Over half of my nursing career has been spent in renal nursing. As an experienced nurse in acute and maintenance haemodialysis, I felt I needed to broaden my horizons and accept a new challenge.
Calderdale and Huddersfield NHS Foundation Trust had recognised the potential benefits of having an acute kidney injury (AKI) nurse in a district general hospital, such as reducing the reliance on a tertiary renal hub and providing local support as an in-house, in-hours service in collaboration with the consultant nephrologists based locally.
My appointment, in April 2020, coincided with the first lockdown due to COVID-19. It was a particularly challenging time. I was redeployed onto the wards twice within my first 12 months at the Trust. I was able to use this time to look at the dynamics within the ward settings and develop my prime goals to improve fluid balance monitoring and urinalysis.
Quality improvement initiatives
I found the main challenges were staff shortages and use of the electronic patient record to record information.
So how would I improve this? My first priority was to look at the data, almost giving myself a crash course on clinical audit and how this would benefit my quality improvement (QI) initiatives.
I looked at the management guidelines from the National Institute for Health and Care Excellence (NICE) and the UK Kidney Association and started to build a picture on my ‘blank canvas’. This involved analysing the data from the AKI referrals to the renal team as my baseline. On average, we get between 20 and 30 AKI alerts each day and as I am the sole AKI nurse, looking at all referrals would take me away from seeing face to face those patients who were at higher risk of deterioration.
The results were not surprising. Typically, 0% fluid balance results had been documented and only 12.5% urinalysis results had been recorded in the correct part of the electronic patient record.
Targeted education sessions
Education programmes were constructed and developed to target my prime audience of healthcare assistants (HCAs) who typically record this information. This was delivered in bite-size sessions on the ward. I felt that the HCAs needed to know that such observations are fundamental because fluid balance results could trigger a NEWS2 score and that if fluids were initiated on recognition of the NEWS2 trigger score a patient's deterioration could be prevented. In my experience, fluid balance is often the ‘forgotten observation’.
But why do HCAs need to know? As those who will see the patient for the majority of their shift, they may notice signs of dehydration sooner than the registered nurse. This was where I needed to target my education – on the physical signs of dehydration, such as darker-coloured urine, which should prompt the HCA to alert the registered nurse that a patient's fluid status is compromised. This is also the case for those patients who are fluid overloaded – monitoring oral intake and urine output can ensure the patient has the correct fluid management plan.
Scenarios were provided of a typical history of AKI: dehydration, hypovolaemia and oliguria secondary to diarrhoea and vomiting. The majority of HCAs recognised that the patient was dehydrated. I followed this up with another scenario around two or three days later, typically on one of my follow-up visits. Again, most of the HCAs were able to recognise that the patient had been rehydrated. The final scenario was a ‘spot the difference’ task where I had simulated an accurately documented fluid balance chart and another that had no oral intake documented. I explained why documentation is fundamental by highlighting that the difference between the accurate chart and the other, without any documented oral intake, was 900 ml. This could potentially be interpreted as a negative balance and IV fluids might be given inappropriately. This could result in the patient becoming overloaded.
At the end of the session, I asked the HCAs what was the one thing they would take back to their ward area. The main response was to record fluid balance more often.
Urinalysis recording was a significant challenge as the general view is that urinalysis is not appropriate in those individuals over 65 years of age. This was based on communications from the microbiology team to ensure that urinalyses were not obtained unnecessarily in this age group. However, this is not the case in patients over 65 with AKI.
This remains a challenge both locally and nationally. Therefore the rationale for urinalysis needed to be clearly communicated. Posters were placed in sluices with clear messaging that all patients with an AKI needed a urinalysis to rule out a possible intrinsic cause and this determined whether an autoimmune screen needed to be carried out. Giving the nursing teams support with this was a significant factor if improvements were to be achieved.
Improvements in care
Over the next 12 months, these interventions contributed to an improvement in fluid balance and urinalysis recording for those with a diagnosis of AKI, which also contributed to a shorter length of stay for some individuals. Fluid balance compliance had gone from 0% to 83% and urinalysis compliance had improved from 12.5% to 69% over the first 6 months. The awareness of AKI management has improved, and this has clearly been seen with the increased level of referrals to the service, now that the presence of an AKI service is becoming better established.
Further developments
Local universities were contacted, and a student placement has been established over the past 12 months. The student nurses have benefitted from the underpinning knowledge surrounding AKI management and have been able to directly link this into practice. Feedback has been consistently positive from each student.
The Trust now facilitates the Acute Illness Management (AIM) Course, which has been developed by the Greater Manchester Critical Care Network and is targeted towards registered nurses and nursing associates, focusing on the ‘A-E’ approach in the acutely ill. Fluid balance is heavily focused on during the course and also within its assessment. I have facilitated sessions on oliguria and AKI workshops and this has helped to ensure staff know that fluid balance is a key component in the risk of deterioration.
I am also involved, at a regional and national level, as a member of the Yorkshire and Humber Kidney Network, and the Association of Nephrology Nurses' AKI Special Interest Group. I am also Co-chair of the UK Kidney Association AKI Special Interest Group – Governance and Partnership Workstream. This has fuelled my passion to deliver nationally recognised standards and filter them into local guidelines. This workstream has focused my initiatives between specialties and other areas of pre-registration nurse education, such as mental health and learning disability. The aims of the workstream are to ensure that AKI is clearly highlighted throughout all aspects of the patient's journey, particularly if a patient has been stepped down from critical care. This has involved collaboration with key stakeholders – cardiology, diabetes, rheumatology, urology, primary care and any specialty caring for individuals who develop an AKI.
Another key initiative that is a priority on a national level is post-discharge care and reducing the risk of re-admission within 90 days. I had set up a nurse-led AKI and Renal Hot Clinic, which is managed currently with consultant support. This is for urgent low clearance follow-up appointments if no face-to-face consultant appointment is available within 4 weeks. Patients who attend the clinic are assessed on their level of recovery, and whether withheld medications can be restarted. Outstanding results are reviewed from their admission, such as an autoimmune screen, and the decision is made whether the patient needs to remain under the renal team or can be discharged to the care of their GP.
This has been a profound success and is the only AKI clinic within the West Yorkshire and Humber region. The potential benefits of other trusts setting up their own clinics are a reduction of pressure within acute service provision and the promotion of admission avoidance.
The percentage of re-admissions over the first 12 months of the set up of the clinic was 8% within 90 days; 17% of patients were discharged to the GP for future monitoring and 62% of those seen remained under the care of the renal team for routine monitoring. Twenty-one per cent needed to be referred to the low clearance Hot Clinic as their estimated glomerular filtration rate (eGFR) failed to improve above 20 ml/minute. In total, 83% of patients were alive after 12 months and 86% achieved their baseline function or had improved renal function since discharge.
Personal development
In addition, I have now completed my Non-Medical Prescribing course, so this will benefit the team by providing additional capacity for re-prescribing and de-prescribing without the direct supervision of a consultant, but the emphasis on ensuring safety will be paramount. This will provide ongoing learning opportunities and ultimately benefit the service by improving the quality of patient care.
I am immensely proud of my hard work in the development of the AKI service, especially as I felt a lack of confidence in myself and my ability to work at this level. My journey has been surrounded by continued support from all colleagues within the renal team. Achieving a Bronze Award in the BJN Awards 2023 will encourage me to achieve further improvements within the service.