Service evaluation of the implementation of a digitally-enabled care pathway for the recognition and management of acute kidney injury

Connell, Alistair; Montgomery, Hugh; Morris, Stephen; Nightingale, Claire; Stanley, Sarah; Emerson, Mary; Jones, Gareth; Sadeghi-Alavijeh, Omid; Merrick, Charles; King, Dominic; Karthikesalingam, Alan; Hughes, Cían; Ledsam, Joseph R.; Back, Trevor; Rees, Geraint; Raine, Rosalind; Laing, Christopher

doi:10.12688/f1000research.11637.2

Cited by 8 publications

(8 citation statements)

References 11 publications

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“…Implementation of an AKI care pathway triggered by an abnormal serum-creatinine value is an example of an intervention that may reduce AKI-associated morbidity and improve outcomes by early diagnosis and treatment. 21…”

Section: Discussionmentioning

confidence: 99%

Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty

Singh

Cleveland

2020

Therapeutic Advances in Musculoskeletal

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Background: The objective of this study was to assess healthcare utilization and complications associated with acute kidney injury (AKI) in patients undergoing primary total knee arthroplasty (TKA). Methods: We used the 1998–2014 US National Inpatient Sample to assess whether AKI is associated with healthcare utilization or in-hospital postoperative complications post-TKA using multivariable-adjusted logistic regression analyses. We calculated odds ratios (ORs) and a 95% confidence intervals (CIs). Sensitivity analyses additionally adjusted for hospital characteristics (location/teaching status, bed size, and region). Results: Of the 8,127,282 people who underwent primary TKA from 1998 to 2014, 104,366 (1.3%) had a diagnosis of AKI. People with AKI had longer unadjusted mean hospital stay, 6.1 versus 3.5 days, higher mean hospital charges, US$71,385 versus US$42,067, and higher rates of all in-hospital postoperative complications, including mortality. Adjusted for age, sex, race, underlying diagnosis, medical comorbidity, income, and insurance payer, AKI was associated with a significantly higher OR (95% CI) of total hospital charges above the median, 2.76 (2.68, 2.85); length of hospital stay > 3 days, 2.21 (2.14, 2.28); and discharge to a rehabilitation facility, 4.68 (4.54, 4.83). AKI was associated with significantly higher OR (95% CI) of in-hospital complications, including infection, 2.60 (1.97, 3.43); transfusion, 2.94 (2.85, 3.03); revision, 2.13 (1.72, 2.64); and mortality, 19.75 (17.39, 22.42). Sensitivity analyses replicated the main study findings, without any attenuation of ORs. Conclusions: AKI is associated with a significantly higher risk of increased healthcare utilization, complications, and mortality after primary TKA. Future studies should assess significant factors associated and interventions that can prevent AKI.

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Section: Discussionmentioning

confidence: 99%

Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty

Singh

Cleveland

2020

Therapeutic Advances in Musculoskeletal

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“…The digitally enabled pathway was designed and implemented at the Royal Free Hospital (RFH)—a large, acute, tertiary referral hospital providing a range of acute services (including a 34-bed intensive treatment unit and an inpatient nephrology service) in central London, United Kingdom. The care pathway has been described in detail elsewhere [20] and is summarized in brief below.…”

Section: Methodsmentioning

confidence: 99%

“…However, simple alerting to the presence of AKI does not seem to improve outcome [19]. We therefore designed a new care pathway that encompassed AKI detection, mobile alerting of a dedicated response team comprising multiple specialists, and the provision of protocolized care [20]. Evaluation of the implementation of the digitally enabled care pathway with regard to impacts on processes of care, clinical outcome, and the cost of care delivery are described elsewhere [21,22].…”

