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Acutely ill patients in hospital

About

What is covered

This interactive flowchart covers the recognition of, and response to, acute illness in adults in hospital.

Updates

Updates to this interactive flowchart

5 June 2017 SecurAcath for securing percutaneous catheters (NICE medical technologies guidance 34) added to venous or arterial catheter insertion.
15 March 2017 Structure revised and summarised recommendations replaced with full recommendations.
11 April 2016 The following guidance was added to venous or arterial catheter insertion:
  • guidance on the use of ultrasound locating devices for placing central venous catheters (NICE technology appraisal guidance 49)
  • the 3M Tegaderm CHG IV securement dressing for central venous and arterial catheter insertion sites (NICE medical technologies guidance 25)
  • the Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters (NICE medical technologies guidance 24).
22 December 2014 Acute kidney injury (NICE quality standard 76) added.
27 August 2013 Recommendation 1.2.2 from acute kidney injury (NICE clinical guideline 169) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on recognising and responding to acute illness in adults in hospital in an interactive flowchart

What is covered

This interactive flowchart covers the recognition of, and response to, acute illness in adults in hospital.

Updates

Updates to this interactive flowchart

5 June 2017 SecurAcath for securing percutaneous catheters (NICE medical technologies guidance 34) added to venous or arterial catheter insertion.
15 March 2017 Structure revised and summarised recommendations replaced with full recommendations.
11 April 2016 The following guidance was added to venous or arterial catheter insertion:
  • guidance on the use of ultrasound locating devices for placing central venous catheters (NICE technology appraisal guidance 49)
  • the 3M Tegaderm CHG IV securement dressing for central venous and arterial catheter insertion sites (NICE medical technologies guidance 25)
  • the Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters (NICE medical technologies guidance 24).
22 December 2014 Acute kidney injury (NICE quality standard 76) added.
27 August 2013 Recommendation 1.2.2 from acute kidney injury (NICE clinical guideline 169) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Acute kidney injury: prevention, detection and management (2013 updated 2016) NICE guideline CG169
SecurAcath for securing percutaneous catheters (2017) NICE medical technologies guidance 34
Acute kidney injury (2014) NICE quality standard 76
Biopatch for venous or arterial catheter sites (2017) NICE medtech innovation briefing 117
Needle-free arterial non-injectable connector (2016) NICE medtech innovation briefing 85
VitalPAC for assessing vital signs of patients in hospital (2016) NICE medtech innovation briefing 79
AccuVein AV400 for vein visualisation (2014) NICE medtech innovation briefing 6

Quality standards

Quality statements

Raising awareness in people at risk

This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People who are at risk of acute kidney injury are made aware of the potential causes.

Rationale

Many people who develop acute kidney injury are not aware of the potential causes and how to prevent it. Acute kidney injury can be prevented by educating people about the risks and how to stop it from developing. Better education delivered in primary care settings, outpatient settings and on discharge from hospital will help to reduce the number of people developing acute kidney injury outside hospital and the number being admitted to hospital with the condition.

Quality measures

Structure
Evidence of local arrangements to ensure that people who are at risk of acute kidney injury are made aware of the potential causes.
Data source: Local data collection.
Process
Proportion of people who are at risk of acute kidney injury who are made aware of the potential causes.
Numerator – the number in the denominator who are made aware of the potential causes of acute kidney injury in a documented discussion with their healthcare professional.
Denominator – the number of people who are at risk of acute kidney injury.
Data source: Local data collection.
Outcome
Incidence of acute kidney injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (GPs and district general hospitals) ensure that systems are in place for people who are at risk of acute kidney injury to be made aware of the potential causes and steps for prevention in a discussion with their healthcare professional (that also involves their parents or carers, if appropriate).
Healthcare professionals ensure that they discuss the potential causes of acute kidney injury and steps for prevention with people who are at risk (and with their parents or carers, if appropriate).
Commissioners (clinical commissioning groups) ensure that they commission services in which people who are at risk of acute kidney injury are made aware of the potential causes and steps for prevention in a discussion with their healthcare professional (that also involves their parents or carers, if appropriate).

