Acute Kidney Injury
Conditions
Keywords
Acute kidney injury, Major surgery, Clinical decision support
Brief summary
Acute kidney injury (AKI) is common and costly complication of major surgery. AKI can lead to prolonged hospitalization and a higher likelihood of dialysis, chronic kidney disease and death. However, AKI can be reversed when recognized early, by ensuring that patients receive adequate fluids and medications that worsen kidney function or cause toxicity are avoided or appropriately prescribed. Past research suggests that AKI in surgical settings can be missed early in its onset, leading to delayed intervention and progression to more severe stages. The purpose of this project is to implement clinical decision support for early recognition and management of AKI on surgical units in Alberta hospitals, and to determine whether the initiative leads to improvements in the quality of care for AKI, length of hospital stay for patients, and costs to the healthcare system.
Detailed description
Overview: Cluster-randomized stepped-wedge trial to evaluate the impact of implementing a clinical decision support initiative for early recognition and management of hospital-acquired AKI. Study Population: Adult patients hospitalized on surgical units in Alberta who develop acute kidney injury will be eligible if not already receiving dialysis. Intervention: The multidimensional clinical decision support intervention consists of: (1) electronic and non-computerized tools for early recognition of AKI, (2) educational program for clinical staff, (3) decision support resources and guidance for the management of AKI and consultation with specialists. Study Design: Using a stepped-wedge design, eight general and vascular surgery unit clusters in Calgary (Foothills Medical Centre, Peter Lougheed Centre) and Edmonton (University of Alberta Hospital, Grey Nuns Community Hospital), Alberta will be randomly ordered to be sequentially introduced to the clinical decision support intervention. The pre-implementation period will include all patients admitted to the participating hospital units in the year before the random timing of introduction of the initiative on each participating unit. The post-implementation study cohort will include patients admitted in the year after the random timing of introduction of the initiative on each unit. Analysis of processes of care and outcomes will focus on patients on these units who develop AKI during the pre- and post-implementation time periods (i.e. are eligible to receive care under the AKI decision support initiative). Additionally, health care providers (e.g. physicians, nursing staff, pharmacists) who have direct experience with the clinical decision support tools and processes will be invited to participate in the surveys and interviews pre- and post-implementation.
Interventions
OTHERSUPPORT AKI Clinical Decision Support
Surgical units will receive a multidimensional clinical decision support intervention consisting of: (1) electronic and non-computerized tools to alert for early recognition of AKI, (2) educational program for physicians and nursing staff, (3) decision support tools with guidance on fluid therapies, medication management, investigations for AKI, and consultation with specialists.
Sponsors
Alberta Health services
University of Alberta
Covenant Health, Canada
University of Calgary
Study design
Allocation
RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult patients (18 years of age and older) who develop hospital-acquired acute kidney injury on identified general and vascular surgery units in Alberta
Exclusion criteria
* Hospitalized on non-surgical units * Receiving dialysis prior to admission on surgery unit
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression of AKI | From date of AKI onset to discharge from hospital, assessed up to 30 days | Incidence of progression of AKI to higher AKI stage (including progression to dialysis or death) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Resource use for AKI | Duration of index hospital admission, assessed up to 30 days | Mean total health care costs of hospital care during the index admission |
| Time to initial response to AKI | From AKI onset up to 48 hours following AKI onset | Time from AKI onset to clinical response with fluid or medication management intervention |
| Volume intervention (change in fluid or diuretic order) for AKI | Within 48 hours following AKI onset | New or modified intravenous fluid or diuretic order |
| Length of AKI hospital stay, days | From date of AKI onset to discharge from hospital, assessed up to 30 days | Mean length of hospital stay from acute kidney injury to discharge |
| Medical consultation for AKI | Within 7 days of AKI onset | Consultation with nephrology or general internal medicine |
| Change in estimated Glomerular Filtration Rate (eGFR) | From most recent baseline eGFR measurement prior to AKI onset to eGFR measurement closest to 3 months after AKI onset | The difference in eGFR from baseline to 3 months after development of AKI |
| Mortality | Within 30 days of AKI onset | All cause mortality |
| Adverse medication exposure | Within 48 hours following AKI onset | Dose modification or suspension or a medication that may cause AKI or that is cleared by the kidney |
Countries
Canada
Outcome results
None listed