ACUTE KIDNEY INJURY AND TRANSITIONS OF CARE BETWEEN HOSPITAL AND PRIMARY CARE: A QUALITATIVE STUDY APPLYING SYSTEMS THINKING METHODOLOGY

Targeting the harms associated with Acute kidney injury (AKI) is a major patient safety priority. People affected by AKI experience potentially avoidable adverse outcomes following hospital discharge. These include high rates of unplanned readmissions and poor long-term health outcomes including development or progression of chronic kidney disease as well risk of sustaining a major adverse cardiovascular event. Since 2015, it has been mandatory for all acute NHS hospital trusts in England to implement a clinical decision support system to improve detection and acute response to AKI. With AKI affecting around half a million people in England each year, improved followed up care after AKI also has potential to result in sizable overall benefits across the United Kingdom.

The management of patients following an AKI is particularly challenging because many of these interactions occur across the interface between hospital and primary care settings. We aimed to explore patient experience and everyday working practices to illuminate key areas within the systems that are important to improve follow-up care for people affected by AKI.  

Twenty-six patients were interviewed following an admission complicated by AKI and six focus groups were conducted with primary and secondary healthcare professionals (n=35). AKI patients were identified by clinical care teams across six NHS Hospital Trusts in England. Semi-structured interviews with patients were conducted remotely up to four weeks after discharge between January 2023 and May 2024. Eleven patient participants agreed to take part in a follow-up interview four to six months later to explore follow-up care over this time.

We applied system methods to explore areas important for success and adaptations to challenges. The Functional Resonance Analysis Method modelled interactions between activities across the primary/secondary care interface. The Systems Thinking for Everyday Work principles were used to identify how people adapted to challenges.  

Follow-up care was conceptualised as entailing three key areas of work: generating a post-AKI discharge plan; involving patients in a post-AKI plan; and enacting a post-AKI following discharge from hospital. Seven key themes described the challenges faced by patients and professionals within and across the system of care. Senior oversight of discharge planning was variable, staff completing discharge documents felt under pressure, requiring trade-offs between competing priorities. Patients experienced anxiety and vulnerability yet were expected to be active participants in their care, with little evidence of education and involvement. Enacting the post-AKI discharge plan in primary care was complicated by inadequate communication, with imperfect systems to optimise monitoring and medication management.

Follow-up care for people affected by AKI requires clear and timely communication across secondary and primary care settings. The study highlights the importance of addressing system constraints, variability in work practices, and resource limitations to improve kidney healthcare in primary care settings post-discharge. Key findings relate to development of more explicit discharge summaries, clarity around medicines management and the purpose of further tests are important to improve the transition of post AKI discharge support for this patient population. 

A related abstract was presented at the Society for Academic Primary Care, Cardiff, United Kingdom, July 2025 (https://sapc.ac.uk/doi/10.37361/asm.2025.1.1)