AKI mortality -the coding of these patients

Countess of Chester Hospital NHS Foundation Trust

Team Details

Dr Tim Webster, Consultant Physician

Sarah Balogh, Clinical Information Analyst

Michael Jones, Coding Team Leader

Michael Spry, Clinical Improvement & Assurance Manager

Mr Ian Harvey, Medical Director

Email: michaelspry@nhs.net

What was your original project Aim and has this changed?

AIM: To improve the accuracy of mortality data for AKI at the Countess.

To remove the “it’s the data not us” argument from mortality conversations

And fix the “FCE”

Driver Diagram

Measures and Data

• Identified as an outlier for renal failure

deaths

• 46 deaths in 12 months

46 case notes

Reviewed from admission to

death

Checked against audit

standards

Summary of resultsStandard Aim Compliance

EWSs score 100% 78%

Urine dip requested 100% 58%

MSSU requested 100% 42%

Fluid balance requested 100% 58%

Nephrotoxics stopped 100% 74%

Anti-hypertensives stopped 100% 78%

Catheter decision documented 100% 36%

Urgent Renal USS 100% 31%

Daily U&E requested 100% 49%

Senior review 100% 87%

Appropriate referral 100% 69%

AKI staged 100% 0%

Time from U&E taken to patient seen

Was AKI diagnosed on first documentation

Coding

Why is this?• 1 = no AKI• 9 = resolved to normal• 6 = ‘end of life’

Represents 35% of the cases

In relation to death certificates?‘End of life’:

Resolved:

Coding: conclusionsNot appearing on death certificate• 11 of 13 appropriately so

16 of 46 did not die from AKI

The FCE…..• A Finished Consultant Episode is the time a

patient spends in the continuous care of one consultant using hospital site or care home bed(s) of one health care provider or, in the case of shared care, in the care of two or more consultants. Where care is provided by two or more consultants within the same episode, one consultant will take overriding responsibility for the patient and only one consultant episode is recorded.

What we’ve tried• Casenote review of all TW patients coded

with AKI in 3 months= 0

• Casenote review of all AKI deaths coded over 3 months. – Only 3 cases identified. All appropriate.

• Endless meetings to try and alter the way FCEs are identified through meditech- unable to unpick this problem

• Pilot of block coding all FCEs together on MAU to ensure no part of MAU spell is missed - no change in outcome achieved as FCE2 still remains on MAU.

• Need FCE 2 on base ward following MAU stay to achieve accurate coding – how this can be achieved remains an issue

Other Related Work• Clinical improvements in AKI ongoing

through separate AQ/CQUIN working party

• Live coding pilot within stroke department is showing significant benefits - ?could translate into other areas

Key Achievements & Lessons Learnt• Proud of persevering with ‘dry’ topic, complex – better understanding of coding issues and

improved communication with coding department• Live coding on one COE ward as a pilot – daily coding to go through casenotes to ensure agree

with coding and have a co-morbidity checklist. Re-enforced use of diagnosis at PTWR, and coders now attending specialty meetings to re-enforce coding.

• What would you do differently – unpicking of clinical and administrative complexity of mortality – difficult to focus on both

• IT issues have been very frustrating – creating our own process constraints effecting our performance

• Live coding due to roll out – reduced FCEs, improved coding – clearer indication of focus• Team regularly meeting to keep momentum• More focused brief – avoid duplication of clinical aspects e.g. multiple projects looking at AKI

What should AQuA do differently

• Collaborative working could have been very useful

• Timescale seems to have lost some momentum• Initial focus on choosing a project could have

been helpful – some difference of opinion between team and AQuA around the value of ‘coding/FCEs’ as a project- this could have been raised earlier