A Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report

Abstract

Background Frequently, prescribers fail to account for changing kidney function when prescribing medications. We evaluated the use of a computerized provider order entry intervention to improve medication management during acute kidney injury (AKI). Study Design Quality improvement report with time series analyses. Setting & Participants 1598 adult inpatients with a minimum 0.5 mg/dl increase in serum creatinine over 48 hours following an order for at least one of 122 nephrotoxic or renally cleared medications. Quality Improvement Plan Passive, non-interactive warnings about increasing serum creatinine appeared within the computerized provider order entry interface and on printed rounding reports. For contraindicated or high toxicity medications that should be avoided or adjusted, an interruptive alert within the system asked providers to modify or discontinue the targeted orders, mark the current dosing as correct and to remain unchanged, or defer the alert to reappear in the next session. Outcomes & Measurements Intervention effect on drug modification or discontinuation, time to modification or discontinuation, provider interactions with alerts. Results The modification or discontinuation rate per 100 events for medications included in the interruptive alert within 24 hours of increasing creatinine improved from 35.2 pre-intervention to 52.6 post-intervention (p<0.001); orders were modified or discontinued more quickly (p<0.001). During the post-intervention period, providers initially deferred 78.1% of interruptive alerts, although 54% of these were eventually modified or discontinued prior to patient death, discharge, or transfer. The response to passive alerts about medications requiring review did not significantly change when compared to baseline. Limitations Single tertiary care academic medical center; provider actions were not independently adjudicated for appropriateness. Conclusions A computerized provider order entry-based alerting system to support medication management following AKI significantly increased the rate and timeliness of modification or discontinuation of targeted medications.

Use of Electronic Results Reporting to Diagnose and Monitor AKI in Hospitalized Patients

“…The value of electronic alerts was shown in patients taking nephrotoxic drugs, in whom an email alert resulted in a 55% risk reduction of AKI (this study predated the current AKIN definition) (22). In a similar, more recent study, interruptive electronic alerts were also shown to improve medicines management in those with AKI (23). However, the alert system prompted responses in only 52% of cases and passive alerts were less effective.…”

Adverse Drug Events during AKI and Its Recovery

“…Our study highlights the challenges of caring for patients with AKI and was conducted in a medical center with many medication safety strategies, including electronic medical records, CPOE with clinical decision support (17), and rounding clinical pharmacists. We could not quantify the impact of these safeguards on our outcome rates, but previous studies suggest substantial improvement (4,(46)(47)(48).…”

“…Study data were collected as part of a quality improvement program with Institutional Review Board approval to improve drug safety (16). Briefly, the program featured CPOEbased clinical decision support (17,18), prospective monitoring, and as necessary, intervention by a clinical pharmacist through an electronic surveillance tool. Data for this observational study were collected at discharge by an independent outcome assessor.…”

“…Patients with both increasing and decreasing SCr changes were included in the study and classified as AKI or AKI recovery based on the direction of the initial SCr change. The threshold of 0.5 mg/dl was selected by an internal committee of expert nephrologists in 2005 before the publication of standard AKI stages by the Acute Kidney Injury Network (AKIN), and it is intended to represent the threshold above which medication use needs to be reassessed (17,19). We calculated AKI severity using AKIN staging, which compares a baseline creatinine (SCr before minimum 0.5 mg/dl rise) with a 7-day peak (19).…”

Acute kidney injury: top ten tips

“…Studies looking at the efficacy of the systems currently in use have shown a 55% reduction in the risk of AKI in patients taking nephrotoxic drugs and an improvement in medicines management in 52%. 20,21 More recently, Selby et al described a real-time electronic resultsreporting system for AKI, which is linked to clinical guidelines on the hospital intranet. This system not only improved early recognition of AKI but also encouraged timely management of patients and early escalation of sick patients in accordance with local guidelines.…”