Acute Kidney Injury E-alert Research Articles

Electronic Alert Systems for Patients With Acute Kidney Injury

The acute kidney injury (AKI) electronic alert (e-alert) system was hypothesized to improve the outcomes of AKI. However, its association with different patient outcomes and clinical practice patterns remains systematically unexplored. To assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns. A search of Embase and PubMed on March 18, 2024, and a search of the Cochrane Library on March 20, 2024, to identify all relevant studies. There were no limitations on language or article types. Studies evaluating the specified outcomes in adult patients with AKI comparing AKI e-alerts with standard care or no e-alerts were included. Studies were excluded if they were duplicate cohorts, had insufficient outcome data, or had no control group. Two investigators independently extracted data and assessed bias. The systematic review and meta-analysis followed the PRISMA guidelines. Random-effects model meta-analysis, with predefined subgroup analysis and trial sequential analyses, were conducted. Primary outcomes included mortality, AKI progression, dialysis, and kidney recovery. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAID), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, hospital length of stay, costs, and AKI documentation. Thirteen unique studies with 41 837 unique patients were included (mean age range, 60.5-79.0 years]; 29.3%-48.5% female). The risk ratios (RRs) for the AKI e-alerts group compared with standard care were 0.96 for mortality (95% CI, 0.89-1.03), 0.91 for AKI stage progression (95% CI, 0.84-0.99), 1.16 for dialysis (95% CI, 1.05-1.28), and 1.13 for kidney recovery (95% CI, 0.86-1.49). The AKI e-alerts group had RRs of 1.45 (95% CI, 1.04-2.02) for nephrologist consultation, 0.75 (95% CI, 0.59-0.95) for post-AKI NSAID exposure. The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06) and 1.28 (95% CI, 1.04-1.58) for AKI documentation. Use of AKI e-alerts was not associated with lower hospital length of stay (mean difference, -0.09 [95% CI, -0.47 to 0.30] days) or lower cost (mean difference, US $655.26 [95% CI, -$656.98 to $1967.5]) but was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]). Trial sequential analysis confirmed true-positive results of AKI e-alerts on increased nephrologist consultations and reduced post-AKI NSAID exposure and its lack of association with mortality. In this systematic review and meta-analysis, AKI e-alerts were not associated with a lower risk for mortality but were associated with changes in clinical practices. They were associated with lower risk for AKI progression. Further research is needed to confirm these results and integrate early AKI markers or prediction models to improve outcomes.

Improving acute kidney injury alerts in tertiary care by linking primary care data: An observational cohort using routine care data.

Acute kidney injury (AKI) is easily missed and underdiagnosed in routine clinical care. Timely AKI management is important to decrease morbidity and mortality risks. We recently implemented an AKI e-alert at the University Medical Center Utrecht, comparing plasma creatinine concentrations with historical creatinine baselines, thereby identifying patients with AKI. This alert is limited to data from tertiary care, and primary care data can increase diagnostic accuracy for AKI. We assessed the added value of linking primary care data to tertiary care data, in terms of timely diagnosis or excluding AKI. With plasma creatinine tests for 84,984 emergency department (ED) visits, we applied the Kidney Disease Improving Global Outcome guidelines in both tertiary care-only data and linked data and compared AKI cases. Using linked data, the presence of AKI could be evaluated in an additional 7886 ED visits. Sex- and age-stratified analyses identified the largest added value for women (an increase of 4095 possible diagnoses) and patients ≥60 years (an increase of 5190 possible diagnoses). We observed 398 additional visits where AKI was diagnosed, as well as 185 cases where AKI could be excluded. We observed no overall decrease in time between baseline and AKI diagnosis (28.4 days vs. 28.0 days). For cases where AKI was diagnosed in both data sets, we observed a decrease of 2.8 days after linkage, indicating a timelier diagnosis of AKI. Combining primary and tertiary care data improves AKI diagnostic accuracy in routine clinical care and enables timelier AKI diagnosis.

