Learning the ABCDE of acute kidney injury How the ‘ABCDE’ checklist for acute kidney injury was implemented at Ulster Hospital

Kidney specialists at Ulster Hospital introduced an ‘ABCDE’ checklist for acute kidney injury, which led to a dramatic improvement in the care of patients who developed the condition while in hospital. This work was featured in our ‘Bottoms up’ film. Here we look in more detail at what the team achieved and how they did it.

Dr Jennifer McCaughan and Dr Niall Leonard wanted to find a way to improve the detection of acute kidney injury. It was an issue that affected the whole hospital – one in five patients admitted to the hospital ended up with some degree of an acute problem with their kidneys. Early recognition and action is vital for successful treatment of the condition, but only 30% of cases were being recognised within 24 hours and just 20% of patients were receiving four out of the five essential treatment steps.

The checklist

Inspiration for the ABCDE checklist came from The Checklist Manifesto by Atul Gawande. When she read the book, Jennifer was struck by the importance of checklists in aviation safety. ‘They’ve a checklist for the doors shutting, a checklist for the engines working, and anytime anything goes wrong, they follow a checklist. And that’s why it’s so safe, because there are checklists to follow,’ she explains.

‘I thought we must be able to come up with something that would be easy for people to remember and easy for them to do. So that was how it started: ABCDE – five things you should do for anyone who gets a problem with their kidneys.’

Those five ABCDE steps are:

• address the drugs the person is on
• boost the blood pressure
• calculate their fluids
• dipstick the urine
• exclude obstruction.

Testing the idea

The Safety, Quality, Experience project mentors recommended trialling the checklist on a small number of patients. The team introduced health professionals on a surgical ward to the checklist and with their input, added in three warning signs that someone’s kidneys are failing.

At the end of the first week of the trial, the team found that the checklist wasn’t being used at all. They began to realise that people needed to understand how the checklist would benefit patients, so they spent time talking to nurses, nursing assistants, junior doctors and pharmacists. Then they asked them to put in place just one of the five steps each week.

This approach was labour intensive, but it paid off. After three months, recognition of acute kidney injury had risen from 30% to 100%, with all five steps being completed for 80% of patients.

Changing the way we work

The team replicated the approach on a second ward and achieved the same level of success, before rolling it out to more wards, where they found people had heard about the checklist and were keen to start using it. ‘It was impossible for us to be there on all those wards, so we thought we would go back and the data would be pretty hopeless,’ comments Niall. ‘But the data showed that improvement had been sustained, and it had been sustained across all the wards.’

By the end of the first year of the new approach, almost every patient who developed acute kidney injury was having it recognised. The team were seeing other changes too – when other doctors in the hospital contacted them about patients with kidney problems, the doctor had often already completed the ABCDE checklist and was able to provide the results.