Nicole V Tolan1,2, Salman Ahmed3, Tolumofe Terebo1,4, Zain M Virk2, Athena K Petrides1,2, Jaime R Ransohoff5, Christiana A Demetriou6,7, Yvelynne P Kelly8, Stacy E F Melanson1,2, Mallika L Mendu2,4. 1. Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts. 2. Harvard Medical School, Boston, Massachusetts. 3. Department of Medicine, Baylor College of Medicine, Houston, Texas. 4. Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts. 5. Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland. 6. Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus. 7. The Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus. 8. Department of Critical Care Medicine, St. James Hospital, Dublin, Ireland.
Abstract
Background: AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear. Methods: We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months; n=159) along with an email to the provider (intervention II; 3 months; n=105), compared with a control (baseline; 6 months; n=176). A comment was generated if a patient's creatinine increased by >0.5 mg/dl (previous creatinine ≤2.0 mg/dl) or by 50% (previous creatinine >2.0 mg/dl) within 180 days. Process measures included documentation of AKI and clinical actions. Clinical outcomes were defined as recovery from AKI within 7 days, prolonged AKI from 8 to 89 days, and progression to CKD with in 120 days. Results: Providers were more likely to document AKI in interventions I (P=0.004; OR, 2.80; 95% CI, 1.38 to 5.67) and II (P=0.01; OR, 2.66; 95% CI, 1.21 to 5.81). Providers were also more likely to discontinue nephrotoxins in intervention II (P<0.001; OR, 4.88; 95% CI, 2.27 to 10.50). The median time to follow-up creatinine trended shorter among patients with AKI documented (21 versus 42 days; P=0.11). There were no significant differences in clinical outcomes. Conclusions: An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. Translation of these findings into improved outcomes may require corresponding standardization of clinical practice protocols for managing AKI.
Background: AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear. Methods: We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months; n=159) along with an email to the provider (intervention II; 3 months; n=105), compared with a control (baseline; 6 months; n=176). A comment was generated if a patient's creatinine increased by >0.5 mg/dl (previous creatinine ≤2.0 mg/dl) or by 50% (previous creatinine >2.0 mg/dl) within 180 days. Process measures included documentation of AKI and clinical actions. Clinical outcomes were defined as recovery from AKI within 7 days, prolonged AKI from 8 to 89 days, and progression to CKD with in 120 days. Results: Providers were more likely to document AKI in interventions I (P=0.004; OR, 2.80; 95% CI, 1.38 to 5.67) and II (P=0.01; OR, 2.66; 95% CI, 1.21 to 5.81). Providers were also more likely to discontinue nephrotoxins in intervention II (P<0.001; OR, 4.88; 95% CI, 2.27 to 10.50). The median time to follow-up creatinine trended shorter among patients with AKI documented (21 versus 42 days; P=0.11). There were no significant differences in clinical outcomes. Conclusions: An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. Translation of these findings into improved outcomes may require corresponding standardization of clinical practice protocols for managing AKI.
Authors: F Perry Wilson; Michael Shashaty; Jeffrey Testani; Iram Aqeel; Yuliya Borovskiy; Susan S Ellenberg; Harold I Feldman; Hilda Fernandez; Yevgeniy Gitelman; Jennie Lin; Dan Negoianu; Chirag R Parikh; Peter P Reese; Richard Urbani; Barry Fuchs Journal: Lancet Date: 2015-02-26 Impact factor: 79.321
Authors: Joe M El-Khoury; Melanie P Hoenig; Graham R D Jones; Edmund J Lamb; Chirag R Parikh; Nicole V Tolan; F Perry Wilson Journal: J Appl Lab Med Date: 2021-05-11
Authors: Jennie Lin; Hilda Fernandez; Michael G S Shashaty; Dan Negoianu; Jeffrey M Testani; Jeffrey S Berns; Chirag R Parikh; F Perry Wilson Journal: Clin J Am Soc Nephrol Date: 2015-09-03 Impact factor: 8.237
Authors: Jay L Xue; Frank Daniels; Robert A Star; Paul L Kimmel; Paul W Eggers; Bruce A Molitoris; Jonathan Himmelfarb; Allan J Collins Journal: J Am Soc Nephrol Date: 2006-02-22 Impact factor: 10.121
Authors: Ravindra L Mehta; John A Kellum; Sudhir V Shah; Bruce A Molitoris; Claudio Ronco; David G Warnock; Adeera Levin Journal: Crit Care Date: 2007 Impact factor: 9.097
Authors: Matthew T James; Charles E Hobson; Michael Darmon; Sumit Mohan; Darren Hudson; Stuart L Goldstein; Claudio Ronco; John A Kellum; Sean M Bagshaw Journal: Can J Kidney Health Dis Date: 2016-02-26