Implementation of clinical decision support to manage acute kidney injury in secondary care: an ethnographic study

Abstract

BackgroundOver the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care.MethodsAn ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption.ResultsThe two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice.ConclusionsOur analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.

Summarised, verified and accessible: improving clinical information management for potential haematopoietic stem cell transplantation patients

“…Other QI work has also reported that it can be hard for staff to incorporate new practices into routine work and that it takes sustained effort and encouragement to embed new practices and habits. 7 8 The T&F group helped navigate the obstacles and sustain the new process after the PDSA cycles.…”

Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation

“…This resonates with findings from an ethnographic study examining the implementation of AKI clinical decision support systems within hospital trusts. 61 Strategies aimed at eradicating under-diagnosis and containing over-diagnosis may help maximise the utility of AKI as a driver of patient safety and reduce unnecessary additional work and downstream noise within the health system. 61 62 The role of AKI nurse specialists to help place AKI alerts in clinical context and then to coordinate safer transitions of care back into the community warrants further examination.…”

“… 61 62 The role of AKI nurse specialists to help place AKI alerts in clinical context and then to coordinate safer transitions of care back into the community warrants further examination. 61 …”

Influential factors in the adoption of clinical decision support systems in hospital settings: a systematic review and meta-synthesis of qualitative studies

“…Table 1 summarizes the studies included in the synthetic analysis. All the studies were conducted in the context of developing countries with the majority conducted in the UK (Bailey et al, 2020;Cresswell et al, 2015Cresswell et al, , 2017Lee et al, 2016;Mozaffar et al, 2016a, b) and the USA (Ash et al, 2012(Ash et al, , 2015Joshi et al, 2022;Simon et al, 2013) as the frontrunners in healthcare digitisation leaving the developing countries context under-investigated. All but three studies investigated the adoption of commercial CDSS (Ash et al, 2012;Bailey et al, 2020;Joshi et al, 2022) in hospitals, leaving the home-grown context under-investigated.…”