-----Original Message-----
From: Hill Robert (NORTH BRISTOL NHS TRUST) [mailto:[log in to unmask]]
Sent: 30 July 2014 08:35
To: Kingdon, Edward; 'Mike Bosomworth'; Oliver Louise (BARTS HEALTH NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Stott Richard (DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; HAZARA ADIL (HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST); Laing Chris (ROYAL FREE LONDON NHS FOUNDATION TRUST); Mulgrew Chris (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST); Ashley Emma (KINGSTON HOSPITAL NHS FOUNDATION TRUST); Ireland Jennifer (MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST); Monaghan John (DERBY HOSPITALS NHS FOUNDATION TRUST); Selby Nick (DERBY HOSPITALS NHS FOUNDATION TRUST); Ayrton Puja (BARNET AND CHASE FARM HOSPITALS NHS TRUST); Fluck Richard (DERBY HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Teresa Jane Wallace; [log in to unmask]; [log in to unmask]; [log in to unmask]; Murray Jonathan (RTR) South Tees NHS Trust; [log in to unmask]; Hewins Peter (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Pankhurst Tanya (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Baines Richard (UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]
Cc: Bottoms David (COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST); [log in to unmask]; Frater John (RVW)Pathology; Reaich David (RTR) South Tees NHS Trust; Main John (RTR) South Tees NHS Trust; Kardasz Stephen (RTR) South Tees NHS Trust; Pattman Stewart (RTR)South Tees NHS Trust
Subject: RE: Reflection post AKI Scientific Day 19th June 2014
Thanks for your e-mail Edward,
Following the AKI scientific day in June we agreed to set up a discussion forum. This is now available on JISCMAIL. It allows you to subscribe to a moderated email discussion list focused on implementing the NHS England AKI Warning Algorithm. Please copy your e-mail to [log in to unmask] and follow the instructions below to follow the discussion.
To become invoved, go to www.jiscmail.ac.uk and from the home page hit the link "Subscribe or Unsubscribe"
Search for the list ACB-AKI-ALGORITHM, fill in your chosen e-mail account and, for starters, accept the default settings. Each time a message is sent to the forum it will appear in the e-mail account that you have selected.
This list is not confined to ACB members. It is open, so others can join in.
Dr Robert Hill
Consultant Clinical Biochemist
________________________________________
From: Kingdon, Edward [[log in to unmask]]
Sent: 29 July 2014 15:41
To: 'Mike Bosomworth'; Oliver Louise (BARTS HEALTH NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Stott Richard (DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; HAZARA ADIL (HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST); Laing Chris (ROYAL FREE LONDON NHS FOUNDATION TRUST); Mulgrew Chris (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST); Ashley Emma (KINGSTON HOSPITAL NHS FOUNDATION TRUST); Ireland Jennifer (MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST); Monaghan John (DERBY HOSPITALS NHS FOUNDATION TRUST); Selby Nick (DERBY HOSPITALS NHS FOUNDATION TRUST); Ayrton Puja (BARNET AND CHASE FARM HOSPITALS NHS TRUST); Fluck Richard (DERBY HOSPITALS NHS FOUNDATION TRUST); Hill Robert (NORTH BRISTOL NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Teresa Jane Wallace; [log in to unmask]; [log in to unmask]; [log in to unmask]; Murray Jonathan (RTR) South Tees NHS Trust; [log in to unmask]; Hewins Peter (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Pankhurst Tanya (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Baines Richard (UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]
Cc: Bottoms David (COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST); [log in to unmask]; Frater John (RVW)Pathology; Reaich David (RTR) South Tees NHS Trust; Main John (RTR) South Tees NHS Trust; Kardasz Stephen (RTR) South Tees NHS Trust; Pattman Stewart (RTR)South Tees NHS Trust
Subject: RE: Reflection post AKI Scientific Day 19th June 2014
Dear All,
I had delayed entering the conversation anticipating
a) A response to the NPSA alert from the LIMS manufacturer CSC (Royal Surrey and BSUH LIMS provider)
b) A decision from Sunquest about whether they are applying for an MHRA licence for their products (ICE in general or their calculation engine in particular)
Aware that time is moving on, I should like to comment on the conversation
Rather like in the North-East, Kent Surrey and Sussex have great heterogeneity in both LIMS and patient management systems in use in primary and secondary care. Before the NPSA alert not all LIMS manufacturers had engaged with AKI alerts or incorporating a calculation script to ascertain cases. Until now, CSC have not yet been able to let acute trusts in KSS know their plans in respect of NPSA alert compliance.
