Thanks for your comments Gary,

You are highlighting that what works in secondary care does not necessarily work in primary care. Patients who have a single serum creatinine result that is outside the reference interval are effectively on the periphery of the algorithm with insufficient information to generate an AKI warning stage test result. Nevertheless, to ignore such results makes little sense in the context of trying to increase the detection of AKI in primary care.
So the issue is, if we are to do something, what should we do? It does not seem unreasonable to us to invite a closer inspection of the results and to suggest a repeat. A suggestion, to us implies a fairly weak degree of compulsion and can be dismissed when knowledge of the patient's clinical status requires it.

That said, the wording of comments is a fine art and the same words mean different things to different people. We can always improve or even make the comment locally configurable.
Other comments are welcome on this.

Dr Robert Hill
Chair Detection Workstream
Think Kidneys National Programme
________________________________________
From: ACB AKI-Detection-Algorithm [[log in to unmask]] On Behalf Of Gary Mascall [[log in to unmask]]
Sent: 23 October 2015 14:42
To: [log in to unmask]
Subject: ?AKI ?CKD patient results

Since reporting AKI warnings using the WinPath interpretation of the national algorithm, we have seen large numbers of samples (approx 85% of the number of AKI warnings 1 to 3) where the creatinine is above the relevant upper reference limit but with no creatinine in the previous 12 months.
So this is reported as per national algorithm as ?AKI ?CKD suggest repeat.
It is creating a problem for Primary Care clinicians who rightly tell us the patient isn't on annual/regular monitoring, but has always had creatinine of a similar level, and waves are starting to be created.

I realise the algorithm was initially for secondary care, but as we already had something in place for primary care we decided to go "big bang" and introduce it across all clinical areas. So, this may be a problem others only reporting on secondary care patients have not yet encountered, but it is something you do need to be aware of.

Possibly when the algorithm is reviewed this issue might be addressed? I can envisage a few ways to improve things, but as these are outside of the algorithm, and something we have no control of the software to change, this really does need some thought and consideration.

Gary Mascall
Worcestershire Acute Hospitals NHS Trust.

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