Transitions of care following acute kidney injury: a systems-based analysis.

backgroundPeople affected by Acute Kidney Injury (AKI) experience poor short and long-term outcomes following discharge from hospital. Attempts to improve care have recognised the complexity of the healthcare system. We applied systems methods to explore everyday work and illuminate areas important for success, challenges faced and how people adapted to these challenges.

methodsTwenty-six patients who had recently been discharged from six hospitals after an admission complicated by AKI were interviewed. Focus groups were conducted with healthcare staff across six sites in England. Using the Functional Resonance Analysis Method (FRAM), the activities undertaken by patients and professionals across the primary-secondary care interface were modelled and interactions examined. The Systems Thinking for Everyday Work (STEW) principles were then applied to understand how people coped with system challenges to achieve successful outcomes.

resultsTwenty-two interacting activities were identified and modelled. These formed three interlinked subsystems that underpin effective management after an admission affected by AKI: (1) generating a post-AKI plan; (2) involving patients in their care; and (3) enacting the plan following discharge. Within these, seven themes captured the key challenges. Senior oversight of discharge planning was inconsistent, and staff preparing discharge documents felt under pressure and had to make trade-offs between competing priorities. Patients reported anxiety and vulnerability and yet were expected to be active participants in their care with little evidence of education and involvement. Finally, enacting the post-AKI discharge plan in the community was complicated by inadequate communication, imperfect systems with limited capacity and tensions between short-term stability and long-term condition management.

conclusionTo optimise follow-up care for people affected by AKI, development of improvement strategies should focus on co-design of interventions with patients and healthcare professionals to address the inherent trade-offs at discharge and strengthen coordination across care boundaries.