Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation

Abstract

ObjectivesTackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care.DesignAn appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method.SettingClinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result.ParticipantsA 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and ‘overdiagnosis’.ResultsThere was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia.ConclusionsThe study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs.

Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

“…For further information regarding the methodology, the development of guidance on the timeliness in response to AKI warning-stage test results for adults in primary care can be found in a 2016 evaluation by Blakeman et al, where a similar approach was adopted. 24 Developing clinical scenarios for appropriateness rating An AKI working group (see Funding) was established through the RCGP to develop clinical scenarios for appropriateness rating, and built on the experience of the previous Think Kidneys working group. 24 There was representation from primary and secondary care clinicians, as well as a methodologist with expertise in the RAM and patient safety in primary care.…”

“…It is a recognised approach that systematically generates consensus through appropriateness ratings to help address clinical decision in areas where ‘robust evidence’ is lacking. 21 – 24 It combines best available evidence with the shared knowledge of experts to provide a measure of the appropriateness of undertaking particular actions. 21 – 23 It recognises that an appropriate response requires an understanding of the clinical context, which in this study related to the consideration of AKI within both primary and secondary care settings.…”

“…For further information regarding the methodology, the development of guidance on the timeliness in response to AKI warning-stage test results for adults in primary care can be found in a 2016 evaluation by Blakeman et al , where a similar approach was adopted. 24 …”

“…An AKI working group (see Funding) was established through the RCGP to develop clinical scenarios for appropriateness rating, and built on the experience of the previous Think Kidneys working group. 24 There was representation from primary and secondary care clinicians, as well as a methodologist with expertise in the RAM and patient safety in primary care. The working group collated and reviewed current evidence, including current guidance from NICE, CQUIN, and Think Kidneys for AKI, as well as recent international guidance.…”

“…Rating scales were as defined by established RAM. 21,24 The RAND/UCLA process entails two rounds of ratings:…”