Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial

Abstract

Objective To determine whether electronic health record alerts for acute kidney injury would improve patient outcomes of mortality, dialysis, and progression of acute kidney injury. Design Double blinded, multicenter, parallel, randomized controlled trial. Setting Six hospitals (four teaching and two non-teaching) in the Yale New Haven Health System in Connecticut and Rhode Island, US, ranging from small community hospitals to large tertiary care centers. Participants 6030 adult inpatients with acute kidney injury, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. Interventions An electronic health record based “pop-up” alert for acute kidney injury with an associated acute kidney injury order set upon provider opening of the patient’s medical record. Main outcome measures A composite of progression of acute kidney injury, receipt of dialysis, or death within 14 days of randomization. Prespecified secondary outcomes included outcomes at each hospital and frequency of various care practices for acute kidney injury. Results 6030 patients were randomized over 22 months. The primary outcome occurred in 653 (21.3%) of 3059 patients with an alert and in 622 (20.9%) of 2971 patients receiving usual care (relative risk 1.02, 95% confidence interval 0.93 to 1.13, P=0.67). Analysis by each hospital showed worse outcomes in the two non-teaching hospitals (n=765, 13%), where alerts were associated with a higher risk of the primary outcome (relative risk 1.49, 95% confidence interval 1.12 to 1.98, P=0.006). More deaths occurred at these centers (15.6% in the alert group v 8.6% in the usual care group, P=0.003). Certain acute kidney injury care practices were increased in the alert group but did not appear to mediate these outcomes. Conclusions Alerts did not reduce the risk of our primary outcome among patients in hospital with acute kidney injury. The heterogeneity of effect across clinical centers should lead to a re-evaluation of existing alerting systems for acute kidney injury. Trial registration ClinicalTrials.gov NCT02753751 .

Design, development, and deployment of an indication- and kidney function-based decision support tool to optimize treatment and reduce medication dosing errors

“…It will be crucial to monitor for unanticipated untoward effects, given the potential harm that can be induced by CDS. 17 , 67 …”

The Impact of Outpatient Laboratory Alerting Mechanisms in Patients with AKI

“…Previous studies on the impact of AKI alerts were performed on hospitalized patients and reported variable impacts on clinical outcomes. [8][9][10][11][12][13][15][16][17] Aiyegbushi et al performed a study on hospitalized patients and showed that an AKI alert was associated with a dramatic reduction in the repeat testing interval for creatinine. 15 However, Wilson et al in a single-center, randomized controlled trial of more than 23,000 hospitalized adult patients found that an AKI alert had no impact on the clinical outcomes of peak creatinine concentration, initiation of RRT, or death during the current hospital admission or within 30 days.…”

“…9,10 Most reports of electronic notification of AKI have focused on in-hospital AKI events. [11][12][13] However, early identification and management of AKI in the outpatient setting may prevent worsening AKI and the associated consequences of severe and/or prolonged AKI. Kidney function in the 72-hour period immediately following AKI in hospitalized patients is associated with specific clinical outcomes: the development or progression of CKD, initiation of long-term dialysis, or death from any cause within a median follow-up of approximately 4.7 years.…”

For Whom the Bell Tolls: Acute Kidney Injury and Electronic Alerts for the Pediatric Nephrologist

“…A 2-year follow-up study on an additional 337,433 patients demonstrated sustained decrease in mortality rate and length of stay, as well as a significant decrease in the use of nephrotoxic agents (39). More recently, Wilson et al looked at e-alerts for AKI in 6,030 patients in a double blinded, parallel, randomized controlled trial across six centers (34). In the electronic health record alerts for acute kidney injury (ELAIA-1) study, they found that patients randomized to alerts were more likely to receive intravenous fluids, get a urinalysis or repeat SCr measured, and have documentation of AKI.…”

“…Currently, care bundles include general common sense measures such as optimal fluid management, medication review, and urinalyses (Table 1). However, as seen in the ELAIA-1 study (34), care bundles that do not provide patient specific recommendations may not be helpful, and have the potential to cause more harm. Additional research is needed on this aspect of CDSS.…”