What the quality statement means for patients, service users and carers

People who are at risk of acute kidney injury are told about the risk in a discussion with their healthcare professional, which also involves their parents or carers if appropriate. The discussion should cover possible causes of acute kidney injury (for example, dehydration caused by diarrhoea and vomiting, and certain drugs that can affect the kidney) and what they can do to avoid it.

Source guidance

Definitions of terms used in this quality statement

People at risk of acute kidney injury
People who are particularly at risk of developing acute kidney injury in the community, and should have the risk discussed with them, include those who have any of the following:
  • history of acute kidney injury (determined by the discharge summary from an inpatient episode, documenting the stage and cause of acute kidney injury)
  • chronic kidney disease with an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73 m2
  • neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer.
[Expert opinion and NICE guideline CG169, recommendation 1.6.4]
Potential causes of acute kidney injury
The potential causes of acute kidney injury include conditions leading to dehydration (for example, diarrhoea and vomiting) and drugs that have nephrotoxic potential (including over the counter NSAIDs [non steroidal anti inflammatory drugs]). Healthcare professionals should discuss these causes and how to avoid them with people who are at risk (and their parents or carers if appropriate). The discussion should include the importance of staying hydrated, should be had at least once and should be documented in the person’s notes. [Adapted from NICE guideline CG169, recommendation 1.6.4 with expert opinion]

Equality and diversity considerations

Young age, neurological or cognitive impairment or disability may result in limited access to fluids and a risk of dehydration for some people because of their reliance on others to maintain adequate fluid intake. This may include frail older people, people with dementia in care homes and people with physical disabilities. Also, the risk of acute kidney injury might increase for people of Muslim faith during periods of fasting if they have other risk factors (for example, if they are taking diuretics).

Identifying acute kidney injury in people with no obvious acute illness

This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for this condition.

Rationale

People with acute kidney injury may present with no obvious signs or symptoms of this condition in primary or secondary care settings. Early assessment for acute kidney injury when making decisions about treatment for people who are at risk may prevent delays in treating the condition, leading to improved outcomes. It is important for healthcare professionals to be aware of when it is necessary to assess the risk of acute kidney injury so that a diagnosis is not missed.

Quality measures

Structure
Evidence of local arrangements to ensure that people who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for acute kidney injury.
Data source: Local data collection.
Process
Proportion of presentations of illness with no clear acute component along with 1 or more indications or risk factors for acute kidney injury where an assessment for acute kidney injury is done.
Numerator – the number in the denominator where an assessment for acute kidney injury is done.
Denominator – the number of presentations of illness with no clear acute component along with 1 or more indications or risk factors for acute kidney injury.
Data source: Local data collection.
Outcome
Incidence of acute kidney injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care providers) ensure that people who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for acute kidney injury.
Healthcare professionals consider and assess for acute kidney injury in people who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury.
Commissioners (clinical commissioning groups) ensure that they commission services in which people who present with an illness with no clear acute component and 1 or more indications or risk factors for acute kidney injury are assessed for acute kidney injury.

What the quality statement means for patients, service users and carers

People who are generally unwell with no obvious recent or sudden illness and who have indications or risk factors for acute kidney injury are assessed to see whether they have this condition. This should include blood tests and having their urine volume measured, as well as reviewing any medications they are taking.

Source guidance

Definitions of terms used in this quality statement

Illness with no clear acute component
A person with an illness with no clear acute component feels generally unwell (for example, tired with perhaps nausea or swelling of the legs), and has no clear idea of when the illness began, and no clear sudden acute illness. [Expert opinion]
Indications or risk factors for acute kidney injury in people with an illness with no clear acute component
The following are indications or risk factors for acute kidney injury in people with an illness with no clear acute component:
  • chronic kidney disease (especially stage 3B, 4 or 5) or urological disease
  • new onset or significant worsening of urological symptoms
  • symptoms suggesting complications of acute kidney injury
  • symptoms or signs of a multi system disease affecting the kidneys and other organ systems (for example, signs or symptoms of acute kidney injury plus a purpuric rash).
[NICE guideline CG169, recommendation 1.1.4]
Assessment for acute kidney injury
Clinical assessment for acute kidney injury involves doing a blood test to check serum creatinine levels against a previous result, measuring urine volume and reviewing medication. This assessment can be undertaken in a primary care setting as well as a hospital setting, although the frequency of blood testing may be less in a primary care setting. [Expert opinion]

