Abstract
BackgroundAcute kidney injury (AKI) affects a large proportion of the critically ill and is associated with worse patient outcomes. Early identification of AKI can lead to earlier initiation of supportive therapy and better management. In this study, we evaluate the impact of computerized AKI decision support tool integrated with the critical care clinical information system (CCIS) on patient outcomes. Specifically, we hypothesize that integration of AKI guidelines into CCIS will decrease the proportion of patients with Stage 1 AKI deteriorating into higher stages of AKI.MethodsThe study was conducted in two intensive care units (ICUs) at University Hospitals Bristol, UK, in a before (control) and after (intervention) format. The intervention consisted of the AKIN guidelines and AKI care bundle which included guidance for medication usage, AKI advisory and dashboard with AKI score. Clinical data and patient outcomes were collected from all patients admitted to the units. AKI stage was calculated using the Acute Kidney Injury Network (AKIN) guidelines. Maximum AKI stage per admission, change in AKI stage and other metrics were calculated for the cohort. Adherence to eGFR-based enoxaparin dosing guidelines was evaluated as a proxy for clinician awareness of AKI.ResultsEach phase of the study lasted a year, and a total of 5044 admissions were included for analysis with equal numbers of patients for the control and intervention stages. The proportion of patients worsening from Stage 1 AKI decreased from 42% (control) to 33.5% (intervention), p = 0.002. The proportion of incorrect enoxaparin doses decreased from 1.72% (control) to 0.6% (intervention), p < 0.001. The prevalence of any AKI decreased from 43.1% (control) to 37.5% (intervention), p < 0.05.ConclusionsThis observational study demonstrated a significant reduction in AKI progression from Stage 1 and a reduction in overall development of AKI. In addition, a reduction in incorrect enoxaparin dosing was also observed, indicating increased clinical awareness. This study demonstrates that AKI guidelines coupled with a newly designed AKI care bundle integrated into CCIS can impact patient outcomes positively.
Highlights
Acute kidney injury (AKI) affects a large proportion of the critically ill and is associated with worse patient outcomes
In order to understand the impact of the clinical decision support systems (CDSS) on clinician behavior, we evaluated the effect of the alert on a proxy for guideline compliance by examining the dosing of a commonly prescribed drug, enoxaparin, that requires adjustment in the context of AKI
The study was divided into two phases—the control phase when no AKI guidelines and care bundle was shown to clinicians and the intervention phase when AKI guidelines and care bundle was available to clinicians via IntelliSpace Critical Care and Anesthesia (ICCA)
Summary
Acute kidney injury (AKI) affects a large proportion of the critically ill and is associated with worse patient outcomes. Acute kidney injury (AKI) is a common occurrence in the critically ill, developing in more than 50% of patients at some point during a critical care admission [1] It increases mortality, length of stay and healthcare cost [2]. Automated electronic alerts may be expected to improve early detection of AKI, while clinical decision support systems (CDSS) might further support clinicians in diagnosis, drug dosing and management. Previous studies applying these approaches to AKI have shown variability in results [7,8,9,10]. This is likely due to population differences as well as differences in the nature of the alert and action prompted
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