Risk Prediction for Acute Kidney Injury in Acute Medical Admissions in the UK

Background Acute Kidney Injury (AKI) is associated with adverse outcomes; identifying patients who are at risk of developing AKI in hospital may lead to targeted prevention. This approach is advocated in national guidelines but is not well studied in acutely unwell medical patients. We therefore aimed to undertake a UK-wide study in acute medical units (AMUs) with the following aims: to define the proportion of acutely unwell medical patients who develop hospital-acquired AKI (hAKI); to determine risk factors associated with the development of hAKI; and to assess the feasibility of using these risk factors to develop an AKI risk prediction score. Methods In September 2016, a prospective multicentre cohort study across 72 UK AMUs was undertaken. Data were collected from all patients who presented over a 24-hour period. Chronic dialysis, community-acquired AKI (cAKI) and those with fewer than two creatinine measurements were subsequently excluded. The primary outcome was the development of h-AKI. Results 2,446 individuals were admitted to the AMUs of the 72 participating centres. 384 patients (16%) sustained AKI of whom 287 (75%) were cAKI and 97 (25%) were hAKI. After exclusions, 1,235 participants remained in whom chronic kidney disease (OR 3.08, 95% CI 1.96-4.83), diuretic prescription (OR 2.33, 95% CI 1.5-3.65), a lower haemoglobin concentration and an elevated serum bilirubin were independently associated with development of hAKI. Multivariable model discrimination was moderate (c-statistic 0.75), and this did not support the development of a robust clinical risk prediction score. Mortality was higher in those with hAKI (adjusted OR 5.22; 95% CI 2.23-12.20). Conclusion AKI in AMUs is common and associated with worse outcomes, with the majority of cases community acquired. The smaller proportion of hAKI cases, only moderate discrimination of prognostic risk factor modelling and the resource implications of widespread application of an AKI clinical risk score across all AMU admissions suggests that this approach is not currently justified. More targeted risk assessment or automated methods of calculating individual risk may be more appropriate alternatives

Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures

AIMS—To evaluate the efficacy and safety of nitrous oxide for children undergoing painful procedures.
METHODS—Ninety children requiring repeated painful procedures (lumbar puncture, bone marrow aspirate, venous cannulation, or dressing changes) were given nitrous oxide at a variable concentration of 50-70%. Procedure related distress was evaluated using the Observational Scale of Behavioral Distress-Revised (OSBD-R). OSBD-R scores were obtained for each of the following phases of the procedure: phase 1a, waiting period; phase lb, during induction with nitrous oxide; phase 2, during positioning and cleaning of the skin; phase 3, during the painful procedure; and phase 4, immediately following the procedure and withdrawal of nitrous oxide. Side effects were monitored and recorded by a second observer.
RESULTS—OSBD scores reached a maximum during the induction phase with lower scores during subsequent phases. Children over the age of 6 showed a lower level of distress during nitrous oxide administration and the painful procedure. Eighty six per cent of patients had no side effects. The incidence of vomiting, excitement, and dysphoria was 7.8%, 4.4%, and 2% respectively. Eight patients developed oxygen desaturation (SaO(2) < 95%), but none developed hypoxia, airway obstruction, or aspiration. Ninety three per cent of patients fulfilled the criteria for conscious sedation, and 65% had no recollection of the procedure. Mean recovery time was three minutes.
CONCLUSIONS—Inhalation of nitrous oxide is effective in alleviating distress during painful procedures, with minimal side effects and short recovery time.


Using in situ simulation to improve care of the acutely ill patient by enhancing interprofessional working: a qualitative proof of concept study in primary care in England

Objectives Acutely unwell patients in general practice are uncommon, but their management requires intervention from staff (clinical and non-clinical) working as a team. Despite the advantages of interprofessional education being well documented, there is little research evidence of this in the primary care setting. This study aimed to improve care of the acutely ill patient by enhancing interprofessional working, using in-situ simulation. Methods Mixed methods evaluation study. Phase 1 scoped education provision in GP practices within Health Education England Kent, Surrey and Sussex (HEEKSS) via questionnaire to 668 practices. In Phase 2 a simulation of cardiac arrest occurred in three HEEKSS practices; all staff participated in interviews. Results Phase 1 showed the majority of practices ran sessions involving all staff, predominantly focusing on basic life support (BLS) (63 practices) and practice-specific areas such as managing difficult patients (28 practices). 61 said simulation was not used; 41 responded that it was, 37 specifying for BLS training. Qualitative thematic analysis identified four themes: 1) apprehension, anxiety, and (un)willing participation, 2) reflection on the simulation design, 3) experiences of the scenario and 4) training. Conclusions Practices made changes in their workplace, potentially benefitting the future management of acutely ill patients. The use of actors and involvement of clinical and non-clinical members of staff contributes to a fuller understanding of how in-situ simulation can benefit both workforce and patients.</p