A trial of in-hospital, electronic alerts for acute kidney injury: Design and rationale

Wilson, F. Perry; Reese, Peter P.; Shashaty, Michael G. S.; Ellenberg, Susan S.; Gitelman, Yevgeniy; Bansal, Amar D.; Urbani, Richard; Feldman, Harold I.; Fuchs, Barry D.

doi:10.1177/1740774514542619

Cited by 13 publications

(15 citation statements)

References 29 publications

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“…30 The protocol was reviewed and approved by the Institutional Review Board of the University of Pennsylvania, which granted a waiver to the informed consent process.…”

Section: Methodsmentioning

confidence: 99%

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial

et al. 2015

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Summary Background Acute kidney injury often goes unrecognised in its early stages when effective treatment options might be available. We aimed to determine whether an automated electronic alert for acute kidney injury would reduce the severity of such injury and improve clinical outcomes in patients in hospital. Methods In this investigator-masked, parallel-group, randomised controlled trial, patients were recruited from the hospital of the University of Pennsylvania in Philadelphia, PA, USA. Eligible participants were adults aged 18 years or older who were in hospital with stage 1 or greater acute kidney injury as defined by Kidney Disease Improving Global Outcomes creatinine-based criteria. Exclusion criteria were initial hospital creatinine 4·0 mg/dL (to convert to μmol/L, multiply by 88·4) or greater, fewer than two creatinine values measured, inability to determine the covering provider, admission to hospice or the observation unit, previous randomisation, or end-stage renal disease. Patients were randomly assigned (1:1) via a computer-generated sequence to receive an acute kidney injury alert (a text-based alert sent to the covering provider and unit pharmacist indicating new acute kidney injury) or usual care, stratified by medical versus surgical admission and intensive care unit versus non-intensive care unit location in blocks of 4–8 participants. The primary outcome was a composite of relative maximum change in creatinine, dialysis, and death at 7 days after randomisation. All analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01862419. Findings Between Sept 17, 2013, and April 14, 2014, 23 664 patients were screened. 1201 eligible participants were assigned to the acute kidney injury alert group and 1192 were assigned to the usual care group. Composite relative maximum change in creatinine, dialysis, and death at 7 days did not differ between the alert group and the usual care group (p=0·88), or within any of the four randomisation strata (all p>0·05). At 7 days after randomisation, median maximum relative change in creatinine concentrations was 0·0% (IQR 0·0–18·4) in the alert group and 0·6% (0·0–17·5) in the usual care group (p=0·81); 87 (7·2%) patients in the alert group and 70 (5·9%) patients in usual care group had received dialysis (odds ratio 1·25 [95% CI 0·90–1·74]; p=0·18); and 71 (5·9%) patients in the alert group and 61 (5·1%) patients in the usual care group had died (1·16 [0·81–1·68]; p=0·40). Interpretation An electronic alert system for acute kidney injury did not improve clinical outcomes among patients in hospital. Funding Penn Center for Healthcare Improvement and Patient Safety.

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“…30 The protocol was reviewed and approved by the Institutional Review Board of the University of Pennsylvania, which granted a waiver to the informed consent process.…”

Section: Methodsmentioning

confidence: 99%

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial

et al. 2015

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“…Epidemiological data of this pathology varies depending on how this entity is defined 2 7 8. It occurs in up to 5–10% of hospitalised patients 5. It has been documented that as many as two-thirds of patients in intensive care units have AKI 9.…”

Section: Introductionmentioning

confidence: 99%

“…Wilson et al found that only 43% of patients who had suffered severe AKI had this diagnosis sufficiently documented in their medical records 5. Colpaert et al evaluated the impact of real-time AKI alerts on therapeutic intervention by the physicians and the effect on AKI progression 4.…”

Section: Introductionmentioning

confidence: 99%

“…Studies using these systems have consistently shown that they have the capacity to improve the detection of AKI 6. Wilson et al holds that the provision of an early electronic alert for AKI could also improve outcomes in hospitalised patients 5. Roberts et al implemented a CDSS that improved dosing conformity and management of key renally cleared drugs 14.…”

Section: Introductionmentioning

confidence: 99%

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Improvement of drug prescribing in acute kidney injury with a nephrotoxic drug alert system

et al. 2017

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ObjectiveElectronic alert systems have shown their capacity for improving the detection of acute kidney injury (AKI). The aim of this study was to design and implement a clinical decision support system (CDSS) for improving drug selection and reducing nephrotoxic drug use in patients with AKI.MethodsThe study was designed as an intervention study comparing a pre and post cohort of patients admitted during April 2014 and April 2015, respectively (phase I and phase II). The intervention was a CDSS which provided kidney function and nephrotoxic drug information. Furthermore, an interruptive alert was designed to detect patients suffering an AKI event while taking a nephrotoxic drug and to see if the dose was then reduced or the drug was discontinued by the physicians.ResultsOne-third of the inpatients were included in the analysis because they met the inclusion criteria (1004 and 1002 patients in phases I and II, respectively). 735 and 761 of them received at least one nephrotoxic alert (73% vs 76%; p=0.763). 65 and 88 patients suffered AKI during admission (6.5% vs 8.8%; p=0.051). In phase I, patients received 384 nephrotoxic alerts (55%) with 78 (20%) of them provoking a change or discontinuation of the nephrotoxic drug. In phase II this value increased to 154 out of 526 (29%) after implementation of the CDSS (p<0.01).ConclusionsA CDSS with interruptive alerts that inform of the development of AKI in real time in patients with nephrotoxic drug prescription has a positive impact on the judicious use of these drugs.

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“…Methods to define this cohort have been previously published (17). After approval from the University of Pennsylvania's Institutional Review Board, we obtained data abstracted from the electronic medical record, including demographic and clinical information (admission and discharge International Classification of Disease-9 codes), all SCr values, discharge disposition, and orders for intermittent hemodialysis and continuous venovenous hemodialysis.…”

Section: Reference Cohortmentioning

confidence: 99%

False-Positive Rate of AKI Using Consensus Creatinine–Based Criteria

Lin¹,

Fernández

Shashaty

et al. 2015

Clinical Journal of the American Society of Nephrology

102

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Background and objectives Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false-positive rates because of inherent laboratory and biologic variabilities of creatinine.Design, setting, participants, & measurements We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false-positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient's true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria.Results Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false-positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%-8.1%), whereas patients with true serum creatinine $1.5 mg/dl (representing 21% of the clinical cohort) had a false-positive AKI diagnosis rate of 30.5% (interquartile range =30.1%-30.9%) versus 2.0% (interquartile range =1.9%-2.1%) in patients with true serum creatinine values ,1.5 mg/dl (P,0.001).Conclusions Use of small serum creatinine changes to diagnose AKI is limited by high false-positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies.

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A trial of in-hospital, electronic alerts for acute kidney injury: Design and rationale

Cited by 13 publications

References 29 publications

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial

Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial

Improvement of drug prescribing in acute kidney injury with a nephrotoxic drug alert system

False-Positive Rate of AKI Using Consensus Creatinine–Based Criteria

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