What works in outreach to GPs managing patients with Acute Kidney Injury in the community?

Problem

Acute Kidney Injury (AKI) is a common condition that significantly contributes to morbidity and mortality; its care is often suboptimal and/or delayed. AKI usually occurs in elderly patients and together with other comorbidities. There may be potential for the novel approach of renal outreach where laboratory results identify a patient with AKI.

Approach

We report results from a qualitative study nested within a large pilot of an outreach intervention based at a West Midlands hospital. Patients with AKI were identified using the national algorithm. The intervention consisted of a phone call to the hospital doctor or GP treating the patient, aiming at rapidly establishing the aetiology and correcting reversible causes e.g. nephrotoxic medications. This was supplemented by a ward visit for the most severe AKI (stage 3). The outreach team conducted further investigations where appropriate. We followed a realistic methodology (Pawson and Tilley, 1997), exploring ‘what works, for whom and in what circumstances’; this presentation focuses on GPs and other primary care professionals.

Findings

We conducted focus groups at primary care sites before (n=6) and after (n=2) the intervention (total of participants=54). We aimed to elicit professionals’ perspectives on the helpfulness of renal outreach and how it should be delivered; the later groups also discussed purposively selected patient cases and the utility of interactions between the outreach team and primary care staff. We analysed the data using the Framework method (Ritchie and Spencer 1994), guided by a realistic approach (outlined above).1. What works?• Timeliness of the outreach (after morning surgery but not so late that findings cannot be acted on or out of hours)• Participants also discussed possibilities for a hotline or webchat facility they can contact• Reaching the right person e.g. a GP who knows the patient well• Contacting the patient directly if an emergency admission is needed2. For whom?• GPs who are aware of AKI but need help with complex cases• Patients “in between” primary and secondary care e.g. potentially needing admission or discharged from hospital3. Under what circumstances?• When there is good communication (in person or through IT systems) between primary and secondary care• When both GPs and patients are aware of AKI as potential danger• Where systems do not create ‘alert overload’• Where patients can be contacted (and potentially visited) in the community

Consequences

The outreach programme was overall seen as helpful; however challenges were also noted by participants. Attention needs to be paid to the timing of calls; other avenues for contact might also need to be explored. Relationships between the outreach team and GPs in the community may be crucial and would be expected to develop over time. However, contextual factors (up-to-date records; communication between primary care, hospitals and patients) may also contribute to successful outreach.