Does acute kidney injury alerting improve patient outcomes?

BackgroundElectronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into a variety of different Electronic Health Records (EHR) systems worldwide in order to improve recognition and encourage early appropriate management of AKI. We were interested in the impact on patient safety, specialist referral and clinical management.MethodsAll patients admitted to our institution with AKI were included in the study. We studied AKI progression, dialysis dependency, length of hospital stay, emergency readmission, ICU readmission, and death, before and after the introduction of electronic alerts. The impact on prescription of high risk drugs, fluid administration, and referral to renal services was also analysed.ResultsAfter the introduction of the e-alert, progression to higher AKI stage, emergency readmission to hospital and death during admission were significantly reduced. More prescriptions were stopped for drugs that adversely affect renal function in AKI and there was a significant increase in the ICU admissions and in the number of patients having dialysis, especially in earlier stages. Longer term mortality, renal referrals, and fluid alteration did not change significantly after the AKI e-alert introduction.ConclusionsAKI e-alerts can improve clinical outcomes in hospitalised patients.

Characterising risk of non-steroidal anti-inflammatory drug-related acute kidney injury: a retrospective cohort study.

BackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pain and inflammation. NSAID complications include acute kidney injury (AKI), causing burden to patients and health services through increased morbidity, mortality, and hospital admissions.AimTo measure the extent of NSAID prescribing in an adult population, the degree to which patients with potential higher risk of AKI were exposed to NSAIDs, and to quantify their risk of AKI.Design & settingRetrospective 2-year closed-cohort study.MethodA retrospective cohort of adults was identified from a pseudonymised electronic primary care database in Hampshire, UK. The cohort had clinical information, prescribing data, and complete GP- and hospital-ordered biochemistry data. NSAID exposure (minimum one prescription in a 2-month period) was categorised as never, intermittent, and continuous, and first AKI using the national AKI e-alert algorithm. Descriptive statistics and logistic regression were used to explore NSAID prescribing patterns and AKI risk.ResultsThe baseline population was 702 265. NSAID prescription fell from 19 364 (2.8%) to 16 251 (2.4%) over 2 years. NSAID prescribing was positively associated with older age, female sex, greater socioeconomic deprivation, and certain comorbidities (diabetes, hypertension, osteoarthritis, and rheumatoid arthritis) and negatively with cardiovascular disease (CVD) and heart failure. Among those prescribed NSAIDs, AKI was associated with older age, greater deprivation, chronic kidney disease (CKD), CVD, heart failure, diabetes, and hypertension.ConclusionDespite generally good prescribing practice, NSAID prescribing was identified in some people at higher risk of AKI (for example, patients with CKD and older) for whom medication review and NSAID deprescribing should be considered.

Methods to Accurately Exclude Renal Dialysis Patients from The Welsh Acute Kidney Injury E-Alert System

IntroductionAcute Kidney Injury (AKI) effects up to 20% of emergency hospital admissions. It can be identified from serum creatinine (SCr) levels and as such an e-alert system has been introduced to hospitals in England and Wales to identify AKI. This system relies on manual review by pathology laboratory staff to prevent false alerts in dialysis patients.
 Objectives and ApproachOur aim is to use routinely collected dialysis timeline and dialysis treatment data in order to create dialysis treatment spells using Structured Query Language (SQL), which can then be compared with dialysis prevalence results in the UK renal registry. Furthermore, we will link this data with biochemical results in Secure Anonymised Information Linkage (SAIL) Databank to create an AKI cohort.
 Through identifying when patients are on renal replacement therapy (RRT) at a specific time we are able to exclude false positive AKI Alerts. This is done in two ways – one from a timeline within the data which is used in the UK renal registry. The other using individual dialysis sessions to get accurate coverage, as short periods of acute dialysis are often not been recorded in UK renal registry data.
 ResultsUsing the renal dataset in SAIL we were able identify more renal dialysis patients than the UK renal registry between (2009-17). By applying this to Swansea and Bridgend pathology data in SAIL we were able to identify 60,072 SCr tests in dialysis patients between 2011 and 2013 out of 1,776,101 SCr tests. In this cohort, without ruling out dialysis patients there would be 91,140 AKI alerts, however 19.6% (17,855) of the alerts are during dialysis treatments spells.
 Conclusion / ImplicationsWe were able to recreate the ‘e-Alert’ algorithm using SQL with SAIL and get an accurate picture of RRT in Wales, enabling more accurate AKI analysis.