Section: Introductionmentioning

confidence: 99%

Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals

Connell¹,

Black²,

Montgomery³

et al. 2019

J Med Internet Res

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Background One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally enabled care pathway for patients with acute kidney injury (AKI) at a tertiary referral hospital in the United Kingdom. A dedicated clinical response team—comprising existing nephrology and patient-at-risk and resuscitation teams—received AKI alerts in real time via Streams, a mobile app. Here, we present a qualitative evaluation of the experiences of users and other health care professionals whose work was affected by the implementation of the care pathway. Objective The aim of this study was to qualitatively evaluate the impact of mobile results viewing and automated alerting as part of a digitally enabled care pathway on the working practices of users and their interprofessional relationships. Methods A total of 19 semistructured interviews were conducted with members of the AKI response team and clinicians with whom they interacted across the hospital. Interviews were analyzed using inductive and deductive thematic analysis. Results The digitally enabled care pathway improved access to patient information and expedited early specialist care. Opportunities were identified for more constructive planning of end-of-life care due to the earlier detection and alerting of deterioration. However, the shift toward early detection also highlighted resource constraints and some clinical uncertainty about the value of intervening at this stage. The real-time availability of information altered communication flows within and between clinical teams and across professional groups. Conclusions Digital technologies allow early detection of adverse events and of patients at risk of deterioration, with the potential to improve outcomes. They may also increase the efficiency of health care professionals’ working practices. However, when planning and implementing digital information innovations in health care, the following factors should also be considered: the provision of clinical training to effectively manage early detection, resources to cope with additional workload, support to manage perceived information overload, and the optimization of algorithms to minimize unnecessary alerts.

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“…The digitally enabled AKI care pathway and the technical architecture of the Streams app have been described in detail previously [17], and the pre-existing and novel care pathways are shown in Multimedia Appendix 1. Members of the response team undertook training before implementation.…”

Section: Methodsmentioning

confidence: 99%

“…To address these issues, we developed a digitally enabled care pathway for AKI patients [17]. This uses a mobile app (Streams), which alerts a specialist response team to the presence of AKI in real time, simultaneously providing relevant clinical data in a user-friendly format and allowing communication of key triage decisions among team members.…”

Section: Introductionmentioning

confidence: 99%

Implementation of a Digitally Enabled Care Pathway (Part 1): Impact on Clinical Outcomes and Associated Health Care Costs

Connell¹,

Raine²,

Martin³

et al. 2019

J Med Internet Res

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BackgroundThe development of acute kidney injury (AKI) in hospitalized patients is associated with adverse outcomes and increased health care costs. Simple automated e-alerts indicating its presence do not appear to improve outcomes, perhaps because of a lack of explicitly defined integration with a clinical response.ObjectiveWe sought to test this hypothesis by evaluating the impact of a digitally enabled intervention on clinical outcomes and health care costs associated with AKI in hospitalized patients.MethodsWe developed a care pathway comprising automated AKI detection, mobile clinician notification, in-app triage, and a protocolized specialist clinical response. We evaluated its impact by comparing data from pre- and postimplementation phases (May 2016 to January 2017 and May to September 2017, respectively) at the intervention site and another site not receiving the intervention. Clinical outcomes were analyzed using segmented regression analysis. The primary outcome was recovery of renal function to ≤120% of baseline by hospital discharge. Secondary clinical outcomes were mortality within 30 days of alert, progression of AKI stage, transfer to renal/intensive care units, hospital re-admission within 30 days of discharge, dependence on renal replacement therapy 30 days after discharge, and hospital-wide cardiac arrest rate. Time taken for specialist review of AKI alerts was measured. Impact on health care costs as defined by Patient-Level Information and Costing System data was evaluated using difference-in-differences (DID) analysis.ResultsThe median time to AKI alert review by a specialist was 14.0 min (interquartile range 1.0-60.0 min). There was no impact on the primary outcome (estimated odds ratio [OR] 1.00, 95% CI 0.58-1.71; P=.99). Although the hospital-wide cardiac arrest rate fell significantly at the intervention site (OR 0.55, 95% CI 0.38-0.76; P<.001), DID analysis with the comparator site was not significant (OR 1.13, 95% CI 0.63-1.99; P=.69). There was no impact on other secondary clinical outcomes. Mean health care costs per patient were reduced by £2123 (95% CI −£4024 to −£222; P=.03), not including costs of providing the technology.ConclusionsThe digitally enabled clinical intervention to detect and treat AKI in hospitalized patients reduced health care costs and possibly reduced cardiac arrest rates. Its impact on other clinical outcomes and identification of the active components of the pathway requires clarification through evaluation across multiple sites.

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Service evaluation of the implementation of a digitally-enabled care pathway for the recognition and management of acute kidney injury

Cited by 8 publications

References 11 publications

Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty

Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty

Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals

Implementation of a Digitally Enabled Care Pathway (Part 1): Impact on Clinical Outcomes and Associated Health Care Costs

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