Oxford University Clinical Academic Graduate School, NIHR Oxford Biomedical Research Centre, Oxford, UK
Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
BMJ Open Qual. 2021 May;10(2). doi: 10.1136/bmjoq-2020-000956.
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.
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).
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.
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.
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.
2009 年，国家患者结局和死亡机密调查建议只有 50%的急性肾损伤（AKI）患者接受了良好的护理标准。作为回应，英国国民保健署（NHS）要求在二级保健中使用电子 AKI 警报。然而，我们认识到 AKI 不仅是二级保健问题，初级保健在预防、早期发现和管理以及 AKI 后护理方面也起着至关重要的作用。
在 48 万人口的初级和二级保健服务中实施 AKI 警报。在使用 Byar 近似值（95%CI）前后的年份中，比较 AKI 的发病率、AKI 后的峰值肌酐和肾脏恢复情况。
根据在初级和二级保健的实验室信息管理系统中设计和整合 AKI 警报系统，实施了一项复杂的质量改进举措，并附有一个 URL，供临床医生访问 AKI 指南的护理包，包括安全处方、患者建议和早期与肾脏病学联系。
该干预措施与肌酐检测增加 8%（n=32563）相关。医院获得性 AKI 的检出率增加了 6%，而社区获得性 AKI 的检出率增加了 3%，初级保健中 AKI 3 期的检出率下降了 14%。该干预措施总体上对 AKI 严重程度没有影响，但确实改善了随访检测和肾脏恢复情况。重要的是，医院 AKI 3 期的恢复率提高了 22%。在少数 AKI 病例中，由于算法没有产生警报，与干预前相比，随访检测减少。
在初级和二级保健中引入 AKI 警报，并提供 AKI 护理包，与更高的重复采血、AKI 检出率和肾脏恢复率相关。需要验证警报的准确性，以避免患者受到伤害。
