SAN DIEGO — A strategy to improve the management of hospitalized patients with acute kidney injury (AKI) through rapid personalized recommendations made by a dedicated kidney action team facilitates testing and other measures, but ultimately falls short in improving clinical outcomes, a randomized, multicenter study shows.
Although recommendations from a dedicated physician and pharmacist team improved the rate of a best-practice implementation within 24 hours, the intervention did not lead to improved patient outcomes, said lead author Abinet M. Aklilu, MD, MPH, of Yale University School of Medicine, New Haven, Connecticut.
The study was presented at Kidney Week 2024, organized by the American Society of Nephrology, and simultaneously published in the Journal of the American Medical Association.
While AKI affects as many as 20% of hospitalized patients, the condition often goes undiagnosed, potentially resulting in disease progression and mortality.
Previous efforts to improve AKI outcomes with clinical decision support tools, including an intervention from the team at Yale using electronic alerts for AKI , have had mixed results, with various factors, including the issue of “alert fatigue,” speculated to have hindered the ultimate goal of improving in patient outcomes.
“These studies were probably limited by unintended harm from alerts and limited experience and confidence in managing the diverse [nature] of AKI, where a one-size-fits-all approach will not work,” Aklilu explained.
To address some of those issues, a new intervention was developed to add real-time rapid recommendations from a dedicated kidney action team consisting of a physician and pharmacist directly to a patient’s electronic health record.
The intervention was evaluated in a randomized, investigator-blinded trial in the Yale and Johns Hopkins hospital systems between October 2021 and February 2024.
Personalized Recommendations and Process Outcome
Upon receiving an alert of a patient having AKI, the physician and pharmacist kidney action team remotely reviewed the patient’s individual charts and provided personalized recommendations in the major categories of general diagnostics, volume, potassium, acidosis, and medications.
The patients were then randomized 1:1 to either have the kidney action team’s recommendations appear in their charts or not. The median time from the automated AKI diagnosis to randomization was 56 minutes.
Overall, 4003 patients were included, with 786 (20%) in the ICU. Patients with end-stage kidney disease or stage 5 chronic kidney disease (CKD), solid organ transplant, or meeting urgent renal consult criteria were excluded.
The patients had a median age of 72 years, 47% were female, 23% were Black, and 41% had CKD.
The median number of recommendations made for patients was three, and most patients had at least one recommendation. The kidney action team made a total of 14,539 recommendations.
In terms of the study’s process outcome — defined as the proportion of recommendations completed within 24 hours of randomization — the proportion in the kidney action team intervention arm (n=1,999) was significantly higher at 34% vs 24% in the usual care arm (n=2004; P
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