Abstract
Neck of Femur Fractures (NOFF) - Educational QIP on Medication Management to Reduce Avoidable Hypotension and Acute Kidney Injury (AKI)
Introduction
Hip fractures prevalence increases with age. Patients aged ≥80 years have high morbidity and mortality risk following a hip fracture (hazard ratio for men [HR] 7.95, 95% CI 6.13-10.30 and HR women 5.75, 95% CI 4.94-6.67, respectively). Intraoperative hypotension is a risk factor for Acute Kidney Injury (AKI) after Neck of Femur Fracture (NOFF) surgery. The National NCEPOD AKI Report found a third of AKI is predictable and avoidable. Sodium-Glucose Co-transporter 2 inhibitors (SGLT2i) increase euglycemic ketoacidosis and biguanides can precipitate lactic acidosis in patients with renal insufficiency. This 3-cycle Quality Improvement Project (QIP) in NOFF patients aim to educate on medicine management and reduce avoidable hypotension and AKI.
Method
Cycle 1 - Identifying need for change. A questionnaire identified a knowledge gap in stopping anti-hypertensives in patients awaiting NOFF surgery.
Cycle 2- - Implementing Change. A 15-page booklet was designed to educate on medicine management, incorporating drug pharmacodynamics on AKI. Learning was reinforced with teaching sessions. Questionnaire was redistributed at each cycle to assess knowledge acquisition.
Cycle 3 – Reinforcing Change. Posters on medicine management were displayed on wards, and a QR code introduced to improve digital accessibility of the booklet.
Results
This 3 cycle QIP identified al knowledge gap in junior doctors about stoppage of anti-hypertensives prior to NOFF surgery. Cycle 2 saw an improved stoppage of all classes of anti-hypertensives, especially angiotensin converting enzyme and angiotensin II receptor inhibitors, which particularly increase pre-renal AKI risk. There was 20% and 100% improvement in stopping SGLT2is and biguanides, respectively. Cycle 3 saw the biggest improvement following posters and QR code introduction. Additionally, 60% more doctors appropriately discontinued sulfonylureas and anti-platelets.
Conclusion
Junior doctors reported increased knowledge and confidence in medicine management in NOFF patients. Use of digital technology further enhanced learning and reduced avoidable hypotension and AKI.