UCLPartners delivered two breakthrough series (BTS) collaboratives with 13 acute hospital trusts in the north Thames region to transform the care provided to patients with acute kidney injury (AKI) and sepsis.
The aims for the AKI and sepsis collaboratives were to achieve improvements in the recognition and treatment of patients admitted to hospital with AKI or sepsis, as well as to increase NHS staff quality improvement capability across the region.
The clinical outcome aims were to reduce AKI mortality by 25%, and sepsis mortality by 20%, whilst at the same time reducing hospital length of stay, and improving timely recognition, treatment and follow-up.
The analysis of over 2,000 AKI and sepsis cases throughout the programme showed that both collaboratives exceeded their aims, and reduced AKI mortality by 47%, and sepsis mortality by 24%.
Both collaboratives had strong engagement levels at regular learning sessions, where participating trust teams shared their experiences and progress in the form of storyboards and in group discussions.
The high number of avoidable deaths caused by AKI and sepsis, and the potential for improvements were the main reason for the partnership to prioritise its collaborative work on these conditions. In 2014, it was estimated that 40.000  deaths were caused by AKI, whilst 37.000  deaths were attributed to sepsis in England. With a population of ~6million people in its region, UCLPartners saw the significant impact it could have by improving care for people with AKI and sepsis.
The programme had two key objectives:
- Improving the quality of care and patient safety for people with AKI and sepsis
- Developing the improvement and patient safety capability of staff in the region
The clinical outcome aims of the AKI collaborative were to:
- Reduce 30-day mortality by 25%
- Improve renal function recovery
- Reduce hospital length of stay
These were supported by efforts to improve processes such as the timely recognition of AKI and delivery of AKI treatments.
The clinical outcome aims of the sepsis collaborative were to:
- Reduce 30-day mortality by 20%
- Reduce the number of sepsis related transfers to the intensive care unit
- Reduce hospital length of stay as one of the perceived indicators for care quality and patient safety.
Trusts that participated in the AKI and sepsis collaboratives were:
- Barking, Havering and Redbridge University Hospitals NHS Trust
- Barts Health NHS Trust
- Basildon and Thurrock University Hospitals NHS Foundation Trust
- Homerton University Hospital NHS Foundation Trust
- Luton and Dunstable University Hospital NHS Foundation Trust
- Mid Essex Hospital Services NHS Trust
- North Middlesex Hospital NHS Trust
- Princess Alexandra Hospital NHS Trust
- Royal Free London NHS Foundation Trust
- Southend University Hospital NHS Foundation Trust
- University College London Hospitals NHS Foundation Trust
- West Hertfordshire Hospitals NHS Trust
- Whittington Health NHS Trust
The AKI and sepsis workstreams were delivered as two separate Institute for Healthcare Improvement (IHI) Breakthrough Series collaboratives, which ran in parallel for 22 months, progressing through baseline, improvement and implementation phases. In addition to the classic BTS model, participating teams received a day of measurement training as well as an additional “holding the gains” learning session following the implementation period.
The trusts and their collaborative teams were actively supported by the UCLPartners programme team through all stages of the collaborative. This included the delivery of a total of 46 webinars, the provision of dedicated QI and measurement training, access to the IHI Open School, regular site visits, support with patient engagement, data collection support, and the final analysis of the collaborative.
A researcher-in-residence evaluated the collaboratives, by observing and interviewing participating teams to understand their and their trust’s motivation to take part in improvement collaboratives. This resulted in a separate report, which is in the process of being published and will be shared online when ready.
The programme team, working together with the trusts, also involved AKI and sepsis patients in the collaboratives from the planning phase, as members of the faculty, and learning sessions.
Each collaborative faculty developed a range of outcome and process measures specific to AKI and sepsis. Participating teams were given dedicated data collection forms to collect data for 10 patient episodes per month and report these back to the programme team for collaborative analysis.
AKI and the sepsis collaborative reduced 30-day mortality. Whilst AKI reduced it by 47% the sepsis collaborative did so by 24%, both exceeding the initial aims of 25% for AKI and 20% for sepsis.
The AKI collaborative improved renal function recovery to 20% within baseline creatine (a blood measurement which is important indicator of renal health) by 19.5%. The recognition of AKI within 4 hours of presentation at hospital improved by 33% from 72% to 95%; and the number of AKI treatments given on time by 24% from 74% to 92%. The median hospital length of stay increased slightly by 0.4 days from 8.2 to 8.6 days.
Sepsis related hospital length of stay improved by 1.6 days from 8.2 to 6.6 days and sepsis intensive care unit transfers by 52% from a median of 17% of transfers to 8%. The median number of patients whose vital signs were recorded within 15 minutes, improved by 13.5% from 62% to 70% across the collaborative; and the documentation of intravenous antibiotics improved by 19% from 54% to 63%.
One of the partaking trusts has also been commended by NHS England for their continued and sustained improvements in sepsis care.
Improvements were not only limited to clinical changes that led to improved recognition and timely care of patients with sepsis and AKI, such as sepsis stickers, allocating resources to create AKI and sepsis nursing roles, or utilising electronic triggers. The richness of storyboards, feedback from trust teams, and findings from the researcher-in-residence evaluation also suggest that the combined efforts changed team culture and improved communication within teams and across departments such as A&E, intensive care and maternal or paediatric specialities, who jointly provide care cared for patients with sepsis or AKI.
Data collection and sharing
As expected, continuous data collection was a challenge. Nevertheless, the data return was sufficient for a collaborative analysis. However, organising the collection of outcome and process measure data in a way that works for participating teams is as important as helping teams to learn to spread the data collection workload among team members.
Some trusts did not continuously collect or report AKI or sepsis data throughout the collaborative, but most participating teams engaged with their respective collaboratives at learning sessions. There they presented improvements and data providing evidence for their improvements as part of their storyboards at the collaborative learning sessions, which may not have necessarily been reported for collaborative analysis.
Involving sepsis and AKI patients at all stages of the collaboratives proved to be very impactful. Multiple patients shared their experiences during the learning sessions. Their emotive stories, were often difficult for participants to hear, but they set the right foundations for open and honest sharing and learning. Clinicians felt inspired by the personal stories of AKI and sepsis survivors and could reflect on the learnings and how they may they would have approached these cases. In turn, feedback from patient participants showed how sharing their experiences could be beneficial to them as they could see how the health service is trying to improve.
A programme report for dissemination across the partnership is currently being finalised. Learnings and findings from the AKI and sepsis collaboratives informed the regional patient safety delivery plan, especially for the deteriorating patients theme.
The programme will be highlighted and discussed via relevant national conferences and poster presentations.
The researcher-in-residence evaluation is in the final stages of publication in the BMJ Open Journal.
September 2015 to June 2017
Kate Hall, Director of Capability Development, UCLPartners
 Kerr M et al (2014). The economic impact of acute kidney injury in England. Nephrol Dial Transplant 2014.
 NHS England (2015). Improving outcomes for patients with sepsis – a cross-system action plan.
North East and North Cumbria PSC has also undertaken work in this area. Read the case study.