Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Pediatrics. 2013 Sep;132(3):e756-67. doi: 10.1542/peds.2013-0794. Epub 2013 Aug 12.
Nephrotoxic medication exposure represents a common cause of acute kidney injury (nephrotoxin-AKI) in hospitalized children. Systematic serum creatinine (SCr) screening has not been routinely performed in children receiving nephrotoxins, potentially leading to underestimating nephrotoxin-AKI rates. We aimed to accurately determine nephrotoxin exposure and nephrotoxin-AKI rates to drive appropriate interventions in non-critically ill hospitalized children.
We conducted a prospective quality improvement project implementing a systematic electronic health record (EHR) screening and decision support process (trigger) at a single quaternary pediatric hospital. Patients were all noncritically ill hospitalized children receiving an intravenous aminoglycoside for ≥3 days or ≥3 nephrotoxins simultaneously (exposure). Pharmacists recommended daily SCr monitoring in exposed patients. AKI was defined by the modified pediatric Risk, Injury, Failure, Loss and End-stage Renal Disease criteria (≥25% decrease in estimated creatinine clearance). We developed 4 novel metrics: exposure rate per 1000 patient-days, AKI rate per 1000 patient-days, AKI rate (%) per high nephrotoxin admission, and AKI days per 100 exposure days (AKI intensity).
This study included 21 807 patients accounting for 27 711 admissions. A total of 726 (3.3%) unique exposed patients accounted for 945 hospital admissions (6713 patient-days). AKI occurred in 25% of unique exposed patients and 31% of exposure admissions (1974 patient-days). Our EHR-driven SCr nephrotoxin-AKI surveillance process was associated with a 42% reduction in AKI intensity.
Nephrotoxin-AKI rates are high in noncritically ill children; systematic screening for nephrotoxic medication exposure and AKI detection was accomplished reliably through an EHR based trigger tool.
肾毒性药物暴露是住院儿童急性肾损伤（肾毒物相关性急性肾损伤）的常见原因。在接受肾毒物治疗的儿童中，并未常规进行系统性血清肌酐（SCr）筛查，这可能导致低估了肾毒物相关性急性肾损伤的发生率。我们旨在准确确定肾毒物暴露和肾毒物相关性急性肾损伤的发生率，以便为非危重症住院儿童提供适当的干预措施。
我们开展了一项前瞻性质量改进项目，在一家单所四级儿科医院实施了一项系统的电子健康记录（EHR）筛查和决策支持流程（触发）。所有患者均为非危重症住院儿童，接受静脉用氨基糖苷类药物治疗≥3 天或同时接受≥3 种肾毒物治疗（暴露）。药师建议对暴露患者进行每日 SCr 监测。急性肾损伤的定义采用改良儿科风险、损伤、衰竭、丧失和终末期肾病标准（估算肌酐清除率下降≥25%）。我们制定了 4 项新指标：每 1000 个患者日的暴露率、每 1000 个患者日的急性肾损伤发生率、每例高肾毒物入院的急性肾损伤发生率（%）和每 100 例暴露天数的急性肾损伤天数（急性肾损伤强度）。
这项研究纳入了 21807 例患者，共计 27711 例住院。共有 726 例（3.3%）独特的暴露患者，共计 945 例住院（6713 个患者日）。25%的独特暴露患者和 31%的暴露入院患者发生了急性肾损伤（1974 个患者日）。我们的 EHR 驱动的 SCr 肾毒物相关性急性肾损伤监测流程使急性肾损伤强度降低了 42%。
非危重症儿童的肾毒物相关性急性肾损伤发生率较高；通过基于 EHR 的触发工具，系统筛查肾毒性药物暴露和急性肾损伤的检测是可靠的。
