Improving the completeness of acute kidney injury follow-up information in hospital electronic discharge letters

Abstract

ObjectivesAcute kidney injury (AKI) is common in hospitalised patients, often mandates changes to regular medications and can be unresolved at hospital discharge. General practitioners (GPs) require apposite AKI-related information in electronic discharge letters (EDLs). In 2015 NHS England introduced a care quality standard that all EDLs should include four items of information for patients with AKI. We performed a 12-month quality improvement project (QIP) aimed at achieving above 90% compliance with the quality standard.MethodsHospital-wide episodes of AKI were detected using the nationally approved electronic AKI alerts system. 25 patient AKI episodes were audited per month for 12 months using the electronic patient record. The target compliance rate was staggered at 35%, 65% and 90% for each subsequent 3-month block. Baseline compliance was 22%. Measures taken to improve compliance included email information, grand rounds, ward-level meetings, computer screensavers, nurse support, clinical governance meetings, and face-to-face rapid education. Annotation of AKI within the computer EDL system was progressively enhanced such that in the final quarter the presence of an AKI-alert mandated the user to complete the AKI annotation before the EDL could be signed off.ResultsThe completion rate improved to 37% in the second quarter, 51% in the third quarter and 92% in the fourth quarter. This change has been sustained in the 14 months since.ConclusionsBy the end of the study, omissions relating to AKI information were reduced from 78% to less than 10%, indicating our QIP was highly effective—meeting the quality standard. The single most important factor in improving documentation was to mandate user review of AKI aftercare in patients with electronic AKI alerts. Our study encompassed hospital-wide inpatients, and our results could be replicated at other acute hospitals that have implemented an EDL system connected to an AKI alert system.

Impact of postoperative acute kidney injury in patients undergoing major gastrointestinal surgery on 1-year survival and renal outcomes: a national multicentre cohort study

“…There was also no significant difference in the time to first serum creatinine measurement after discharge for patients with stage 1 AKI, compared with patients without AKI. This conflicts with Royal College of General Practitioners guidance on post-discharge monitoring of AKI 26 , and may reflect poor recognition of stage 1 AKI, or challenges in communication between secondary and primary care 37 , 38 .…”

Discharge Documentation and Follow-Up of Critically Ill Patients With Acute Kidney Injury Treated With Kidney Replacement Therapy: A Retrospective Cohort Study

“…Given the large number of staff, often junior, and in rotating roles, individual education and training is unlikely to be the best effector of change. Moreover, it is likely that institutions need to develop standardised approaches to recognition, documentation and subsequent management of this patient group, with in-built quality metrics to ensure ongoing improvement in routine patient care, similar to other areas in clinical medicine ( 17 , 49 ). Incorporation of a structured framework into the discharge document has been recommended ( 11 , 17 ).…”

“…Moreover, it is likely that institutions need to develop standardised approaches to recognition, documentation and subsequent management of this patient group, with in-built quality metrics to ensure ongoing improvement in routine patient care, similar to other areas in clinical medicine ( 17 , 49 ). Incorporation of a structured framework into the discharge document has been recommended ( 11 , 17 ). In addition to detailing past events, it should include a recommendation for nephrotoxin avoidance, weight and blood pressure monitoring advice, cardiovascular medication management, and sick day rules ( 28 ).…”

“…Previous reports from centres in France and the United States (US) concluded that hospital discharge summaries were often inadequate to facilitate appropriate follow-up care ( 15 , 16 ). In the scarcity of data from the UK ( 17 ), we aimed to investigate the process and effectiveness of information transfer for critically ill patients with AKI who received KRT and left hospital alive. In particular, we examined the comprehensiveness of the critical care and hospital discharge summaries with regard to AKI diagnosis, the need for KRT, recommendation for follow-up management, and actual kidney and patient outcomes at 1 year.…”

Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital

“…One remedy may be to introduce electronic alerts into medical records regarding vaccination and smoking status. This is not a novel concept and has been successfully trialled in thromboembolism prophylaxis and acute kidney injury notification . Literature from the primary care setting found electronic reminders increased rates of cessation counselling and prescription of cessation medications …”