Equality and diversity considerations

All people presenting with no obvious acute illness who have indications or risk factors for acute kidney injury should be assessed for a possible diagnosis. Symptoms suggesting acute kidney injury should not be dismissed based on a person’s age – for example, ignoring urological symptoms in older people. Young age, neurological or cognitive impairment or disability may mean that people are less able to describe their symptoms, so it is important that healthcare professionals look out for changes in behaviour that suggest acute kidney injury in these groups.

Monitoring in hospital for people at risk

This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored.

Rationale

Acute kidney injury can be a ‘silent’ condition with no external signs or symptoms. Because many episodes of acute kidney injury are preventable, identifying people who are at risk and monitoring their clinical condition is important. Changes in serum creatinine level and urine output are indicators of risk, and it is important that these biomarkers are monitored alongside a ‘track and trigger’ system. Recognising and responding to these changes will ensure appropriate and quick intervention to prevent acute kidney injury developing.

Quality measures

Structure
Evidence of local arrangements to ensure that people in hospital who are at risk of acute kidney injury have their serum creatinine level and urine output monitored.
Data source: Local data collection.
Process
Proportion of admissions to hospital of people who are at risk of acute kidney injury where serum creatinine level and urine output are monitored.
Numerator – the number in the denominator where serum creatinine level and urine output are monitored.
Denominator – the number of admissions to hospital of people who are at risk of acute kidney injury.
Data source: Local data collection. Acute kidney injury (NICE guideline CG169), clinical audit tool adults, standards 5 and 6 and clinical audit tool children, standard 2.
Outcome
Incidence of acute kidney injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (district general hospitals) ensure that protocols are in place for trained healthcare professionals to monitor the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and to respond to any changes.
Healthcare professionals follow local protocols for monitoring the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and respond to any changes.
Commissioners (clinical commissioning groups) ensure that secondary care providers have protocols in place for trained healthcare professionals to monitor the serum creatinine level and urine output of people in hospital who are at risk of acute kidney injury alongside a track and trigger system, and to respond to any changes.

What the quality statement means for patients, service users and carers

People in hospital who are at risk of developing acute kidney injury should have blood tests to measure levels of creatinine (a substance that indicates how well their kidneys are working) and have their urine volume measured. Healthcare professionals should take action if they find any changes. This should be done for patients in acute hospitals and other hospital settings (such as psychiatric hospitals).

Source guidance

Definitions of terms used in this quality statement

People in hospital who are at risk of acute kidney injury
Adults in hospital at risk of acute kidney injury include those:
  • who have non elective admissions
  • who have any major planned interventions, such as interventional radiological procedures (including coronary angiography) and grade 3 or grade 4 surgery, neurosurgery or cardiovascular surgery (see preoperative tests [NICE guideline CG3] for definitions of surgery grades).
[Expert opinion]
NICE guideline CG169, recommendation 1.1.1 has a detailed list of risk factors for acute kidney injury in adults with acute illness.
Children and young people in hospital with acute illness are at risk of acute kidney injury if any of the following are likely or present:
  • chronic kidney disease
  • heart failure
  • liver disease
  • history of acute kidney injury
  • oliguria (urine output less than 0.5 ml/kg/hour)
  • young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer
  • hypovolaemia
  • use of drugs with nephrotoxic potential (such as NSAIDs [non steroidal anti inflammatory drugs], aminoglycosides, ACE [angiotensin converting enzyme] inhibitors, ARBs [angiotensin II receptor blockers] and diuretics) within the past week, especially if hypovolaemic
  • symptoms or history of urological obstruction, or conditions that may lead to obstruction
  • sepsis
  • a deteriorating paediatric early warning score
  • severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)
  • symptoms or signs of nephritis (such as oedema or haematuria)
  • haematological malignancy
  • hypotension.
[NICE guideline CG169, recommendation 1.1.2]
Monitoring of serum creatinine level and urine output
Physiological ‘track and trigger’ systems (early warning scores) should be used to monitor all adult patients in acute hospital settings. The serum creatinine level and urine output should be recorded at admission or in the initial assessment and then as part of routine monitoring.
Measurement of serum creatinine will vary according to clinical need, but daily measurement is typical while a person is acutely ill and/or in hospital. Serum creatinine levels should be compared with a baseline measurement to detect changes that would trigger a response. Details of baseline measurements and detecting acute kidney injury based on changes in serum creatinine level can be found in NHS England’s national algorithm.
Frequency of urine output monitoring will also depend on clinical circumstances. When adults are at risk of acute kidney injury, systems should be in place to recognise and respond to oliguria (urine output of less than 0.5 ml/kg/hour).
For children and young people, physiological observations should be recorded at admission and then according to local protocols for given paediatric early warning scores.
The frequency of monitoring for adults, children and young people should increase if abnormal physiology is detected.

