Specialist pneumonia intervention nurse service improves pneumonia care and outcome.

BACKGROUND: A specialist pneumonia intervention nursing (SPIN) service was set up across a single National Health Service Trust in an effort to improve clinical outcomes. A quality improvement evaluation was performed to assess the outcomes associated with implementing the service before (2011-2013) and after (2014-2016) service implementation. RESULTS: The SPIN service reviewed 38% of community-acquired pneumonia (CAP) admissions in 2014-2016. 82% of these admissions received antibiotic treatment in <4 hours (68.5% in the national audit). Compared with the pre-SPIN period, there was a significant reduction in both 30-day (OR=0.77 (0.70-0.85), p<0.0001) and in-hospital (OR=0.66 (0.60-0.73), p<0.0001) mortality after service implementation, with a review by the service showing the largest independent 30-day mortality benefit (HR=0.60 (0.53-0.67), p<0.0001). There was no change in length of stay (median 6 days). CONCLUSION: Implementation of a SPIN service improved adherence to BTS guidelines and achieved significant reductions in CAP-associated mortality. This enhanced model of care is low cost, highly effective and readily adoptable in secondary care.

Postpartum care of women with renal disease.

Twenty-three percent of women with known chronic kidney disease (CKD) have been reported to demonstrate the first decline in kidney function between giving birth and six-weeks postpartum. As such, these women warrant close monitoring during the postpartum period irrespective of their pregnancy journey. Substantial haemodynamic variability during pregnancy and postpartum renders estimated glomerular filtration rate inaccurate, and poorly defined normal ranges of markers of kidney function at this time pose challenges for accurate assessment of renal complications. Multi-disciplinary specialist care is therefore essential, with consideration of specific implications of any known renal diagnosis and with observation for the development of postpartum complications of pregnancy. Furthermore, the postpartum period affords time to further investigate and diagnose kidney disease revealed by pregnancy. Good care planning and communication in the postpartum period has the potential to improve long-term health outcomes for women with known or new CKD and will be discussed in this review.

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study.

BACKGROUND: Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts. METHODS: We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters). RESULTS: In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001). CONCLUSIONS: Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.