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Quality improvement report
Electronic alerts for acute kidney injury across primary and secondary care
  1. Joseph Barker1,2,
  2. Karl Smith-Byrne3,
  3. Oliver Sayers4,
  4. Krishan Joseph5,
  5. Mark Sleeman6,
  6. Daniel Lasserson7,
  7. Emma Vaux8
  1. 1 Oxford University Clinical Academic Graduate School, NIHR Oxford Biomedical Research Centre, Oxford, UK
  2. 2 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
  3. 3 Genomic Epidemiology Branch, Section of Genetics, International Agency for Research on Cancer, Lyon, France
  4. 4 Independent Scholar, London, UK
  5. 5 Department of Opthalmology, Oxford University Hospitals NHS Trust, Oxford, UK
  6. 6 Department of Pathology, Royal Berkshire NHS Foundation Trust, Reading, UK
  7. 7 Department of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
  8. 8 Department of Nephrology, Royal Berkshire NHS Foundation Trust, Reading, UK
  1. Correspondence to Dr Joseph Barker; joseph.barker{at}nhs.net

Abstract

Problem In 2009 the National Confidential Enquiry into Patient Outcome and Death suggested only 50% of patients with acute kidney injury (AKI) receive good standards of care. In response National Health Service (NHS) England mandated the use of electronic AKI alerts within secondary care. However, we recognised AKI is not just a secondary care problem, where primary care has a crucial role to play in prevention, early detection and management as well as post-AKI care.

Methods AKI alerts were implemented in primary and secondary care services for a population of 480 000. Comparisons were made in AKI incidence, peak creatinine following AKI and renal recovery in the years before and after using Byar’s approximation (95% CI).

Intervention A complex quality improvement initiative was implemented based on the design and integration of an AKI alerting system within laboratory information management systems for primary and secondary care, with an affixed URL for clinicians to access a care bundle of AKI guidelines on safe prescribing, patient advice and early contact with nephrology.

Results The intervention was associated with an 8% increase in creatinine testing (n=32 563). Hospital acquired AKI detection increased by 6%, while community acquired AKI detection increased by 3% and AKI stage 3 detected in primary care fell by 14%. The intervention overall had no effect on AKI severity but did improve follow-up testing and renal recovery. Importantly hospital AKI 3 recoveries improved by 22%. In a small number of AKI cases, the algorithm did not produce an alert resulting in a reduction in follow-up testing compared with preintervention levels.

Conclusion The introduction of AKI alerts in primary and secondary care, in conjunction with access to an AKI care bundle, was associated with higher rates of repeat blood sampling, AKI detection and renal recovery. Validating accuracy of alerts is required to avoid patient harm.

  • acute kidney injury
  • clinical decision-making
  • patient safety
  • healthcare quality improvement
  • quality improvement
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2020-000956

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    Footnotes

    • Twitter @VauxEmma

    • Contributors EV was primarily responsible for conceiving, planning and implementing the project. MS oversaw data collection and retrieval from the laboratory information management system. DL provided strategic oversight for project evaluation. JB was primarily responsible for data analysis with KS-B and OS. KJ wrote a narrative literature review to inform manuscript write up. JB wrote up the project where all authors provided critical insight for manuscript revisions. JB, DL and EV are the overall content guarantors.

    • Funding JB is supported by National Institute for Health Research (NIHR), undertaken as part of the Oxford UK Academic Foundation Programme and Leicester Academic Clinical Fellowship with no formal grant/award number. DL is supported by the NIHR Applied Research Collaboration (ARC) West Midlands and the NIHR Community Healthcare MedTech and In Vitro Diagnostics Co-operative (MIC) at Oxford Health NHS Foundation Trust.

    • Disclaimer The views expressed are those of the authors and not necessarily those of the NIHR, the NHS or the Department of Health and Social Care.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.