Identification of AKI using work? - CRRTonline
Transcript of Identification of AKI using work? - CRRTonline
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Identification of AKI using
electronic reporting: does it
work? Dr Nick Selby Consultant Nephrologist, Royal Derby
Hospital, UK
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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
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Published experience with
electronic alerts for AKI
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Royal Derby Hospital
• 1100 bedded teaching
hospital
• Tertiary referral renal
unit
• Central lab for all inpt
and outpt blood
samples
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Combination of IT and human algorithms
Based on serum creatinine criteria only
Disregards time window when selecting
baseline
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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
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Baseline creatinine
used and date also
included
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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
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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
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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
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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
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In-hospital AKI associated with
worse outcomes
p<0.0001
Selby NM et al, in press CJASN 2012
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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
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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
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Audit after
introduction of AKI
reporting
Urinalysis
Renal imaging
Medication review
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AKI distribution across
specialties
7.5% of patients under nephrology
Selby NM et al, in press CJASN 2012
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E-alerts for AKI
Intranet Guidelines
Streamlined nephrology
referral
Care bundles
Education programme
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Outcomes since multi-faceted
interventions Unadjusted mortality per
quarter
% AKI pts in stage 3 per
quarter
p=0.03
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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