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If you have not yet heard of sick day rules for reducing patients’ risk of acute kidney injury (AKI), you probably will soon. That was the message conveyed by Liz Lamerton, principal clinical pharmacist at Salford Royal NHS Foundation Trust, in a presentation delivered at the Prescribing Show — held on 3 December 2014 in Bradford, England. The initiative, which aims to reduce the incidence of patients being admitted to hospital with AKI, appears to be going viral.
The premise is that patients who become dehydrated are at risk of AKI — particularly if they take medicines that worsen dehydration or can deteriorate kidney function. Therefore, when such patients become unwell with diarrhoea, vomiting, fever or sweats, they may be safer not taking some of their medicines until their acute illness resolves. Specifically, this refers to:
- Angiotensin-converting enzyme inhibitors
- Angiotensin-2 receptor blockers
- Non-steroidal anti-inflammatory drugs
- Diuretics
- Metformin
The patient-empowering initiative has been operating in parts of Scotland and Wales since 2013. During July of that year, at NHS Highland, patient information cards explaining the above advice were produced and distributed to patients through community pharmacists and dispensing practices (with a supply also being sent to other GP surgeries, hospitals and care workers). An unpublished evaluation of the project, circulated in July 2014, appears to have captured the attention of health boards and clinical commissioning groups either side of the border.
Clare Morrison, lead pharmacist (north) for NHS Highland, who led the project, says: “It’s important that the cards are not just put on general public display. They should be given to patients as part of a discussion to explain the medicines involved and clarify what level of illness would warrant temporarily stopping medicines. Patients also need to be made aware of the importance of restarting their medicines once their illness resolves — otherwise they could put themselves at risk of hospital admission from other causes, such as an exacerbation of heart failure.”
A similar project has been operating concurrently in the Betsi Cadwaladr University Health Board area in North Wales. Community pharmacies and GP surgeries have been advising patients with the aid of a leaflet containing similar advice to that offered in NHS Highland. However, the leaflets also advise patients who are under the care of a specialist clinic (eg, for renal disease or heart failure) to seek medical advice before withholding their medication. Janet Thomas, patient safety pharmacist at the health board, believes this addition is essential for preventing potential heart failure admissions.
English Pharmacy Board (EPB) member Liz Butterfield says the Royal Pharmaceutical Society (RPS) is working with NHS England as part of its AKI risk reduction workstream to explore how pharmacists can contribute to preventive initiatives. “Work is under way to evaluate the benefit of greater pharmacist involvement, particularly via community pharmacists, in reducing the risk of medicines-related AKI,” she says. “We must make sure, however, that the message being given to patients is consistent across all healthcare professionals.”
She adds that community pharmacists are currently being surveyed by Think Kidneys (a programme jointly run by NHS England and the UK Renal Registry — www.thinkkidneys.nhs.uk) to determine their awareness of AKI and help identify whether further training is required. She also reveals that AKI will be the subject of a medicines optimisation briefing, to be circulated to RPS members in early 2015.
There is merit in the EPB’s standpoint — there is little point in pharmacists offering advice if it contrasts with that offered by GPs. But that should not prevent preliminary local discussions from taking place. After all, if and when this initiative comes to a health board or commissioning group near you, it would be good if the local community pharmacy workforce was already engaged.
