Reducing Contrast-Induced Acute Kidney Injury Using a Regional Multicenter Quality Improvement Intervention

Abstract

Background Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality following percutaneous coronary interventions (PCI) and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine if a six-year regional multi-center quality improvement intervention could reduce CI-AKI following PCI. Methods and Results We conducted a prospective multi-center quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21,067 non-emergent patients undergoing PCI at ten hospitals between 2007 and 2012. Six ‘intervention’ hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as “benchmark” sites and were used to develop the intervention and two hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital-level we calculated adjusted risk ratios (RR) for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (RR 0.79; 95%CI: 0.67 to 0.93; p=0.005) for all patients and by 28% in patients with baseline eGFR<60 ml/min/1.73 m2 (RR 0.72; 95%CI: 0.56 to 0.91; p=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included: multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. Conclusions Simple cost-effective quality improvement interventions can prevent up to one in five CI-AKI events in patients with undergoing non-emergent PCI.

Reducing Acute Kidney Injury Due to Contrast Material: How Nurses Can Improve Patient Safety

“…Because most improvement efforts and protocols were for high-risk patients with eGFR less than 60 mL/min per 1.73 m analyses were repeated for patients who had that eGFR value at baseline. 32 All statistical analyses were conducted by using Stata, version 11.2, software (StataCorp, LP).…”

“…Teams were also innovative in developing hard stops in a patient's process of care by delaying a procedure if the patient had not received an adequate fluid bolus until the ordered fluid bolus was delivered. 32 Although many studies have been done on interventions to reduce the risk of CI-AKI, no previous investigations were focused on nurse-implemented quality improvement efforts to reduce CI-AKI. The most recent attempt of using a quality improvement initiative to reduce the incidence of CI-AKI was published in 2006 when the Michigan Cardiovascular Consortium reported on nephropathy due to contrast material and multiple quality indicators from a 1998 to 2002 intervention.…”

“…Their experiences were used to inform the intervention, but these sites did not take part in the active intervention. 31,32 Quality Improvement Intervention Phase…”

“…In addition to monthly conference calls and annual focus groups, representatives from each hospital attended 3 regional NNECDSG meetings each year where trends of CI-AKI, implementing best practices, and novel approaches to minimize CI-AKI were presented and discussed. 32 …”

“…40 Patients generally were hospitalized 2.7 (median, 2.0) days during the baseline period and 2.6 (median, 2.0) days during the follow-up period. 32 …”