Impact of an Electronic Alert in Combination with a Care Bundle on the Outcomes of Acute Kidney Injury

Tome, Ana Carolina Nakamura; Ramalho, Rodrigo José; Santos, Karise Fernandes Dos; Ponte, Bianca; Agostinho, Helga; Machado, Maurício de Nassau; Lopes, Marcelo Barreto; Abbud-Filho, Mário; Lima, Emerson Quintino de

doi:10.3390/diagnostics12123121

Cited by 5 publications

(2 citation statements)

References 41 publications

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“… 8 , 27 Furthermore, research on alerts allows us to reconsider care processes for AKI, and future improvements in interventions are expected to improve the prognosis of AKI. More recent studies showed the benefits associated with the AKI alert, such as decreased 30-day mortality rate, 28 early recovery from AKI after major surgery, 29 and shorter LOS. 11 The cost-effectiveness of AKI alerts also needs further research.…”

Section: Discussionmentioning

confidence: 99%

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Li,

Wu,

et al. 2024

JAMA Netw Open

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ImportanceDespite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients.ObjectiveTo evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI.Design, Setting, and ParticipantsThis single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population.InterventionsA programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures.Main Outcomes and MeasuresThe primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI.ResultsA total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (−6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (−9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P &lt; .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P &lt; .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P &lt; .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups.Conclusions and RelevanceResults of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice.Trial RegistrationClinicalTrials.gov Identifier: NCT03736304

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Section: Discussionmentioning

confidence: 99%

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Li,

Wu,

et al. 2024

JAMA Netw Open

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“…Recent studies of AKI electronic alert and clinical decision support systems demonstrated variable results, which likely result from differences in study design, patient population, local context, and implementation strategies. Non-randomized studies evaluating AKI eAlerts enrolled heterogenous hospitalized patients, frequently used pre-and postdesign, and reported a reduction of higher AKI stages, requirement of renal replacement therapy, length of stay, and in-hospital mortality [12][13][14]. Randomized controlled trials also included heterogeneous patient populations of hospitalized patients from all wards; however, they did not demonstrate patient benefit regarding mortality, renal replacement therapy requirement, or renal function recovery (Appendix A, Table A1).…”

Section: Discussionmentioning

confidence: 99%

Care Bundle for Acute Kidney Injury in Cardiac Patients: A Cluster-Randomized Trial

Iwers,

Sliziuk,

Haase

et al. 2023

JCM

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Detection and timely intervention of acute kidney injury (AKI) is a major challenge worldwide. Electronic alerts for AKI may improve process- and patient-related endpoints. The present study evaluated the efficacy of an AKI electronic alert system and care bundle. This is a two-arm, prospective, cluster-randomized, controlled trial enrolling patients with AKI (KDIGO criteria) and cardiac diseases. Patients were randomly assigned to a routine care group or intervention group (DRKS-IDDRKS00017751). Two hundred patients (age 79 years, 46% female) were enrolled, with 100 patients in each group. The primary endpoint did not differ between patients in the routine care group 0.5 (−7.6–10.8) mL/min/1.73 m2 versus patients in the intervention group 1.0 (−13.5–15.1) mL/min/1.73 m2, p = 0.527. Proportions of patients in both study groups with hyperkalemia, pulmonary edema, and renal acidosis were comparable. The stop of antihypertensive medication during hypotensive periods was more frequent in patients in the intervention group compared to patients in the control group, p = 0.029. The AKI diagnosis and text module for AKI in the discharge letter were more frequently documented in patients in the intervention group (40%/48% vs. 25%/34%, p = 0.034; p = 0.044, respectively). Continued intake of RAAS inhibitors and the presence of a cardiac device were independently associated with a less pronounced decrease in eGFR from admission to the lowest value. In this RCT, electronic alerts for AKI and a care bundle improved process- but not patient-related endpoints.

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Electronic Alert Systems for Patients With Acute Kidney Injury

Chen,

Lee,

Chan

et al. 2024

JAMA Netw Open

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ImportanceThe 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.ObjectiveTo assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns.Data SourcesA 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.Study SelectionStudies 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.Data Extraction and SynthesisTwo 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.Main Outcomes and MeasuresPrimary 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.ResultsThirteen 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.Conclusions and RelevanceIn 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.

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Impact of an Electronic Alert in Combination with a Care Bundle on the Outcomes of Acute Kidney Injury

Cited by 5 publications

References 41 publications

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Care Bundle for Acute Kidney Injury in Cardiac Patients: A Cluster-Randomized Trial

Electronic Alert Systems for Patients With Acute Kidney Injury

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