Impact of introducing electronic acute kidney injury alerts in primary care

Abstract

Background Acute kidney injury (AKI) is associated with decreased survival, future risk of chronic kidney disease and longer hospital stays. Electronic alerts (e-alerts) for AKI have been introduced in the UK in order to facilitate earlier detection and improve management. The aim of this study was to establish if e-alerts in primary care were acted on by examining timing of repeat creatinine testing. Methods The National Health Service England Acute Kidney Injury electronic alert algorithm was introduced in April 2015 across both primary and secondary care in NHS Tayside accompanied by a programme of education. Data from a 12-month period (2012) predating introduction of the e-alerts were compared with a 12-month period following implementation of e-alerts for AKI. Biochemistry testing following the AKI episode, timing of repeat tests and numbers of patients hospitalized within 7 days of episode were compared between the two time periods. Results During the 12 months after e-alert introduction, 9781 AKI e-alerts were generated. Of these, 1460 (14.9%) alerts were generated in primary care. Median duration to repeat blood testing for these primary care alerts was 5 days for AKI Stage 1 [interquartile range (IQR) 2–10], 2 days for Stage 2 (IQR 1–5) and 1 day (IQR 0–2) for Stage 3. During 2012 (prior to e-alert implementation) 8812 AKI episodes were identified. Of these, 2650 tests (30.1%) were requested by primary care staff. Median duration to repeat creatinine testing was longer: 55 days (IQR 20–142) for Stage 1, 38 days (IQR 15–128) for Stage 2 was and 53 days (IQR 20–137) for Stage 3. More patients had biochemistry tests repeated within 7 days of AKI onset, pre-alert implementation; 252 (9.5%) versus 857 (58.7%) (P < 0.001). Rates of hospitalization within 7 days of AKI increased from 342 (12.9%) pre-implementation to 372 (25.5%) post-implementation (P < 0.001). Conclusions Within primary care, e-alert implementation was associated with higher rates of creatinine monitoring, but also higher rates of hospitalization.

Acute Kidney Injury in Primary Care: A Review of Patient Follow-Up, Mortality, and Hospital Admissions following the Introduction of an AKI Alert System

“…Our present data are in line with a similar study in Dundee by Aiyegbusi et al [11]. They found 1,205 AKI episodes in 12 months from an approximate catchment population of 400,000 after introducing an e-alert using the same AKI algorithm.…”

“…Follow-up creatinine was measured within 14 days in 55% of AKI1s, 84% of AKI2s, and 86% of AKI3s, compared to 51, 72, and 77%, respectively in our previous paper [9]. This increase in frequency of repeat creatinine measurements was also mirrored in the Dundee study (from 10 to 59% across all AKI stages) though they looked for repeat sampling by day 7 versus 14 [11]. Holmes et al [12] looked at a population of ∼3 million after the introduction of e-alerts.…”

Impact of electronic alerts for acute kidney injury on patient outcomes: interrupted time-series analysis of population cohort data

“…Previous studies have suggested a benefit from using AKI e-alerts on care processes including a reduction in time taken to modify or discontinue medications [ 17 ], and an increase in fluid assessments and prescribing in hospital [ 18 , 19 ]. We have shown in a previous study that the introduction of AKI e-alerts in the community led not only to an increase in creatinine monitoring [ 20 ], but also to higher rates of hospitalization. Several studies have reported reductions in mortality associated with AKI following the introduction of e-alerts [ 21 , 22 ] but have evaluated impact using an uncontrolled before or after comparison, which is at high risk of bias because it does not account for any underlying trend in the data (unlike the ITS analysis used in this study).…”

A scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems

“…Thirty-two studies featured an intervention at the micro (individual patient) level. In 15 the main purpose of the intervention was harm prevention,[13,17,19,21,22,26,28,32,35–39] in 12 it was earlier diagnosis,[14,20,24,25,30,31,40–45] and in two, risk prediction. [12,46] Harm prevention interventions involved alerts to clinicians of the need to change nephrotoxic drugs (non-prescription, dose altering or drug suspension) based on a patient’s renal function.…”

“…[21,24,40,44] Three quarters of these interventions used interruptive alerts,[13,21,38,43–46] and in a third the alert was outside the clinicians’ workflow. [21,25,30,31,35,40,44,45] All early diagnosis alerts, apart from one (urine output [25]), were activated by changes in serum creatinine (SCr) levels. This was similar for harm prevention, with a minority of interventions using nephrotoxic drug exposure instead.…”