title: Preventing Acute Kidney Injury: a qualitative study exploring 'sick day rules' implementation in primary care.
abstract: In response to growing demand for urgent care services there is a need to implement more effective strategies in primary care to support patients with complex care needs. Improving primary care management of kidney health through the implementation of 'sick day rules' (i.e. temporary cessation of medicines) to prevent Acute Kidney Injury (AKI) has the potential to address a major patient safety issue and reduce unplanned hospital admissions. The aim of this study is to examine processes that may enable or constrain the implementation of 'sick day rules' for AKI prevention into routine care delivery in primary care.
  
  
  
  Forty semi-structured interviews were conducted with patients with stage 3 chronic kidney disease and purposefully sampled, general practitioners, practice nurses and community pharmacists who either had, or had not, implemented a 'sick day rule'. Normalisation Process Theory was used as a framework for data collection and analysis.
  
  
  
  Participants tended to express initial enthusiasm for sick day rules to prevent AKI, which fitted with the delivery of comprehensive care. However, interest tended to diminish with consideration of factors influencing their implementation. These included engagement within and across services; consistency of clinical message; and resources available for implementation. Participants identified that supporting patients with multiple conditions, particularly with chronic heart failure, made tailoring initiatives complex.
  
  
  
  Implementation of AKI initiatives into routine practice requires appropriate resourcing as well as training support for both patients and clinicians tailored at a local level to support system redesign.
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, 5th Floor Williamson Building, Oxford Road, M13 9PL, Manchester, UK. Rebecca.morris@manchester.ac.uk.|NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK. Rebecca.morris@manchester.ac.uk.
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Morris
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.|Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK.
authors.forename: Darren
authors.initials: D
authors.lastname: Ashcroft
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.|Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK.
authors.forename: Denham
authors.initials: D
authors.lastname: Phipps
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute for Population Health, University of Manchester, Manchester, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
authors.affiliation: Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK.
authors.forename: Donal
authors.initials: D
authors.lastname: O'Donoghue
authors.affiliation: Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Roderick
authors.affiliation: Park Edge Practice, Leeds, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Harding
authors.affiliation: Department of Renal Medicine, Lincoln Wing, St James's University Hospital, Beckett Street, Leeds, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Lewington
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, 5th Floor Williamson Building, Oxford Road, M13 9PL, Manchester, UK.|NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester, Manchester, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Blakeman
mesh_terms: D058186:Acute Kidney Injury / Q000517:prevention & control*; D000328:Adult; D057911:Angiotensin Receptor Antagonists / Q000008:administration & dosage*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D001291:Attitude of Health Personnel; D003142:Communication; D005260:Female; D058006:General Practice / Q000379:methods* / Q000458:organization & administration; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000523:psychology; D010353:Patient Education as Topic; D010595:Pharmacists / Q000523:psychology; D010820:Physicians / Q000523:psychology; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration; D016730:Program Development; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000150:complications*; D012646:Self Administration; D055815:Young Adult
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: Acute Kidney Injury; Kidney disease; Multimorbidity; Normalisation process theory; Primary care; Qualitative; UK