Christopher M Justice, Connor Nevin, Rebecca L Neely, Brian Dilcher, Nicole Kovacic-Scherrer, Heather Carter-Templeton, Aaron Ostrowski, Jacob Krafcheck, Gordon Smith, Paul McCarthy, Jami Pincavitch, Sandra Kane-Gill, Robert Freeman, John A Kellum, Roopa Kohli-Seth, Girish N Nadkarni, Khaled Shawwa, Ankit Sakhuja
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引用次数: 0
Abstract
Background: Nephrotoxin exposure may worsen kidney injury and impair kidney recovery if continued in patients with acute kidney injury (AKI).
Objectives: This study aimed to determine if tiered implementation of a clinical decision support system (CDSS) would reduce nephrotoxin use in cardiac surgery patients with AKI.
Methods: We assessed patients admitted to the cardiac surgery intensive care unit at a tertiary care center from January 2020 to December 2021, and August 2022 to September 2023. A passive electronic AKI alert was activated in July 2020, followed by an electronic nephrotoxin alert in March 2023. In this alert, active nephrotoxic medication orders resulted in a passive alert, whereas new orders were met with an interruptive alert. Primary outcome was discontinuation of nephrotoxic medications within 30 hours after AKI. Secondary outcomes included AKI-specific clinical actions, determined through modified Delphi process and patient-centered outcomes. We compared all outcomes across five separate eras, divided based on the tiered implementation of these alerts.
Results: A total of 503 patients met inclusion criteria. Of 114 patients who received nephrotoxins before AKI, nephrotoxins were discontinued after AKI in 6 (25%) patients in pre AKI-alert era, 8 (33%) patients in post AKI-alert era, 7 (35%) patients in AKI-alert long-term follow up era, 7 (35%) patients in pre nephrotoxin-alert era, and 14 (54%) patients in post nephrotoxin-alert era (p = 0.047 for trend). Among AKI-specific consensus actions, we noted a decreased use of intravenous fluids, increased documentation of goal mean arterial pressure of 65 mm Hg or higher, and increased use of bedside point of care echocardiogram over time. Among exploratory clinical outcomes we found a decrease in proportion of stage III AKI, need for dialysis, and length of hospital stay over time.
Conclusion: Tiered implementation of CDSS for recognition of AKI and nephrotoxin exposure resulted in a progressive improvement in the discontinuation of nephrotoxins.
背景：急性肾损伤（AKI）患者如果持续暴露肾毒素，可能会加重肾损伤和损害肾脏恢复。目的：本研究旨在确定分级实施临床决策支持系统（CDSS）是否会减少AKI心脏手术患者肾毒素的使用。方法：我们评估了2020年1月至2021年12月、2022年8月至2023年9月在一家三级医疗中心心脏外科重症监护病房住院的患者。被动电子AKI警报于2020年7月启动，随后于2023年3月启动了电子肾毒素警报。在此警报中，主动肾毒性药物订单导致被动警报，而新订单则出现中断警报。主要终点是AKI后30小时内停用肾毒性药物。次要结局包括aki特异性临床行为，通过改进的德尔菲过程和以患者为中心的结局确定。我们比较了五个不同时代的所有结果，根据这些警报的分层实施进行了划分。结果：共有503例患者符合纳入标准。在114例AKI前接受肾毒素治疗的患者中，AKI预警前停用肾毒素6例（25%），AKI预警后停用肾毒素8例（33%），AKI预警长期随访期停用肾毒素7例（35%），肾毒素预警前停用肾毒素7例（35%），肾毒素预警后停用肾毒素14例（54%）（趋势p = 0.047）。在aki特异性共识行动中，我们注意到静脉输液的使用减少，目标平均动脉压为65 mm Hg或更高的记录增加，并且随着时间的推移，床边护理点超声心动图的使用增加。在探索性临床结果中，我们发现随着时间的推移，III期AKI的比例、透析需求和住院时间都有所下降。结论：分级实施CDSS识别AKI和肾毒素暴露导致肾毒素停用的逐步改善。
期刊介绍：
ACI is the third Schattauer journal dealing with biomedical and health informatics. It perfectly complements our other journals Öffnet internen Link im aktuellen FensterMethods of Information in Medicine and the Öffnet internen Link im aktuellen FensterYearbook of Medical Informatics. The Yearbook of Medical Informatics being the “Milestone” or state-of-the-art journal and Methods of Information in Medicine being the “Science and Research” journal of IMIA, ACI intends to be the “Practical” journal of IMIA.
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