I was pleased to be nominated and receive a runner-up award for Renal Nurse of the Year in the BJN Awards 2020. The path to this award began in April 2015, when University Hospital Southampton (UHS) NHS Foundation Trust decided to appoint an acute kidney injury (AKI) clinical nurse specialist (CNS) on a 9-month secondment to deliver the Commissioning for Quality and Innovation (CQUIN) framework for AKI (NHS England, 2015).
This CQUIN aimed to drive better communication between the primary care team and hospital settings and to pass on information about acute episodes of inpatient AKIs. It was to achieve that by assisting in providing vital information to GPs regarding the ongoing management of patients with AKI and medication reviews in the community setting.
This role was to sit within the patient safety team as a Trust-wide position and be led by the AKI lead consultant nephrologist. Despite being a large tertiary hospital with multiple specialties, UHS does not have a renal unit, and in 2015 had a small renal team. The renal team, therefore, did not have capacity to review all AKI patients within the organisation, nor is that appropriate as many patients with AKI have pre- and post-renal AKI related to acute illness. What was required was an acute care practitioner who was experienced in dealing with acutely unwell patients across a range of clinical settings.
Although the primary aim of the role was to achieve the CQUIN, it was decided that it would also include clinical review of adult inpatients with a stage 3 AKI, and I was recruited into the role in September 2015. With a background of being a qualified advanced nurse practitioner (ANP) within a critical care outreach team, with 9 years' experience, I was already an experienced independent and autonomous practitioner, looking for a new challenge. The AKI role was a perfect fit for me as I had previously written my master's dissertation about fluid balance documentation and I was passionate about improving fluid balance documentation to reduce inpatient AKI. The role was split into 80% clinical and 20% education, training and service evaluation and quality improvement, with the ability to choose projects that would benefit patient care. I was very fortunate that my clinical expertise and passion for improvement was recognised and I was allowed to focus my non-clinical time on improving the care of AKI patients through a variety of projects.
The clinical element of the role was to review patients with stage 3 AKI and assist in ascertaining the cause of AKI and deliver appropriate treatment, alongside liaising with the renal team for patients with intrinsic AKI. Within the first year of the role, I was able to assist in achieving the CQUIN of over 90% of discharge summaries including all four aspects of the AKI CQUIN requirements being sent to primary care; something that continues to this day. This was completed through using electronic systems and developing automated responses in patients' discharge summaries. This also allowed us to fully assess the number of patients who had an AKI in a timely fashion and allowed us to audit other areas of AKI practice. We have audited and improved processes for renal ultrasound scanning for patients with an AKI, have audited trauma and orthopaedic pathways and contributed to work to reduce AKI in elective orthopaedic patients—at UHS we now have an incidence of less than 1% in this patient group. The trauma and orthopaedic work has allowed me to learn from other inspiring nurses such as Jacqui Prieto, Associate Clinical Professor, who led the work, and encouraged me to continue to make changes for the benefit of patients.
Alongside achieving the CQUIN, I was able to demonstrate a reduction in length of stay for patients with AKI stage 3, and an improved inpatient morbidity and mortality. This was through early patient reviews and clinical assessment of causes of AKI and treatment, alongside delivering education to all clinical staff involved in AKI patient care. Education was delivered in formal settings, through the development of an online teaching package, for which I received a grant from the Wessex Academic Health Science Network. During almost all patient interactions I also took the opportunity to provide bedside education for staff and patients.
With this success I was able to prove the value of the AKI nurse role in improving patient care and this ensured the role was made into a permanent post and, as a team, we looked at developing the service to include patients with stage 2 AKI by expanding the AKI nursing team. The AKI CNS role was reviewed to assess whether this job description would meet the needs of the AKI service going forward. It was decided that the role would need to be that of an ANP. More recently, due to the strategic work of my role both inside and outside of the Trust, my job is now AKI Lead ANP.
Working clinically 80% of the time allowed me to assess areas where there could be improvements, and I undertook several audits. One of these included looking at the AKI readmissions to hospital and whether there was anything that could be done to prevent such readmissions. An AKI readmission was defined as a patient who had an AKI during their hospital stay and was then readmitted within 90 days with another AKI. This work was about short-term readmissions, but also was part of a larger piece of work looking at preventing chronic kidney disease (CKD) for patients who had an episode of inpatient AKI. I have always been passionate about preventing deterioration and preventing readmissions because this would be beneficial for both patients and for the wider health economy.
To facilitate this work in April 2018, I was awarded a Wessex Health Education England Individual Quality Improvement Fellowship to look at whether providing patients with information about their AKI reduced readmissions. This allowed me to recruit into the AKI team and spend 2 days per week focusing on quality improvement work, and begin to expand the AKI nursing team. The outcome of this work was the finding that giving patients information about their AKI shortly before their discharge reduced readmissions within 90 days by around 13%.
Alongside this, the AKI team (myself, the head of patient safety and the consultant nephrologist) worked with our local commissioners to implement a nurse-led follow-up clinic for patients with stage 2 and stage 3 AKI. We wanted to assist in preventing readmissions, optimising medication in the first 10 days after hospital discharge and improving patients' understanding of AKI management and avoidance. The outcome was that we were able to pilot an AKI nurse-led follow-up clinic.
In April 2019, we recruited a new band 7 ANP to assist in patient reviews and to run the clinic. The aim of the clinic is to see patients before they are discharged from hospital and provide them with some information about AKI. This will be as close to discharge as possible. They will receive safety-netting advice in writing and given an appointment for clinic for bloods to be taken if required. Patients would be triaged at this point into the face-to-face or telephone clinic based on their AKI stage and whether it has resolved or any medications have been changed. Each patient's capacity would be assessed, which would determine whether they would need a telephone appointment because of mobility problems and whether they would need their next of kin present. The need for an interpreter would also be assessed.
The AKI clinic started in April 2019 with AKI stage 3 patients, and when the AKI ANP started work, in July 2019, the clinic expanded to include AKI stage 2 patients. The clinic runs one face-to-face clinic per week and one telephone clinic per week. We are constantly reviewing the AKI clinic pathways and looking at whether there should be joint clinics with other specialties, alongside making changes to the clinic based on patient feedback.
I have always been driven to introduce positive change and joined an informal AKI nurse network through the Think Kidneys work stream. This informal network has recently expanded to an AKI National Network, which I co-chair. I am also co-chair of the AKI Special Interest Group, part of the Association of Nephrology Nurses (ANN). These national groups aim to spread information about AKI and fluid balance, sharing their knowledge, skills and the results of any audits and improvements that have been undertaken in their local areas.
I have been able to be so successful in this role because I was supported by amazing people such as Kirsty Armstrong (Consultant Nephrologist, UHS), Vickie Purdie (Head of Patient Safety) and Juliet Pearce (Deputy Director of Nursing for Quality). These people have helped guide me when I wanted to start nurse-led clinics and inspired me to drive forward the change that appeared at times to be insurmountable. I am extremely proud to lead a team of two fantastic AKI nurses, and to continue to work towards improving the care of AKI patients both in Southampton and on a wider national scale.