Directing specialist care through email admission alerting.

Unscheduled care is complex, particularly because many patients have multiple long term medical conditions. It is difficult to ensure the appropriate care is delivered by specialist services to patients in a timely manner. Lack of specialist input may impact on patient safety and adversely affect outcomes. We describe an automated email alerting system which was developed as result of a clinical incident. Using free software and minimal computing resources an automated email alerting system was developed. The system identified patient admissions, compared them against patient cohorts and created alerts. It used only around 1,000 lines of Java7 code combined with free software and secure NHS mail accounts. The system currently sends alerts to many different teams at our hospital. The patient population includes 6,047 patients on one of our 10 monitored lists or special registers. From May to June 2013 the system alerted to 863 monitored patient admissions in 2,158 separate messages. This system has been adopted across multiple specialties, has been well received and has had a direct impact on patient care. Not only is this system efficient and effective, but importantly can be implemented with low cost and complexity and is hence easily reproducible across the NHS.

Do acute elevations of serum creatinine in primary care engender an increased mortality risk?

BACKGROUND: The significant impact Acute Kidney Injury (AKI) has on patient morbidity and mortality emphasizes the need for early recognition and effective treatment. AKI presenting to or occurring during hospitalisation has been widely studied but little is known about the incidence and outcomes of patients experiencing acute elevations in serum creatinine in the primary care setting where people are not subsequently admitted to hospital. The aim of this study was to define this incidence and explore its impact on mortality. METHODS: The study cohort was identified by using hospital data bases over a six month period. INCLUSION CRITERIA: People with a serum creatinine request during the study period, 18 or over and not on renal replacement therapy.The patients were stratified by a rise in serum creatinine corresponding to the Acute Kidney Injury Network (AKIN) criteria for comparison purposes. Descriptive and survival data were then analysed.Ethical approval was granted from National Research Ethics Service (NRES) Committee South East Coast and from the National Information Governance Board. RESULTS: The total study population was 61,432. 57,300 subjects with 'no AKI', mean age 64.The number (mean age) of acute serum creatinine rises overall were, 'AKI 1' 3,798 (72), 'AKI 2' 232 (73), and 'AKI 3' 102 (68) which equates to an overall incidence of 14,192 pmp/year (adult). Unadjusted 30 day survival was 99.9% in subjects with 'no AKI', compared to 98.6%, 90.1% and 82.3% in those with 'AKI 1', 'AKI 2' and 'AKI 3' respectively. After multivariable analysis adjusting for age, gender, baseline kidney function and co-morbidity the odds ratio of 30 day mortality was 5.3 (95% CI 3.6, 7.7), 36.8 (95% CI 21.6, 62.7) and 123 (95% CI 64.8, 235) respectively, compared to those without acute serum creatinine rises as defined. CONCLUSIONS: People who develop acute elevations of serum creatinine in primary care without being admitted to hospital have significantly worse outcomes than those with stable kidney function.

What is the real impact of acute kidney injury?

BACKGROUND: Acute kidney injury (AKI) is a common clinical problem. Studies have documented the incidence of AKI in a variety of populations but to date we do not believe the real incidence of AKI has been accurately documented in a district general hospital setting.The aim here was to describe the detected incidence of AKI in a typical general hospital setting in an unselected population, and describe associated short and long-term outcomes. METHODS: A retrospective observational database study from secondary care in East Kent (adult catchment population of 582,300). All adult patients (18 years or over) admitted between 1st February 2009 and 31st July 2009, were included. Patients receiving chronic renal replacement therapy (RRT), maternity and day case admissions were excluded. AKI was defined by the acute kidney injury network (AKIN) criteria. A time dependent risk analysis with logistic regression and Cox regression was used for the analysis of in-hospital mortality and survival. RESULTS: The incidence of AKI in the 6 month period was 15,325 pmp/yr (adults) (69% AKIN1, 18% AKIN2 and 13% AKIN3). In-hospital mortality, length of stay and ITU utilisation all increased with severity of AKI. Patients with AKI had an increase in care on discharge and an increase in hospital readmission within 30 days. CONCLUSIONS: This data comes closer to the real incidence and outcomes of AKI managed in-hospital than any study published in the literature to date. Fifteen percent of all admissions sustained an episode of AKI with increased subsequent short and long term morbidity and mortality, even in those with AKIN1. This confers an increased burden and cost to the healthcare economy, which can now be quantified. These results will furnish a baseline for quality improvement projects aimed at early identification, improved management, and where possible prevention, of AKI.