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What is the challenge your project is going to address and how does it connect to your chosen theme?

Acute Kidney Injury (AKI) is a dangerous debilitating condition causing long term problems with renal function, Chronic Kidney Disease and cardiovascular complications. Each year 67,000 patients across the North West are admitted to hospital with a diagnosis of AKI, around one in four AKI3 patients are readmitted within a month.

The risk of readmission for AKI can be reduced by flagging patients to their GP Practice on discharge. Evidence suggests information on AKI diagnosis is not routinely shared between secondary and primary care. Therefore one of the challenges we seek to address is the reliable and timely flow of information from secondary to primary care.

Providing GP Practices with reliable information on AKI diagnosis can only improve outcomes when staff are educated in the management of AKI and the recognition of signs and symptoms. The challenge will be to ensure every AKI patient is identified and followed up so as to mitigate the increased risk of downstream adverse events.

What does your project aim to achieve?

To design and implement metrics on the care that people with AKI receive when they are discharged from hospital in order to support health professionals to use data to identify opportunities for improvement.

We propose the capture of ‘process metrics’ in primary care relating to patients discharged from secondary care:

– AKI is recorded on the discharge letter to the GP

– AKI is coded on the GP system

– Patient education undertaken

– Medication review by the GP within 1 month of discharge

– Serum creatinine checked with 3 months of discharge.

These metrics will enable participants to identify and monitor improvements and should deliver the following outcomes:

– Improved flows of diagnostic information between primary and secondary care.

– A fall in the number of readmissions for AKI in the target population.

– An improvement in patient experience by empowering the patient and health professionals to recognise when they are becoming unwell and knowing when and how to act.

How will the project be delivered?

We will use our established mechanisms from our highly successful Advancing Quality (AQ) programme to map existing processes and develop process metrics with support from our clinical experts and information specialists.

We will partner with Vision Health, an established primary care systems provider, who will offer expertise on the extraction and use of data from GP Practices. In addition, we have a group of interested and motivated GPs who are keen to develop this work. We will work closely with healthcare organisations, clinical networks and our AKI clinical expert group, to devise and deliver new metrics.

This project will expand the existing work the AQ team have delivered on AKI so far in the acute care setting with our tried and tested methodologies. Along with the data extracted by Vision Health it will cover the patient journey beyond discharge.

What and how is your project going to share learning throughout?

We are seeking opportunities to extend the AQ offer into primary care and anticipate one of the outcomes of this work to be able to offer additional measures, covering more of the AKI pathway, to healthcare providers outside of hospital settings. We would use the learning from the project to produce an extended measure set that all AQ participants could access.

Our in-house communications and engagement function will promote the results and key findings and encourage interested organisations to participate. The project will be showcased during webinars, promoted via on-going Trust work, at AQ collaborative events and be posted on the AQuA website and monthly newsletter.

The output will consist of a data dictionary outlining the identification of the patient cohort and the methodology for measurement of care. This will be freely available and easily adapted locally.

How you can contribute

  • How is AKI currently being communication across primary and secondary care in your area?
  • Are there any education packages for patients around sick day rules or managing AKI Risk in your area?
  • Are there any programmes where GPs are actively identifying and managing AKI risk in their community?

Plan timeline

1 Oct 2019 Devise communications strategy for project
6 Oct 2019 Gather expressions of interest from practices
1 Nov 2019 Confirm practice participating and perform visits
4 Nov 2019 Review analysis and generate final report
14 Nov 2019 Share findings with HEE and at networking meetings
14 Nov 2019 Work with Vision to set up software on practice systems
2 Dec 2019 GP training and governance arrangements
5 Jan 2020 Gather and analyse baseline data
3 Feb 2020 Undertake any necessary training to increase documentation
2 Mar 2020 Maintain on-going contact with GPs and Secondary Care
1 Jun 2020 Maintain on-going contact with GPs and Secondary Care
1 Sep 2020 Maintain on-going contact with GPs and Secondary Care
5 Oct 2020 Generate final analytical outcomes


  1. Hi team,

    you may want to connect with the AHSN network as there have been several great AKI programmes.

    good luck

    best wishes


    1. Guest

      Sam Doddridge 1 year, 8 months ago

      Thank you Anna, we are working closely with our regional AHSNs on a number of our clinical focus areas to work collaboratively and prevent overlap.

      Many thanks, Sam

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