Equality and diversity considerations

Young age, neurological or cognitive impairment or disability may result in limited access to fluids and a risk of dehydration for some people because of their reliance on others to maintain adequate fluid intake. This may include frail older people, people with dementia in care homes and those with physical disabilities. Also, the risk of acute kidney injury might increase for people of Muslim faith during periods of fasting if they have other risk factors (for example, if they are taking diuretics).

Identifying the cause – urine dipstick test

This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People have a urine dipstick test performed as soon as acute kidney injury is suspected or detected.

Rationale

Understanding the cause of acute kidney injury by testing the urine for blood and protein is important for guiding further specialised investigations and appropriate treatments. Urine dipstick testing is a simple, effective and inexpensive diagnostic test to identify underlying conditions that can be treated to either prevent acute kidney injury or reduce its severity, thus avoiding more serious consequences.

Quality measures

Structure
Evidence of local arrangements to ensure that people have a urine dipstick test performed as soon as acute kidney injury is suspected or detected.
Data source: Local data collection.
Process
Proportion of presentations where a urine dipstick test is performed within 6 hours of acute kidney injury being suspected or detected.
Numerator – the number in the denominator where a urine dipstick test is performed within 6 hours of acute kidney injury being suspected or detected.
Denominator – the number of presentations in which acute kidney injury is suspected or detected.
Data source: Local data collection.
Outcome
Preventing serious consequences resulting from not treating the causes of acute kidney injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary and secondary care providers) ensure that protocols and clear referral pathways are in place for urine dipstick testing to be carried out as soon as acute kidney injury is suspected or detected, and for appropriate responses to abnormal results.
Healthcare professionals perform urine dipstick testing as soon as acute kidney injury is suspected or detected, and know when and how to respond to abnormal results.
Commissioners (clinical commissioning groups) ensure that primary and secondary care providers have protocols in place for urine dipstick testing to be carried out as soon as acute kidney injury is suspected or detected, and for appropriate responses to abnormal results.

What the quality statement means for patients, service users and carers

People with suspected or detected acute kidney injury have their urine tested with a 'dipstick' as soon as possible to check for causes of acute kidney injury.