Acute kidney injury e-alerts in pregnancy: rates, recognition and recovery.

Acute kidney injury (AKI) in pregnancy (Pr-AKI) is associated with substantial maternal morbidity and mortality. E-alerts are routinely used for detection of AKI in non-pregnant patients but their role in maternity care has not been explored. All pregnant or postpartum women with AKI e-alerts for AKI Stages 1-3 (Kidney Disease Improving Global Outcomes (KDIGO) criteria) were identified at a tertiary centre >2 years. Two women matched by delivery date for each case were selected as controls. AKI stage, recognition of AKI, pregnancy outcomes, renal recovery, AKI aetiology and risk factors were extracted from electronic patient records. 288 of 11 922 (2.4%) women had AKI e-alerts, of which only 118 (41%) were recognized by the obstetric team. Common Pr-AKI causes included infection (48%), pre-eclampsia (26%) and haemorrhage (25%), but no cause was identified in 15% of women. Renal function recovered in 213 (74%) women, but in 47 (17%) repeat testing was not undertaken and 28 (10%) did not recover function. Hypertensive disorders of pregnancy and Caesarean section were associated with increased incidence of Pr-AKI compared with controls. Pr-AKI e-alerts were identified in ∼1 in 40 pregnancies. However, a cause for Pr-AKI was not identified in many cases and e-alerts may have been triggered by gestational change in serum creatinine. Pregnancy-specific e-alert algorithms may be required. However, 1 in 10 women with Pr-AKI had not recovered kidney function on repeat testing. Better understanding of long-term impacts of Pr-AKI on pregnancy and renal outcomes is needed to inform relevant Pr-AKI e-alert thresholds.

The Incidence of Paediatric Acute Kidney Injury Identified Using an AKI E-Alert Algorithm in Six English Hospitals.

Objective: Acute kidney injury (AKI) is a significant cause of morbidity and mortality among hospitalised patients. The objectives in this study were (i) to investigate the incidence of AKI using the National Health Services (NHS) AKI e-alert algorithm as a means of identifying AKI; and (ii) in a randomly selected sub-group of children with AKI identified using the algorithm, to evaluate the recognition and management of AKI.Patients and Methods: Retrospective cross-sectional study with initial electronic retrieval of creatinine measurements at six hospitals in England over a six-month period. Results were evaluated using the NHS AKI e-alert algorithm with recognition and management of AKI stages 1, 2 and 3 reviewed in a sub-set of randomly selected patient case notes. Patients aged 29 to 17 years were included. AKI stage 1 was defined as a rise of 1.5 – ≤2x baseline creatinine level; AKI stage 2 a rise of ≤ 2.0 and < 3.0; AKI stage 3 a rise of ≥ 3.0. Urine output was not considered for AKI staging.Results: 57,278 creatinine measurements were analysed. 5,325 (10.8%) AKI alerts were noted in 1,112 patients with AKI 1 (62%), AKI 2 (16%) and AKI 3 (22%). There were 222 (20%) <1y, 432 (39%) 1 ≤ 6y, 192 (17%) 6 ≤ 11y, 207 (19%) 11 ≤ 16y, and 59 (5%) 16–17y. Case notes of 123 of 1,112 [11.1%] children with AKI alerts were reviewed. Confirmed AKI was recognised with a documented management plan following its identification in n = 32 [26%] patients only.Conclusions: In this first multicentre study of the incidence of AKI in children admitted to selected hospitals across England, the incidence of AKI was 10.8% with most patients under the age of 6 years and with AKI stage 1. Recognition and management of AKI was seen in just over 25% children. These data highlight the need to improve recognition of AKI in hospitalised children in the UK.

Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across...

Assessing the accuracy of ICD-10 coding for measuring rates of and mortality from acute kidney injury and the impact of electronic alerts: an observational cohort study.

BackgroundThe application of a uniform definition for acute kidney injury (AKI) is vital to advance understanding and management of AKI. International Classification of Diseases (Tenth Revision) (ICD-10) coding is frequently used to define AKI, but its accuracy is unclear. The aim of this study was to determine whether ICD-10 coding is a reliable method of monitoring rates and outcomes of AKI in inpatients compared with biochemically defined AKI, and whether electronic alerts (e-alerts) for AKI affect ICD-10 AKI coding. MethodsAn observational cohort study of all 505 662 adult admissions to acute hospitals in two Scottish Health Boards [National Health Service (NHS) Tayside and NHS Fife] from January 2013 to April 2017 was performed. AKI e-alerts were implemented in NHS Tayside in April 2015. Sensitivity, specificity, positive and negative predictive values of ICD-10 coding for AKI compared with biochemically defined AKI using the Kidney Disease: Improving Global Outcomes definition and relative risk of 30-day mortality in people with ICD-10 and biochemically defined AKI before and after AKI e-alert implementation were performed.ResultsSensitivity of ICD-10 coding for identifying biochemically defined AKI was very poor in both health boards for all AKI (Tayside 25.7% and Fife 35.8%) and for Stages 2 and 3 AKI (Tayside 43.8% and Fife 53.8%). Positive predictive value was poor both for all AKI (Tayside 76.1% and Fife 45.5%) and for Stages 2 and 3 AKI (Tayside 45.5% and Fife 36.8%). Measured mortality fell following implementation of AKI e-alerts in the ICD-10-coded population but not in the biochemically defined AKI population, reflecting an increase in the proportion of Stage 1 AKI in ICD-10-coded AKI. There was no evidence that the introduction of AKI e-alerts in Tayside improved ICD-10 coding of AKI.ConclusionICD-10 coding should not be used for monitoring of rates and outcomes of AKI for either research or improvement programmes.

Impact of introducing electronic acute kidney injury alerts in primary care.

BackgroundAcute 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.MethodsThe 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.ResultsDuring 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).ConclusionsWithin primary care, e-alert implementation was associated with higher rates of creatinine monitoring, but also higher rates of hospitalization.

The ICE-AKI study: Impact analysis of a Clinical prediction rule and Electronic AKI alert in general medical patients.

BackgroundAcute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes.Methods and findingsA controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014–16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981–1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858–0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560–0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation.ConclusionsIn acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness.Trial registrationClinicaltrials.org NCT03047382.

Replication of Acute Kidney Injury e-Alerts

BackgroundAcute Kidney Injury (AKI) is a serious condition occurring in approximately 20% of emergency hospital admissions. A Welsh AKI e-Alert (electronic alerts) system was introduced from 2013 with the aim of improving patient outcomes through early recognition of AKI.&#x0D; ObjectivesOur objective is to replicate the AKI e-Alert system which has been implemented throughout Wales and create a retrospective AKI cohort to facilitate data linkage.&#x0D; MethodsThe e-alert algorithm was re-produced in SQL (Structured Query Language) and applied to serum creatinine (SCr) values 2011-2014 held in the Secure Anonymised Information Linkage (SAIL) Databank. The algorithm utilises ratios between current SCr value (C1) to lowest SCr value within the previous 7 days (RV1), SCr median values from the previous 8-365 days (RV2), and lowest SCr within 48hrs (D). &gt;50% increase in RV1 or RV2 or &gt;26µmol/L above D triggers an alert. We created a temporal AKI cohort by using a renal dataset to exclude patients undergoing chronic dialysis.&#x0D; Findings2,407,590 SCr tests were performed on adult patients with 2,077,493 of these coming from people in Abertawe Bro Morgannwg University Health Board who were not on dialysis at the time of the test. The average population for 2011-2014 was 520,293. 85,272 (4.1%) of these tests triggered alerts for AKI. The average incidence of AKI per 100,000 population per year for 2011-2014 was 1,717. The average first AKI episodes per year for 2011-2014 respectively were stage 1 (least severe): 79.2%; stage 2: 13.5%; stage 3 (most severe): 7.3%.&#x0D; ConclusionsThe e-alert can be effectively reproduced using SQL to identify AKI in this large dataset, enabling subsequent validation of these alerts and evaluation of their impact through multisource data linkage.

