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The ICE-AKI study: impact analysis of a clinical prediction rule and Electronic AKI alert in general medical patients

The ICE-AKI study: impact analysis of a clinical prediction rule and Electronic AKI alert in general medical patients
The ICE-AKI study: impact analysis of a clinical prediction rule and Electronic AKI alert in general medical patients

Background: acute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes. 

Methods and findings: a controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014–16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981–1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858–0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560–0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation. 

Conclusions: in acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness.

1932-6203
Hodgson, Luke E.
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Roderick, Paul J.
dbb3cd11-4c51-4844-982b-0eb30ad5085a
Venn, Richard M.
4d068c0f-2f26-4358-934a-da0a3e936b6e
Yao, Guiqing L.
d777f84c-cf3d-4fad-bbc1-ea01dec01695
Dimitrov, Borislav D.
366d715f-ffd9-45a1-8415-65de5488472f
Forni, Lui G.
e9ca402c-ea28-4d1a-8c4f-7fbaf205bad8
Hodgson, Luke E.
f1159289-e374-4f11-b923-5781094b6de1
Roderick, Paul J.
dbb3cd11-4c51-4844-982b-0eb30ad5085a
Venn, Richard M.
4d068c0f-2f26-4358-934a-da0a3e936b6e
Yao, Guiqing L.
d777f84c-cf3d-4fad-bbc1-ea01dec01695
Dimitrov, Borislav D.
366d715f-ffd9-45a1-8415-65de5488472f
Forni, Lui G.
e9ca402c-ea28-4d1a-8c4f-7fbaf205bad8

Hodgson, Luke E., Roderick, Paul J., Venn, Richard M., Yao, Guiqing L., Dimitrov, Borislav D. and Forni, Lui G. (2018) The ICE-AKI study: impact analysis of a clinical prediction rule and Electronic AKI alert in general medical patients. PLoS ONE, 13 (8), [e0200584]. (doi:10.1371/journal.pone.0200584).

Record type: Article

Abstract

Background: acute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes. 

Methods and findings: a controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014–16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981–1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858–0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560–0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation. 

Conclusions: in acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness.

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More information

Accepted/In Press date: 28 June 2018
e-pub ahead of print date: 8 August 2018
Published date: 8 August 2018

Identifiers

Local EPrints ID: 424443
URI: http://eprints.soton.ac.uk/id/eprint/424443
ISSN: 1932-6203
PURE UUID: 1322466f-d70e-4d8c-b44a-ed6154bcda52
ORCID for Paul J. Roderick: ORCID iD orcid.org/0000-0001-9475-6850

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Date deposited: 05 Oct 2018 11:37
Last modified: 17 Dec 2019 01:59

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Contributors

Author: Luke E. Hodgson
Author: Richard M. Venn
Author: Guiqing L. Yao
Author: Borislav D. Dimitrov
Author: Lui G. Forni

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