Source guidance

Definitions of terms used in this quality statement

Suspected or detected acute kidney injury
Symptoms or signs of acute kidney injury can vary and include passing less urine than normal, nausea and sickness, poor appetite, swelling of the legs or other parts of the body and breathlessness [NICE guideline CG169, information for the public].
Acute kidney injury is detected in line with the (p)RIFLE, AKIN or KDIGO definitions, by using any of the following criteria:
  • a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
  • a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
  • a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people
  • a 25% or greater fall in estimated glomerular filtration rate (eGFR) in children and young people within the past 7 days.
[NICE guideline CG169, recommendation 1.3.1]
A national algorithm that standardises the definition of acute kidney injury has been agreed and endorsed by NHS England.
(p)RIFLE= Risk, injury, failure, loss, end stage renal disease, (p) refers to the paediatric classification.
AKIN= Acute Kidney Injury Network.
KDIGO= Kidney disease: improving global.
Urine dipstick test
A urine dipstick tests the urine sample for blood, protein, leukocytes, nitrites and glucose, and can help to determine an underlying cause of acute kidney injury. The test should be done as soon as possible after acute kidney injury is suspected or detected, and within 6 hours at most. Catheterisation for the sake of performing the test should be avoided. The results of the test should be documented and appropriate action taken when results are abnormal. The interpretation of urine dipstick findings in a child with acute kidney injury should always be undertaken by a paediatrician or a paediatric nephrologist. [Adapted from NICE guideline CG169, full guideline with expert opinion]
Risk, injury, failure, loss, end stage renal disease, (p) refers to the paediatric classification.Acute Kidney Injury Network.Kidney disease: improving global outcomes.

Discussion with a nephrologist

This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People with acute kidney injury have the management of their condition discussed with a nephrologist as soon as possible, and within 24 hours of detection, if they are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant.

Rationale

Input from nephrologists to the management of acute kidney injury is needed as soon as possible for people who are at risk of their condition worsening or of adverse outcomes. This helps to ensure that people get the specialist care they need to help their condition improve and to prevent it from deteriorating further.

Quality measures

Structure
Evidence of local arrangements to ensure that people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant have the management of their condition discussed with a nephrologist as soon as possible and within 24 hours of detection.
Data source: Local data collection.
Process
Proportion of presentations of people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant where management is discussed with a nephrologist within 24 hours of detection.
Numerator – the number in the denominator where management is discussed with a nephrologist within 24 hours of detection of acute kidney injury.
Denominator – the number of presentations of people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant.
Data source: Local data collection. Acute kidney injury (NICE guideline CG169) clinical audit tool adults, standard 9 and clinical audit tool children, standard 5.
Outcomes
Mortality from acute kidney injury.
Data source: Mortality statistics from the Office for National Statistics.
Progression of acute kidney injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (district general hospitals) ensure that the management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant is discussed with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.
Healthcare professionals discuss the management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.
Commissioners (clinical commissioning groups) ensure that secondary care providers have protocols in place so that the management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant is discussed with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.

What the quality statement means for patients, service users and carers

People with acute kidney injury who are at risk of kidney disease or have stage 3 acute kidney injury or a kidney transplant have their condition discussed with a specialist as soon as possible (within 24 hours at most), so that they get the right treatment.

Source guidance

Definitions of terms used in this quality statement

People with acute kidney injury
Acute kidney injury is detected in line with the (p)RIFLE , AKIN or KDIGO definitions, by using any of the following criteria:
  • a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
  • a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
  • a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people
  • a 25% or greater fall in estimated glomerular filtration rate (eGFR) in children and young people within the past 7 days.
[NICE guideline CG169, recommendation 1.3.1]
A national algorithm that standardises the definition of acute kidney injury has been agreed and endorsed by NHS England.
(p)RIFLE= Risk, injury, failure, loss, end stage renal disease, (p) refers to the paediatric classification.
AKIN= Acute Kidney Injury Network.
KDIGO= Kidney disease: improving global.
People with acute kidney injury who are at risk of intrinsic renal disease
People with acute kidney injury are at risk of intrinsic renal disease when one or more of the following is present:
  • a possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)
  • acute kidney injury with no clear cause
  • inadequate response to treatment
  • complications associated with acute kidney injury
  • chronic kidney disease stage 4 or 5.
[NICE guideline CG169, recommendation 1.5.15]
People who have stage 3 acute kidney injury
Stage 3 acute kidney injury is defined in the (p)RIFLE, AKIN or KDIGO definitions as:
  • eGFR decrease by 75% or greater
  • or 200% or greater rise in creatinine from baseline within 7 days. (Where the rise is known (based on a prior blood test) or presumed (based on the patient history) to have occurred within 7 days.)
  • or rise in creatinine to 354 micromol/litre or greater with an acute rise of 44 micromol/litre or greater
  • or rise in creatinine to 354 micromol/litre or greater with an acute rise of 26 micromol/litre or greater within 48 hours or 50% or greater within 7 days
  • or (pRIFLE only) eGFR less than 35 ml/min/1.73 m2
  • or any requirement for renal replacement therapy.
[NICE guideline CG169, full guideline, table 36]
Referral for renal replacement therapy
This quality statement is taken from the acute kidney injury quality standard. The quality standard defines clinical best practice in acute kidney injury care and should be read in full.