Improved management of acute kidney injury in primary care using e-alerts and an educational outreach programme

Acute kidney injury (AKI) detected in primary care is associated with increased morbidity and mortality. AKI electronic alerts (e-alerts) and educational programmes have recently been implemented but their contribution to improve AKI care is unknown. This project aimed to improve response to AKI detected in primary care and used a factorial design to evaluate the impact of the UK National Health Service (NHS) AKI e-alert and AKI educational outreach sessions on time to response to primary care AKI stages 2 and 3 between April and August 2016. A total of 46 primary care practices were randomized into four groups. A 2 × 2 factorial design exposed each group to different combinations of two interventions. The primary outcome was 'time to repeat test' or hospitalization following AKI e-alert for stages 2 and 3. Yates algorithm was used to evaluate the impact of each intervention. Time to response and mortality pre- and post-intervention were analysed using Mann-Whitney U test and chi-square test respectively. The factorial design included two interventions: an AKI educational outreach programme and the NHS AKI e-alerts. 1807 (0.8%) primary care blood tests demonstrated AKI 1-3 (78.3% stage 1, 14.8% stage 2, 6.9% stage 3). There were 391 stage 2 and 3 events from 251 patients. E-alerts demonstrated a reduction in mean response time (-29 hours). Educational outreach had a smaller effect (-3 hours). Median response time to AKI 2 and 3 pre- and post-interventions was 27 hours versus 16 hours respectively (P = 0.037). Stage 2 and 3 event-related 30-day all-cause mortality decreased following the interventions (15.6% versus 3.9% P = 0.036). AKI e-alerts in primary care hasten response to AKI 2 and 3 and reduce all-cause mortality. Educational outreach sessions further improve response time.

Value of electronic alerts for acute kidney injury in high-risk wards: a pilot randomized controlled trial

PurposeTo investigate the application value of “electronic alerts” (“e-alerts”) for acute kidney injury (AKI) among high-risk wards of hospitals.MethodsA prospective, randomized, controlled study was conducted. We developed an e-alert system for AKI and ran the system in intensive care units and divisions focusing on cardiovascular disease. The e-alert system diagnosed AKI automatically based on serum creatinine levels. Patients were assigned randomly to an e-alert group (467 patients) or non-e-alert group (408 patients). Only the e-alert group could receive pop-up messages.ResultsThe sensitivity, specificity, Youden Index and accuracy of the AKI e-alert system were 99.8, 97.7, 97.5 and 98.1%, respectively. The prevalence of the diagnosis for AKI and expanded-AKI (AKI or multiple-organ failure) in the e-alert group was higher than that in the non-e-alert group (AKI 7.9 and 2.7%, P = 0.001; expanded-AKI 16.3 and 6.1%, P < 0.001). The prevalence of nephrology consultation in the e-alert group was higher than that in the non-e-alert group (9.0 and 3.7%, P = 0.001). There was no significant difference in the prevalence dialysis, rehabilitation of renal function or death in the two groups.ConclusionThe e-alert system described here was a reliable tool to make an accurate diagnosis of AKI.

