Baird David Paul, Rae Fraser, Beecroft Christina, Gallagher Katherine, Sim Stephanie, Vaessen Robert, Wright Emily, Bell Samira
Renal Medicine, Ninewells Hospital, Dundee, UK.
Orthopaedic Department, Perth Royal Infirmary, Perth, Perth and Kinross, UK.
BMJ Open Qual. 2019 Mar 29;8(1):e000306. doi: 10.1136/bmjoq-2017-000306. eCollection 2019.
Patients undergoing surgery are at increased risk of acute kidney injury (AKI). AKI is associated with adverse outcomes such as increased mortality and future risk of developing chronic kidney disease. We have developed a validated preoperative scoring tool to predict postoperative AKI in patients undergoing orthopaedic surgery using seven readily available parameters. The aim of this project was to establish the use of this scoring tool with a target compliance of 80% in patients undergoing orthopaedic surgery requiring an overnight stay at Perth Royal Infirmary, a district general hospital in NHS Tayside. We created an intervention bundle for patients at high risk of AKI, which we defined as greater than 10%. An electronic tool available on smartphones and desktop computers was developed that can be used to calculate the score. The interventions were incorporated into the electronic tool and posters outlining the intervention were placed in clinical areas. Patients undergoing elective procedures were scored in the preassessment clinic while emergency patients were scored by the admitting doctors. The score was introduced using four PDSA cycles. This confirmed that the scoring tool functioned well and was being used accurately. Compliance for patients undergoing elective surgery was reasonable at 19/24 (79%) in the third and fourth PDSA cycles but was poorer for emergency admissions with compliance of only 3/7 (43%). There was excellent compliance with the suggested medication changes and postoperative blood test monitoring as advised by our intervention bundle for those at high risk of AKI. Fluid balance monitoring was advised for all patients but the outcome was similar following our intervention at 27/41 (66%) compared with 23/37 (62%) in the baseline data collection. Compliance with fluid balance monitoring was higher in patients at high risk of AKI (9/12, 75%).
接受手术的患者发生急性肾损伤（AKI）的风险增加。AKI与不良后果相关，如死亡率增加以及未来发生慢性肾脏病的风险。我们开发了一种经过验证的术前评分工具，使用七个易于获得的参数来预测接受骨科手术患者的术后AKI。本项目的目的是在泰赛德国民保健服务体系（NHS Tayside）的一家区级综合医院——珀斯皇家医院，对需要过夜留院的骨科手术患者使用该评分工具，目标依从率为80%。我们为AKI高危患者创建了一个干预包，我们将高危定义为大于10%。开发了一种可在智能手机和台式计算机上使用的电子工具，用于计算评分。干预措施被纳入电子工具，并在临床区域张贴了概述干预措施的海报。择期手术患者在术前评估诊所进行评分，而急诊患者由接诊医生评分。通过四个计划-实施-检查-处理（PDSA）循环引入该评分。这证实了评分工具运行良好且使用准确。在第三个和第四个PDSA循环中，择期手术患者的依从率为19/24（79%），较为合理，但急诊入院患者的依从率较差，仅为3/7（43%）。对于AKI高危患者，按照我们的干预包建议进行的药物更改和术后血液检查监测的依从性极佳。建议对所有患者进行液体平衡监测，但我们干预后的结果与基线数据收集时相似，分别为27/41（66%）和23/37（62%）。AKI高危患者的液体平衡监测依从率更高（9/12，75%）。
