Clinical Decision Support to Reduce Contrast-Induced Kidney Injury During Cardiac Catheterization: Design of a Randomized Stepped-Wedge Trial

Abstract

Background: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. Methods: The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, pointof-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision

Development and Evaluation of an Audit and Feedback Process for Prevention of Acute Kidney Injury During Coronary Angiography and Intervention

“… 27 , 32 , 46 Data are physician-specific Choose comparators that reinforce desired behaviour change Comparators can help inform goals. Should be simple/clear and minimize possible mixed messages 41 Comparisons to peers at the same hospital and to peers across the province Closely link the visual display and summary message Visual representations of summary messages should be consistent and should be linked clearly. 50 Plots are consistent with tables and written notes Minimize extraneous cognitive load for feedback participants Graphical displays should be simple and consistent with the message being conveyed.…”

“…We implemented an audit and feedback process for CA-AKI prevention for all cardiologists performing coronary angiography or PCI in Alberta, Canada between November 2017 and November 2019, as part of a pragmatic clinical trial that introduced a multifaceted intervention comprised of provider education, computerized clinical decision support, and an audit and feedback process for CA-AKI prevention. The design of the clinical trial within which the audit and feedback process was implemented has been described in detail elsewhere; the trial included a study population of patients who were not on dialysis and were undergoing coronary angiography or PCI (excluding emergency primary PCI for ST-elevation myocardial infarction), with a predicted risk of AKI > 5%, compared∖an intervention that included point-of-care computerized decision support and auditing and feedback regarding individualized targets for safe radiocontrast media volume use and hemodynamically guided IV fluid administration based on left-ventricular end diastolic pressure 41 vs usual care, and evaluated the primary outcome of AKI. We conceived audit and feedback reporting to be part of the intervention, to give participating physicians data on their actual performance, compared with the desired performance on these process-of-care measures, for which guidance was provided by the computerized decision-support tool.…”

“…The first was the volume of iodinated radiocontrast media used for each patient’s procedure, accompanied by comparison with targets for the desired contrast volume to achieve a low risk of CA-AKI ( Table 1 ), as previously described. 41 , 42 , 43 The second was the amount of IV crystalloid fluid provided to each patient in the peri-procedural period, accompanied by comparison with the desired hemodynamically guided IV fluid volume for prevention of CA-AKI based on left-ventricular end-diastolic pressure measurement in patients without active (within the last 2 weeks) heart failure or severe aortic valvular heart disease. 44 We selected one clinical outcome, the incidence of CA-AKI, based on evidence that lowering radiocontrast media volume and optimizing IV fluid administration can reduce the incidence of CA-AKI.…”

“…We selected two process of care outcomes that were under the control of physicians performing coronary angiography or intervention and were modifiable. The first was the volume of iodinated radiocontrast media used for each patients' procedure, accompanied by comparison with targets for the desired contrast volume to achieve a low risk of CA-AKI (Table 1), as previously described [41][42][43] . The second was the amount of intravenous crystalloid fluid provided to each patient in the peri-procedural period, accompanied by comparison with the desired hemodynamically-guided intravenous fluid volume for prevention of CA-AKI based on LVEDP measurement in patients without active (within the last 2 weeks) heart failure or severe valvular heart disease 44 .…”

Hospital Adoption of Electronic Decision Support Tools for Preeclampsia Management

“…Furthermore, hospitals with a single EHR system may be more likely to have robust, centralized training programs for clinicians and staff to implement evidence-based practices. For example, some hospital systems with robust EHR capabilities also have programs for academic detailing of physicians on evidence-based practices 33–35. Private for-profit hospitals were more likely to adopt EHR-based decision support tools for preeclampsia management than public hospitals, which suggests that hospital resources and access to capital support the adoption and use of electronic decision support tools.…”