Quality statement

People with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist.

Rationale

It is important to ensure that people with acute kidney injury who need treatment receive it in the right care setting (such as an intensive care unit or renal unit) at the right time, and that delays in treatment that put people at risk are avoided. This can be achieved through immediate referral supported by effective referral and transfer protocols that prioritise people with the greatest need. Prompt treatment offers potential benefits that include preventing further deterioration of renal function, improving chances of renal recovery, shorter hospital stays, lower mortality and better long term outcomes.

Quality measures

Structure

Evidence of local arrangements to ensure that people with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist and transferred according to local protocols.
Data source: Local data collection.

Process

Proportion of people with acute kidney injury who meet the criteria for renal replacement therapy who are referred immediately to a nephrologist or critical care specialist.
Numerator – the number in the denominator who are referred immediately to a nephrologist or critical care specialist.
Denominator – the number of people with acute kidney injury who meet the criteria for renal replacement therapy.
Data source: Local data collection.

Outcomes

a) Duration of renal replacement therapy for acute kidney injury.
Data source: Local data collection.
b) Mortality from acute kidney injury.
Data source: Mortality statistics from the Office for National Statistics.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (district general hospitals and specialised renal centres) ensure that clear referral pathways and transfer protocols are in place for the immediate referral of people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist.
Healthcare professionals immediately refer people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist and transfer them according to local protocols.
Commissioners (clinical commissioning groups and NHS England) ensure that secondary care providers have clear referral pathways and transfer protocols in place for the immediate referral of people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist. Commissioners should work with NHS England when necessary to ensure that there is enough capacity within specialist nephrology teams for referrals.

What the quality statement means for patients, service users and carers

People with acute kidney injury who need renal replacement therapy (such as dialysis) are referred immediately to specialist services so that delays in having the treatment are avoided.

Source guidance

Definitions of terms used in this quality statement

People with acute kidney injury

Acute kidney injury is detected in line with the (p)RIFLE, AKIN or KDIGO definitions, by using any of the following criteria:
  • a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
  • a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
  • a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people
  • a 25% or greater fall in estimated glomerular filtration rate (eGFR) in children and young people within the past 7 days.
[NICE guideline CG169, recommendation 1.3.1]
A national algorithm that standardises the definition of acute kidney injury has been agreed and endorsed by NHS England.
(p)RIFLE= Risk, injury, failure, loss, end stage renal disease, (p) refers to the paediatric classification.
AKIN= Acute Kidney Injury Network.
KDIGO= Kidney disease: improving global.

Immediate referral

Immediate referral by healthcare professionals is needed to ensure timely initiation of therapy. Effective and timely referral should be made using locally developed referral and transfer protocols. These protocols should be based on local physiological early warning scores, which include urine output and parameters from the National Early Warning Score (NEWS), to ensure that people who meet the criteria for renal replacement therapy are seen by a suitable specialist and that there is appropriate triage of people with acute kidney injury, including those arriving from other hospitals. [Adapted from The Renal Association Acute kidney injury guideline 5.3 with expert opinion]

Criteria for renal replacement therapy

If any of the following are not responding to medical management:
  • hyperkalaemia
  • metabolic acidosis
  • symptoms or complications of uraemia (for example, pericarditis or encephalopathy)
  • fluid overload
  • pulmonary oedema.
[NICE guideline CG169, recommendation 1.5.8]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Tip Confirmation System

Paths in this pathway

Pathway created: August 2012 Last updated: August 2017

© NICE 2017

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