Emerging concepts and spectrum of renal injury following Intravesical BCG for non-muscle invasive bladder cancer

BackgroundIntravesical Bacilli Calmette-Guerin (IVBCG) therapy for non-muscle invasive bladder cancer (NMIBC) has long been in use successfully. Albeit rarely, we still face with its safety concerns more than 25 years on since its approval by US Food and Drug Agency in 1990. Local and systemic infection following intravesical BCG is widely reported as compared to immune mediated local or systemic hypersensitivity reactions involving kidneys; acute kidney injury (AKI) and other renal manifestations are well reported but not of chronic kidney disease (CKD).CaseAn interesting case of a female was referred to nephrologists in advanced stages of CKD at an eGFR of 10 ml/min/1.732 following IVBCG for NMIBC. Our patient’s renal function plateaued when IVBCG was held; and worsened again when reinstilled. It introduces the concept of ‘repetitive’ immune mediated renal injury presenting as progressive CKD rather than AKI, as is generally reported. Although response was poor, corticosteroids stopped CKD progression to end stage renal disease.ConclusionsWe highlight the need for increased awareness and early recognition of IVBCG renal complications by both urologists and nephrologists in order to prevent progressive and irreversible renal damage. Low incidence of IVBCG renal complications may also be due to under recognition in the era prior to CKD Staging and AKI Network (and AKI e-alerts) that defined AKI as a rise in serum creatinine of ≥26umol/L; hence an unmet need for urgent prospective studies. Major literature review focuses on emerging spectrum of histopathological IVBCG related renal complications and their outcomes.

Impact of e-alert systems on the care of patients with acute kidney injury.

With the recent advancement in electronic health record systems and meaningful use of information technology incentive programs (i.e., the American Recovery and Reinvestment Act, the Health Information Technology for Economic and Clinical Health Act, and the Centers for Medicare & Medicaid Services), interest in clinical decision support systems has risen. These systems have been used to examine a variety of different syndromes with variable reported effects. In recent years, electronic alerts (e-alerts) have been implemented at various institutions to decrease the morbidity associated with acute kidney injury (AKI). AKI is common, accounting for 1 in 7 hospital admissions, and is associated with increased length of hospital stay and mortality. AKI is often underrecognized, causing delayed intervention. The use of e-alerts may result in earlier recognition and intervention, as well as decreased morbidity and mortality. This must be balanced with the possibility of increased resource utilization that e-alerts may cause. Before widespread implementation, the ethical and legal consequences of not following e-alert recommendations must be established, and the optimal algorithm for AKI e-alert detection must be determined.

The acute kidney injury e-alert and clinical care bundles: the road to success is always under construction.

The acute kidney injury e-alert and clinical care bundles: the road to success is always under construction.

KDIGO-based acute kidney injury criteria operate differently in hospitals and the community-findings from a large population cohort.

BackgroundEarly recognition of acute kidney injury (AKI) is important. It frequently develops first in the community. KDIGO-based AKI e-alert criteria may help clinicians recognize AKI in hospitals, but their suitability for application in the community is unknown.MethodsIn a large renal cohort (n = 50 835) in one UK health authority, we applied the NHS England AKI ‘e-alert’ criteria to identify and follow three AKI groups: hospital-acquired AKI (HA-AKI), community-acquired AKI admitted to hospital within 7 days (CAA-AKI) and community-acquired AKI not admitted within 7 days (CANA-AKI). We assessed how AKI criteria operated in each group, based on prior blood tests (number and time lag). We compared 30-day, 1- and 5-year mortality, 90-day renal recovery and chronic renal replacement therapy (RRT).ResultsIn total, 4550 patients met AKI e-alert criteria, 61.1% (2779/4550) with HA-AKI, 22.9% (1042/4550) with CAA-AKI and 16.0% (729/4550) with CANA-AKI. The median number of days since last blood test differed between groups (1, 52 and 69 days, respectively). Thirty-day mortality was similar for HA-AKI and CAA-AKI, but significantly lower for CANA-AKI (24.2, 20.2 and 2.6%, respectively). Five-year mortality was high in all groups, but followed a similar pattern (67.1, 64.7 and 46.2%). Differences in 5-year mortality among those not admitted could be explained by adjusting for comorbidities and restricting to 30-day survivors (hazard ratio 0.91, 95% confidence interval 0.80–1.04, versus hospital AKI). Those with CANA-AKI (versus CAA-AKI) had greater non-recovery at 90 days (11.8 versus 3.5%, P < 0.001) and chronic RRT at 5 years (3.7 versus 1.2%, P < 0.001).ConclusionsKDIGO-based AKI criteria operate differently in hospitals and in the community. Some patients may not require immediate admission but are at substantial risk of a poor long-term outcome.

