QJM Advance Access originally published online on January 30, 2008
QJM 2008 101(3):249-250; doi:10.1093/qjmed/hcn001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Transfer of patients with acute kidney injury to specialist renal services—physiological early-warning systems, applied prior to transfer from outside hospitals, can identify those at risk of deterioration*
Sir,
The UK National Service Framework for Renal Services1—a template for both clinical practice and organization—acknowledges the variety of settings in which acute kidney injury (AKI) may be managed. However, specialist renal management may well be needed for those whose case complexity or severity requires transfer from non-specialist hospitals or for those receiving single-organ (renal) support on the ICU. Unfortunately, as demonstrated in this journal,2 significant delays in transfer do exist and may consume ICU resources and adversely affect patient outcomes. Although timely renal management is the core goal, the arrival of such patients on a specialist unit with unheralded critical illness is a potential disaster in terms of both immediate patient safety and the unexpected burden that this may place on local critical care services. Our challenge is how best to decide, prior to actual transfer, whether such patients should be managed solely by renal services or in conjunction with critical care.
With this in mind, we assessed the utility of a generic illness severity scoring tool as a predictor of later escalation of care in all off-site AKI patients already accepted for transfer to our regional renal unit. In the 1 year from 15th October 2005, a SOFA score, a composite assessment of organ dysfunction,3 was calculated for all such patients at the time of referral. The subsequent need for escalation to higher-level care was determined, retrospectively.
Sixty-five AKI patients (mean age 60.4 years; 35 male) transferred to the renal unit, 24 from critical care, the remainder from other in-patient settings. The mean SOFA score at referral was 4.7 (2–11) with 19 patients scoring 
6. Nine of the 65 required escalation of care after transfer (including reescalation of four of the 24 transferred from critical care). The three who deteriorated within 24 hours of transfer all had a SOFA score 6, two who had only just stepped down from critical care, one from accident and emergency. The remaining six requiring later escalation of care had an initial SOFA score of 3–5.
AKI patients accepted onto our unit with an initial SOFA score 6 carry a higher risk of early escalation of care. These findings might well be regarded as intuitive but it is only recently that the UK National Institute of Health and Clinical Excellence has had to reinforce the importance of well-defined protocols for the early recognition and management of the acutely unwell in-patient.4 Although our tool cannot determine the most appropriate venue for transfer, it can augment subjective assessments of illness severity, trigger preemptive responses, such as early liaison with critical care and senior colleagues and warn of the need for more frequent physiological observation on arrival on the unit. The principle of remote application of an illness severity score has been maintained in our unit protocol although now we use the in-house, modified early warning score (instituted after the start of the audit), along with its equivalent action trigger points, to facilitate understanding across all involved disciplines. This is the subject of an ongoing (re-) audit.
By extending the radar of severity scoring systems to all outside hospital transfers we can be given early warning of the patient with the potential for deterioration. Such processes may also be applicable in other specialist settings, where we have the luxury of being able to employ such systems at a distance.
Conflict of interest statement: None declared.
Department of Renal Medicine
Freeman Hospital
High Heaton
Newcastle-upon-Tyne NE7 7DN, UK
email: suren.kanagasundaram{at}nuth.nhs.uk
Notes
*The results presented in this paper have not been published previously in whole or part, except in abstract format (UK Renal Association, annual meeting, May 2007). 
References
1. Department of Health Renal NSF team. In: The National Service Framework for Renal Services. Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life Care. (2005) London: UK Department of Health.
2. Hegarty J, Middleton RJ, Krebs M, Hussain H, Cheung C, Ledson T, et al. Severe acute renal failure in adults: place of care, incidence and outcomes. Q J Med (2005) 98:661–6.[Web of Science]
3. Armitage M, Eddleston J, Stokes T. Recognising and responding to acute illness in adults in hospital: summary of NICE guidance. Br Med J (2007) 335:258–9.
4. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-related problems of the European Society of Intensive Care Medicine. Intensive Care Med (1996) 22:707–10.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||