Fluid balance education
- IV administration
- Acute illness management (AIM).
As the AKI specialist nurse, I am involved in all the courses. I have also been involved in education and development strategies focusing on the redevelopment of fluid balance monitoring protocols, rewriting the fluid balance chart used across the Trust, and implementing the use of the chart trust-wide, with an accompanying education programme.
‘The role was developed to expedite time from diagnosis to treatment of AKIs and ensure correct and appropriate intervention’
Expansion
Our plans for the future include an expansion of the nursing team with a view to providing a 7-day service for AKI intervention. We are also working to expand CKD clinic preparation provision at the ‘spoke’ hospital site and planning to collaborate with the local hospice for provision of conservative management of palliated CKD patients in the community, managed by a nephrologist.
One thing I have missed since starting my role is having the support of colleagues with specialist knowledge of AKI. Although the ward teams and nephrologists are extremely supportive, much of my role is carried out independently. In my previous roles I was part of small, well-organised teams and the independent nature of my current role stands in sharp contrast to this previous teamworking.
It is an autonomous role and, as such, I have been looking for ways to expand the support I can provide for people. It was my intention to set up a Midlands network for AKI nurses to provide a point of contact and a platform for us to support each other in our individual roles. The idea was floated, and there was much enthusiasm about it. Unfortunately, COVID-19 intervened, interrupting the plans, as many of those in AKI roles were redeployed to support the extra workload generated during the pandemic. It is still my intention to pursue this initiative, with the aim of launching the network in May this year.