Impact of electronic-alerting of acute kidney injury: workgroup statements from the 15(th) ADQI Consensus Conference.

Purpose of the reviewAmong hospitalized patients, acute kidney injury is common and associated with significant morbidity and risk for mortality. The use of electronic health records (EHR) for prediction and detection of this important clinical syndrome has grown in the past decade. The steering committee of the 15th Acute Dialysis Quality Initiative (ADQI) conference dedicated a workgroup with the task of identifying elements that may impact the course of events following Acute Kidney Injury (AKI) e-alert.Sources of informationFollowing an extensive, non-systematic literature search, we used a modified Delphi process to reach consensus regarding several aspects of the utilization of AKI e-alerts.FindingsTopics discussed in this workgroup included progress in evidence base practices, the characteristics of an optimal e-alert, the measures of efficacy and effectiveness, and finally what responses would be considered best practices following AKI e-alerts. Authors concluded that the current evidence for e-alert system efficacy, although growing, remains insufficient. Technology and human-related factors were found to be crucial elements of any future investigation or implementation of such tools. The group also concluded that implementation of such systems should not be done without a vigorous plan to evaluate the efficacy and effectiveness of e-alerts. Efficacy and effectiveness of e-alerts should be measured by context-specific process and patient outcomes. Finally, the group made several suggestions regarding the clinical decision support that should be considered following successful e-alert implementation.LimitationsThis paper reflects the findings of a non-systematic review and expert opinion.ImplicationsWe recommend implementation of the findings of this workgroup report for use of AKI e-alerts.

A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital.

Acute kidney injury (AKI) is a common and serious problem in hospitalized patients. Early detection is critical for optimal management but in practice is currently inadequate. To improve outcomes in AKI, development of early detection tools is essential. We developed an automated real-time electronic alert system employing algorithms which combined internationally recognized criteria for AKI [Risk, Injury, Failure, Loss, End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN)]. All adult patients admitted to Nottingham University Hospitals were included. Where a patient's serum creatinine increased sufficiently to define AKI, an electronic alert was issued, with referral to an intranet-based AKI guideline. Incidence of AKI Stages 1-3, in-hospital mortality, length of stay and distribution between specialties is reported. Between May 2011 and April 2013, 59,921 alerts resulted from 22,754 admission episodes, associated with 15,550 different patients. Overall incidence of AKI for inpatients was 10.7%. Highest AKI stage reached was: Stage 1 in 7.2%, Stage 2 in 2.2% and Stage 3 in 1.3%. In-hospital mortality for all AKI stages was 18.5% and increased with AKI stage (12.5, 28.4, 35.7% for Stages 1, 2 and 3 AKI, respectively). Median length of stay was 9 days for all AKI. This is the first fully automated real time AKI e-alert system, using AKIN and RIFLE criteria, to be introduced to a large National Health Service hospital. It has provided one of the biggest single-centre AKI datasets in the UK revealing mortality rates which increase with AKI stage. It is likely to have improved detection and management of AKI. The methodology is transferable to other acute hospitals.