Some time ago, ICE was used in the Heart of England trust to identify AKI, but only by making a comparison of 2 results irrespective of the time interval between the 2 results http://ndt.oxfordjournals.org/content/26/7/2161.abstract. Subsequently, Sunquest have incorporated a calculation script for an AKI identification algorithm in parts of Kent Surrey and Sussex. Output from the calculation script can be sent to distant sites and we have set up ftp transfer of anonymised data to an informatics company who support KSS AHSN quality improvement projects. More recently Sunquest have developed a calculation engine which can add or alter the calculations it performs independent of software upgrades/ new product launches. ICE is set up differently in sites across the country with variation in whether it is used by primary or secondary care requesters, whether it is used to view results and which interfaces/add-ons are in use. One additional Sunquest product/service in use locally, LabComm is already used at BSUH to send PMIP messages to primary care systems. The version of Sunquest-ICE installed at Brighton can be updated at very low cost to include the calculation engine and options to send alerts by email/ICEmail or ftp and export to trust interface engines. Existing ICE products can draw the secondary care users' attention to an AKI test result when looking up test results and this functionality is in use in Luton and Dunstable, Liverpool and Lancashire.
I guess that there may be lots of variation on local installation and before deciding on LIMS upgrades/ new interfaces between LIMS and patient management systems it may be worth an inventory of the local ICE setup. There may be gains for regions if the number of interfaces that need to be developed is reduced.
The original AKI calculation script incorporated into ICE used the national algorithm but with mean outpatient creatinine (0 to -365 days) as the baseline. This was based on a comparison of surrogate baseline creatinines by Siew and colleagues- Estimating baseline kidney function in hospitalized patients with impaired kidney function ED Siew, TA Ikizler, ME Matheny, et al.Clinical Journal of the American Society of Nephrology 2012;7:712-9. Following the NPSA alert we have revised the calculation script in ICE so that it precisely mirrors the national algorithm using a median creatinine. It may be possible to make a comparison between these 2 baselines in future.
I hope that CSC will announce its plans for NPSA compliance shortly and that Sunquest will decide whether to go for MHRA licencing. It seems likely that the criteria for NPSA compliance in the FAQs can be met by Sunquest ICE if they apply for and are granted an MHRA licence. http://www.england.nhs.uk/wp-content/uploads/2014/06/psa-aki-alg-faqs.pdf
BW
Ed Kingdon
Nephrologist
Brighton and Sussex University Hospitals NHS Trusts
From: Mike Bosomworth [mailto:[log in to unmask]]
Sent: 21 July 2014 10:37
To: Oliver Louise (BARTS HEALTH NHSTRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; Kingdon, Edward; [log in to unmask]; [log in to unmask]; [log in to unmask]; Stott Richard(DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Andrew Lewington; [log in to unmask]; [log in to unmask]; HAZARAADIL (HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST); Laing Chris (ROYAL FREE LONDON NHS FOUNDATIONTRUST); Mulgrew Chris (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST); Ashley Emma (KINGSTON HOSPITAL NHS FOUNDATIONTRUST); Ireland Jennifer (MAIDSTONE ANDTUNBRIDGE WELLS NHS TRUST); Monaghan John (DERBY HOSPITALS NHSFOUNDATION TRUST); Selby Nick(DERBY HOSPITALS NHS FOUNDATION TRUST); Ayrton Puja (BARNET AND CHASE FARM HOSPITALSNHS TRUST); Fluck Richard (DERBY HOSPITALS NHSFOUNDATION TRUST); Hill Robert (SHEFFIELD TEACHING HOSPITALSNHS FOUNDATION TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; [log in to unmask]; Teresa Jane Wallace; [log in to unmask]; [log in to unmask]; [log in to unmask]; Murray Jonathan (RTR) South Tees NHS Trust; [log in to unmask]; Hewins Peter (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Pankhurst Tanya (UNIVERSITYHOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); Baines Richard (UNIVERSITY HOSPITALS OFLEICESTER NHS TRUST); [log in to unmask]; [log in to unmask]; [log in to unmask]
Cc: Bottoms David (COUNTY DURHAM AND DARLINGTON NHSFOUNDATION TRUST); [log in to unmask]; Frater John (RVW)Pathology; Reaich David (RTR) South Tees NHS Trust; Main John (RTR) South Tees NHS Trust; Kardasz Stephen (RTR) South Tees NHS Trust; Pattman Stewart (RTR)South Tees NHS Trust
Subject: RE: Reflection post AKI Scientific Day 19th June 2014
Dear Jon et al,
Thank you for raising these points in your thoughtful email.
Baseline creatinine will always be a problem and the way to determine this was the subject of a lot of debate. There were strong voices for taking the lowest serum creatinine, but there were those who argued against this because of the possibility of false positives as shown by Chris. There was much concern over our clinical colleagues suffering alert fatigue (remember they are not only getting AKI alerts).
Whether the AKI staging should be embedded in the LIMS (it is really staging rather than an e-alert) was also debated. This option was selected because the LIMS feeds many other clinical systems, either directly or through integration engines. If the calculation was left to ICE then potentially it will only reside in ICE and clinicians using other systems would not see it. This would be true for GPs unless they went in to ICE as their systems are fed via PMEP.
As I think everyone acknowledges it is good that we have one system, warts and all. It was not meant to be set in stone and I am sure that it will be reviewed regularly. It will be good to see how it performs against existing systems. Such comparisons will be valuable at review time.
