The final theme is concerned with establishing the extent to which respondents felt that their involvement in the alert system had any effects, beneficial or otherwise, on patient care and clinical practice, as well as cost-effectiveness.
Making a difference to patient care
Some respondents could point to circumstances in which they might have had some positive impact on patient outcomes, and outreach nurses tended to have a firm conviction that they were essentially contributing to patient benefit:
. . . for the patients. I know . . . I mean I don’t know how many we’ve seen . . . but I know that there are some that we’ve changed things for.
ON1:24
. . . how can it not be a benefit? It has to be, doesn’t it? It has to be.
ON2:25
. . . most AKI is . . . secondary to sepsis or dehydration, or excess diuresis, you know, so actually if you can alert the teams to it and get them to intervene early, then actually you will significantly
improve outcomes.
C5:12
I think sometimes . . . when we pitch up a lot of the relatives and the patients are,‘Oh thank goodness somebody’s going to come and do something,’ because they’ve got . . . they’ve noticed that there’s something wrong and it looks as if somebody’s coming to sort it out so that’s a patient benefit, isn’t it, from their perception.
But consultants were largely sceptical about the benefits. This was mostly because of the observation that either teams were already aware or full-scale intervention was not clinically appropriate:
I question whether phoning a junior doctor team or consultant . . . about a patient admitted the day before with acute kidney injury and who, they must be aware if they’ve looked at the blood results, has AKI, I wonder whether that actually provides any added value at all.
C2:7
. . . I’d say three-quarters of the patients you ring up . . . they’re either dying and there is nothing you can do or the team’s got it in hand and they know exactly what they’re doing and they’re doing fine. So you know it does feel sometimes like quite a lot of work for very little benefit.
C5:11
One respondent indicated that the lack of perceived benefits stemmed from advice not being followed:
I think that generally speaking it doesn’t improve patient care . . . there was one case only where I did give advice which was the correct advice and then we subsequently found that the advice wasn’t followed and that patient was eventually transferred here for dialysis therapy so I feel that it doesn’t really add to patient management . . .
C1:5
Comments were also made that suggested a need for proper comparative research and larger samples to better estimate benefits:
. . . once you’ve, you know, given the information and instructions, what happens it’s not really followed up and whether it would have made any difference you would have to compare it with somebody who has not had that, you know, data so you have to compare it with something to know whether there is a difference or not.
C3:5
I think there are too few numbers of patients to really point to whether it has a benefit or not, but it’s brought AKI to people’s attention . . . we just need to have the means to track patients . . .
C6:10
The following respondent indicated that more benefits could potentially be achieved through the outreach team, who focus on patients with the earlier stages of AKI:
I think the outreach team have been looking at going out to see people with acute kidney injury stage 2 and they’ve actually physically seen patients and put information in the notes . . . I suspect that probably the biggest benefits will have come from that intervention, getting in there a little bit earlier and actually steering people in the right direction.
C5:12
Impacts on clinical practice
Most respondents saw both positive and negative impacts on clinical practice. The following statements refer to cases in which intervention can be positive and serve an educational purpose:
I think that there are certain groups in the hospital that are very poor at managing the sick patients and particularly patients with AKI . . . so I think that actually, I think that’s where I see that we have the benefit . . . when I ring up some, one of the surgeons to say did you realise your patient has deteriorating renal function . . . they usually haven’t got a clue . . . so it does prompt them to go and actually look and get their medical review.
. . . sometimes it’s not direct intervention, it’s almost preventing intervention . . . you know, facilitating the team making a clinical judgement on what is or isn’t appropriate for the demented ninety seven year old with multiple other illnesses . . . So some of them are sort of much more soft interventions about sort of management strategy rather than medical treatment . . . some of it’s educational as well.
C4:13
The outreach nurses specifically identified the positive and proactive contribution of the stickers, as well as the ability of their involvement to reduce unnecessary work:
And they’re actually now approaching us when we go onto the unit and say, ‘Can we have a sticker?’ and they will have people that haven’t even been identified on the database as acute kidney
injury and they want stickers for those notes.
ON3:7
. . . whoever’s on the nightshift will go round in the early hours of the morning, we’d go into QlikView, get the list out, go and identify these patients and their notes so that when they’re being post-take in the morning it’s identified to the teams . . . Which is . . . certainly cutting out one ward round and potentially 1 day’s worth of medical input.
ON2:17
In addition, outreach nurses in particular saw the educational opportunities for themselves:
I think for me it’s been positive because I’ve . . . it’s done a lot for my knowledge and maybe . . . maybe I see patients in a different way now. Sharing skills which is part of our job, people show interest in the stickers and you’re able to tell them what you’re looking for and why so they might pick things up about the drugs that you’re looking at and so on.
ON1:24
The following comment from a consultant indicates the benefits of an AKI database, again in terms of enhancing educational opportunities in the trust:
. . . the system does mean that we’ve now got a very good database of actually what sort of AKI we have in the trust and where it is . . . which groupings is it happening under and maybe an idea as to you know, who’s doing well and who’s not doing so well and to allow us to focus some education on those areas that aren’t doing well.
C5:11
Conversely, other comments related to the negative personal impact on practice brought about by the alert system:
. . . I think it adds to my busy day already when I’ve put you know, I can actually do other things . . .
