Identification of AKI using work? - CRRTonline
Transcript of 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