identification of aki using work? - crrtonline

Identification of AKI using

electronic reporting: does it

work? Dr Nick Selby Consultant Nephrologist, Royal Derby

Hospital, UK

UK NCEPOD report

Main Findings:

Poor assessment of risk factors for AKI and acute illness

Delays in recognising AKI

Post admission AKI avoidable in 21%

‘Good’ care in <50% cases

Most patients with AKI are not cared for by nephrologists

• Review of 700 patients dying with AKI over 3month period

Published experience with

electronic alerts for AKI

Royal Derby Hospital

• 1100 bedded teaching

hospital

• Tertiary referral renal

unit

• Central lab for all inpt

and outpt blood

samples

Combination of IT and human algorithms

Based on serum creatinine criteria only

Disregards time window when selecting

baseline

Serum creatinine measured

In-patient location? (renal ward and dialysis unit excluded)

Creatinine >1.5x ‘ideal’ creatinine

(measured from reverse eGFR)

Authoriser vets results; selects true

baseline and inputs to AKI calculator

No AKI, result not

flagged Report issued: AKI stage 1

Report issued: AKI stage 2

Report issued: AKI stage 3

No – process ends

No – process ends

Combination of IT and human algorithms

Based on serum creatinine criteria only

Disregards time window when selecting

baseline

Baseline creatinine

used and date also

included

Results from initial 9 months

• Total blood samples: 17,489

• Samples with AKI: 6,047

• AKI episodes: 3,202

• No. of patients: 2,652

• Median age 80yrs (IQR 16)

• 92% non-elective admissions

• False –ve rate: 0.2%

• False +ve rate: 1.7%

Highest AKI stage

1970 61.5 61.5 61.5

638 19.9 19.9 81.4

594 18.6 18.6 100.0

3202 100.0 100.0

1

2

3

Total

Valid

Frequency Percent Valid Percent

Cumulative

Percent

Selby NM et al, in press CJASN 2012

Mortality with AKI stage

p<0.0001 p=0.28

*Rates displayed are unadjusted, crude mortality rates

• Overall AKI group mortality 23.6%

Selby NM et al, in press CJASN 2012

Predictive value of AKI staging

depends on baseline creatinine Baseline CKD Normal baseline renal function

p=0.046 p=0.225

Selby NM et al, in press CJASN 2012

Renal replacement therapy

• 90 (3.4% of total group) patients required RRT

Of those that required RRT:

• 7 (7.8%) remained dialysis dependent

• 63 (70%) became dialysis independent

• 20 (22.2%) died still requiring RRT

• Overall mortality in those that received RRT: 42.6%

Selby NM et al, in press CJASN 2012

In-hospital AKI associated with

worse outcomes

p<0.0001

Selby NM et al, in press CJASN 2012

Renal recovery at hospital

discharge • Complete recovery: 73.1%

• Incomplete/no recovery: 26.9%

(excluded pts. who died/had no rpt creatinine)

• Mean baseline creatinine

112.3 ± 49 mol/l+

• Mean discharge creatinine

130.5 ± 76 mol/l+

+p<0.0001

• Higher AKI stages associated with lower chance of renal recovery

p<0.0001

p<0.0001

Selby NM et al, in press CJASN 2012

Electronic reporting in AKI can be

effective

Time to intervention: 97.5hrs vs. 75.9hrs

(control vs. e-alerts, p<0.001)

The RR of serious renal impairment with e-alerts 0.45 (95% CI, 0.22 to 0.94)

Medication to avoid rate: 34%

vs. 59%

Time to response reduced

Interruptive alerts more effective

Audit after

introduction of AKI

reporting

Urinalysis

Renal imaging

Medication review

AKI distribution across

specialties

7.5% of patients under nephrology

Selby NM et al, in press CJASN 2012

E-alerts for AKI

Intranet Guidelines

Streamlined nephrology

referral

Care bundles

Education programme

Outcomes since multi-faceted

interventions Unadjusted mortality per

quarter

% AKI pts in stage 3 per

quarter

p=0.03

Summary

• Hospital-wide electronic reporting of AKI is

feasible in clinical practice

• Early identification of AKI is an important

tool in improving standards in AKI

• Effectiveness maximised by combining

with other strategies