C1:6
. . . I’m not sure it’s the best use of my time to be perfectly honest . . . a lot of it’s an administrative task which is pretty tedious.
However, all respondents highlighted concerns regarding clinical responsibility for the patient and the impact of the alert system. This comment describes what this means in practice for consultants:
I have quite a lot of concerns about ownership of the patients. So for example if a patient was admitted on my take, I would assume a hundred per cent responsibility for . . . acting and looking into each problem and dealing with it. And when you include a system like this I feel that number one ownership could be eroded and doctors . . . could become more nonchalant and lethargic and say‘oh there is this computer system that could pick this patient up and because they have renal failure it’s not my problem any more’ and I feel strongly about that.
C1:6
As has been noted, outreach nurses had particular concerns about where their involvement began and ended, and how some doctors interpreted this:
I think ownership of the . . . ownership of the alert system from my feeling is . . . becomes an issue. My feeling is that once you document in the notes‘Outreach’, you then become the first point of contact for anything that ever goes wrong or problems . . . you then become embroiled in the rest of the unfolding of the events.
ON2:6/7
. . . some doctors will see the sticker and your signature and think that every day you’re going to make sure their bloods are done and you’re going to check the results. Other teams won’t. Other teams will just manage what they do but it’s very varied.
ON1:9
Even from the medical teams;‘Mrs so-and-so – you’ve seen this person?’ ‘I’ve kind of not really; I just stuck an . . . alert sticker in the notes and signed it.’
ON3:6
This respondent made particular reference to the establishment of a specialist orthogeriatric system that compounded the problem of patient accountability within certain surgical teams:
. . . part of the problem with trauma and orthopaedics is now that there is this orthogeriatric system in place, it’s almost exacerbated the problem of them now completely ignoring anything . . . there’s almost a mentality now that; out of hours– oh that can wait, the orthogeries will be on in the morning.
ON2:15
There were also concerns that the alert system had generally impacted on their professional roles in a negative way, reducing it to an unsatisfactory screening process as a result of being provided with by‘lists’:
I think the problem for us is that we have so many parts of our role and we’ve . . . we’ve become very much a list and screening culture, so we . . . we start off every morning with a list from the alert system, we have a list from the VitalPAC, we have our list of patients and it feels very much as though we’re trawling around the hospital to keep a lot of lists . . . you obviously have to go through that process to get to people that you’re going to have effective interactions with but it’s beginning to feel like we are part of this list culture . . . that’s not very nice really.
Continuing with outreach nurse perceptions of professional issues, respondents were aware that there were numerical differences in patient interactions brought about by the alert system between the three hospital sites. This was explained by an administrative problem with recording on two of the sites (the numbers recorded did not in fact reflect activity in reality) and that there were fewer identified patients on the third site:
. . . we go and see these patients but we don’t always at the end of the day sit down and put them on the system . . . Now, unless we keep all of that documentation we can’t go back retrospectively and put it on the system so we . . . we miss that time slot. So there are a lot of interactions we do on this site that we don’t put on the system.
ON3:19
Probably at [site] our patient numbers are lower . . . And it is doable within our working hours.
ON1:19
Perceptions of cost-effectiveness
It was generally difficult for respondents to express the extent to which they felt that the alert system saved money, but the following comments demonstrate that it is certainly an aspiration:
Well it costs £150 to dialyse a patient, and that’s around £30,000 per patient per year . . . so it would be nice to think it was making some impact on that . . .
C6:10
If you’re highlighting early people that have got an acute kidney injury that’s then being treated and managed it’s got to save money in terms of length of stay and ongoing treatment or higher levels of treatment.
ON2:26
. . . so do we save money? Don’t know . . . do we improve patient outcomes? One would hope to think so and actually you could then say well improving outcomes is going to be a cost saving in terms of if you can prevent somebody needing to go onto dialysis or needing to go up to ITU for haemofiltration, yes you will save money, you will shorten their patient inpatient stay.
C4:14
This respondent, however, was more sceptical:
. . . if somebody’s already in ITU and being managed and they know about AKI I don’t think that will save money just to tell them that he has AKI.
C3:7
Other, more comparative views focused on the cost of respondent time:
I don’t know how much QlikView costs, I’m assuming it’s part of the great IT budget of the hospital so in terms of everything else it’s probably a small cost, but in terms of time at the moment it’s quite costly on time.
C1:7
. . . well it’s highly cost-effective at the moment because it’s not included within any of our job plans to my knowledge, so essentially the trust is getting this additional work for– for nothing!
Summary
Despite some respondents, largely outreach nurses, perceiving positive proactive, preventative and educational benefits for patient outcomes and clinical practice, other respondents were not wholly convinced of the value of the system in terms of inducing these benefits, nor of being cost-effective. This scepticism resulted from the observation that most clinical teams already had the situation in hand, or that intervention was not indicated. In addition, the small number of patients made impacts difficult to assess. An issue of concern centred on the potential of the alert system to divert perceived clinical responsibility of the patient away from the clinician who was actually accountable, and outreach nurses in particular felt that this aspect impacted on their professional roles. It was also revealed that discrepancies in outreach nurse system activity between the sites were largely caused by an administrative recording issue.