Clinical Decision Support for In-Hospital AKI.

AKI carries a significant mortality and morbidity risk. Use of a clinical decision support system (CDSS) might improve outcomes. We conducted a multicenter, sequential period analysis of 528,108 patients without ESRD before admission, from October of 2012 to September of 2015, to determine whether use of a CDSS reduces hospital length of stay and in-hospital mortality for patients with AKI. We compared patients treated 12 months before (181,696) and 24 months after (346,412) implementation of the CDSS. Coprimary outcomes were hospital mortality and length of stay adjusted by demographics and comorbidities. AKI was diagnosed in 64,512 patients (12.2%). Crude mortality rate fell from 10.2% before to 9.4% after CDSS implementation (odds ratio, 0.91; 95% confidence interval [95% CI], 0.86 to 0.96; P=0.001) for patients with AKI but did not change in patients without AKI (from 1.5% to 1.4%). Mean hospital duration decreased from 9.3 to 9.0 days (P<0.001) for patients with AKI, with no change for patients without AKI. In multivariate mixed-effects models, the adjusted odds ratio (95% CI) was 0.76 (0.70 to 0.83) for mortality and 0.66 (0.61 to 0.72) for dialysis (P<0.001). Change in adjusted hospital length of stay was also significant (incidence rate ratio, 0.91; 95% CI, 0.89 to 0.92), decreasing from 7.2 to 6.0 days for patients with AKI. Results were robust to sensitivity analyses and were sustained for the duration of follow-up. Hence, implementation of a CDSS for AKI resulted in a small but sustained decrease in hospital mortality, dialysis use, and length of stay.

[1]  Filip De Turck,et al.  Impact of real-time electronic alerting of acute kidney injury on therapeutic intervention and progression of RIFLE class* , 2012, Critical care medicine.

[2]  A. Go,et al.  Commonly used surrogates for baseline renal function affect the classification and prognosis of acute kidney injury. , 2010, Kidney international.

[3]  Z. Al-Aly,et al.  Early nephrologist involvement in hospital-acquired acute kidney injury: a pilot study. , 2011, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[4]  J. Spertus,et al.  Trends in the incidence of acute kidney injury in patients hospitalized with acute myocardial infarction. , 2012, Archives of Internal Medicine.

[5]  Rinaldo Bellomo,et al.  Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study , 2015, Intensive Care Medicine.

[6]  Laurie Tomlinson,et al.  Acute kidney injury—how does automated detection perform? , 2015, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[7]  Glenn M. Chertow,et al.  Acute Kidney Injury and Mortality in Hospitalized Patients , 2012, American Journal of Nephrology.

[8]  R. Bellomo,et al.  An assessment of the RIFLE criteria for acute renal failure in hospitalized patients* , 2006, Critical care medicine.

[9]  N. Kolhe,et al.  Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. , 2012, Clinical journal of the American Society of Nephrology : CJASN.

[10]  N. Kolhe,et al.  Impact of Compliance with a Care Bundle on Acute Kidney Injury Outcomes: A Prospective Observational Study , 2015, PloS one.

[11]  K. Polderman,et al.  An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine. , 2010, American journal of respiratory and critical care medicine.

[12]  Joseph V Bonventre,et al.  Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. , 2005, Journal of the American Society of Nephrology : JASN.

[13]  J. Gold,et al.  Validation of a combined comorbidity index. , 1994, Journal of clinical epidemiology.

[14]  Norbert Lameire,et al.  Notice , 2012, Kidney International Supplements.

[15]  G. Clermont,et al.  Classifying AKI by Urine Output versus Serum Creatinine Level. , 2015, Journal of the American Society of Nephrology : JASN.

[16]  A. Macleod.  NCEPOD report on acute kidney injury—must do better , 2009, The Lancet.

[17]  C. Geddes,et al.  Acute kidney injury: outcomes and quality of care. , 2013, QJM : monthly journal of the Association of Physicians.

[18]  Harold I Feldman,et al.  Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial , 2015, The Lancet.

[19]  Chien-Te Lee,et al.  Incidence, Outcomes, and Risk Factors of Community-Acquired and Hospital-Acquired Acute Kidney Injury , 2016, Medicine.

[20]  Allison B McCoy,et al.  Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury , 2012, Applied Clinical Informatics.

[21]  R. Fluck,et al.  Making the Right Decision: Do Clinical Decision Support Systems for AKI Improve Patient Outcomes? , 2018, Journal of the American Society of Nephrology : JASN.

[22]  M. Devonald,et al.  A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital. , 2014, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[23]  Brian W. Pickering,et al.  Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis* , 2015, Critical care medicine.

[24]  H. Feldman,et al.  The impact of documentation of severe acute kidney injury on mortality , 2013, Clinical nephrology.

[25]  Gilles Clermont,et al.  A comparison of three methods to estimate baseline creatinine for RIFLE classification. , 2010, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[26]  John A Kellum,et al.  Can decision support systems work for acute kidney injury? , 2015, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[27]  C. McDonald,et al.  A computerized reminder system to increase the use of preventive care for hospitalized patients. , 2001, The New England journal of medicine.