As we all acknowledge it is not perfect, but there again it is hard to see how any AKI staging based on a clinical biochemistry result could be.
Best wishes
Mike
Dr. Mike Bosomworth
Clinical Service Lead for Blood Sciences and Specialist Laboratory Medicine.
Tel. 0113 3922340
Mobile 07789 174344
>>> "Mulgrew Chris (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST)"
>>> <[log in to unmask]<mailto:[log in to unmask]>> 11/07/2014
>>> 16:12 >>>
Dear Jon
Thanks for your email - good to see you again in London last month. As we discussed on the day, the clinicians (renal/acute medicine/others) and clinical chemists in Exeter also have concerns over the use of a median baseline potentially missing AKI in patients admitted to hospital. As you eloquently describe in your example, this is particularly relevant for those who are at high risk, likely to suffer recurrent episodes of AKI and who appear at the AMU/ED having not had a creatinine in the past 7 days but who may have had most of the creatinines which were measured during the preceding 8-365 days done while an inpatient with other illnesses / episodes of AKI, leading to a high median reference point and therefore not generating a flag. Going around the posters led to much debate about the correct choice of baseline and it was recognised that this was a very difficult debate to resolve, but while our algorithm uses the lowest creatinine and therefore has a false positive rate of around 1.5%, we are unlikely to miss cases which may be missed with the new algorithm.
Like you, I completely agree on the need to have a unified algorithm and was encouraged by comments made indicating that feedback would be welcomed and that upgrades / adjustments may be made to the algorithm in future. In the meantime, once we have a quote from our LIMS provider and can install the new algorithm we plan to run both systems simultaneously for at least 3 months later this year but keeping the new system 'blind' to the end-users, collecting the data on both systems and then allowing comparison.
Kind regards
Chris
Dr Chris Mulgrew
Consultant Nephrologist
Exeter Kidney Unit
Royal Devon & Exeter NHS Foundation Trust, Wonford Site, Barrack Road, Exeter. EX2 5DW.
Tel.: 01392 402534
Fax.: 01392 402527
Pager: 07659 530841 (#6502 - internal page) [log in to unmask]<mailto:[log in to unmask]>
From: Murray Jonathan (RTR) South Tees NHS Trust [mailto:[log in to unmask]]<mailto:[mailto:[log in to unmask]]>
Sent: 08 July 2014 16:59
To: Teresa Jane Wallace; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Ashley Emma (KINGSTON HOSPITAL NHS FOUNDATION TRUST); Ayrton Puja (BARNET AND CHASE FARM HOSPITALS NHS TRUST); Baines Richard (UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; HAZARA ADIL (HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST); Hewins Peter (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); [log in to unmask]<mailto:[log in to unmask]>; Hill Robert (SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Ireland Jennifer (MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Laing Chris (ROYAL FREE LONDON NHS FOUNDATION TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Monaghan John (DERBY HOSPITALS NHS FOUNDATION TRUST); Mulgrew Chris (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST); Oliver Louise (BARTS HEALTH NHS TRUST); Pankhurst Tanya (UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Selby Nick (DERBY HOSPITALS NHS FOUNDATION TRUST); Stott Richard (DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST); [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; [log in to unmask]<mailto:[log in to unmask]>; Fluck Richard (DERBY HOSPITALS NHS FOUNDATION TRUST)
Cc: Kardasz Stephen (RTR) South Tees NHS Trust; Reaich David (RTR) South Tees NHS Trust; Main John (RTR) South Tees NHS Trust; Bottoms David (COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST); Pattman Stewart (RTR) South Tees NHS Trust; Frater John (RVW) Pathology; [log in to unmask]<mailto:[log in to unmask]>
Subject: Reflection post AKI Scientific Day 19th June 2014
Hi all,
Thanks to all those who organised the AKI day in a couple of weeks ago. I found the meeting both interesting and enjoyable!
I have attached a couple of reflections / questions primarily for the attention of Richard (Fluck) and Robert (Hill), but in the spirit of embracing the collaborative ethos that was evident throughout the meeting in London, have copied this e-mail to the other attendees too.
The specific points attached build upon thoughts that I have previously discussed with some of you - and may also be of particular interest to Ed Kingdon, Richard Stott, Trevor Hines and Jane Armer's teams (as I have made reference to your very good posters).
In essence the two queries pertain to:-
1. Algorithm baseline creatinine.
2. Location of e-alert system.
As stated throughout attachments, I am not wishing to appear to be making points 'just for the sake of it' (!) and do of course recognise the importance of collaboration and being pragmatic. As such I hope my points come across respectfully and demonstrate reflections that have arisen genuinely following my attendance at the meeting and subsequent review of posters; if anything I hope the points raised reflect that I share everyone's enthusiasm for trying to ensure the e-alert system is a success!
Best Wishes,
Jon (Murray)
Renal Consultant, James Cook University Hospital
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