Justice Christopher M, Nevin Connor, Neely Rebecca L, Dilcher Brian, Kovacic-Scherrer Nicole, Carter-Templeton Heather, Ostrowski Aaron, Krafcheck Jacob, Smith Gordon, McCarthy Paul, Pincavitch Jami, Kane-Gill Sandra, Freeman Robert, Kellum John A, Kohli-Seth Roopa, Nadkarni Girish N, Shawwa Khaled, Sakhuja Ankit
Heart and Vascular Institute, JW Ruby Memorial Hospital, West Virginia University, Morgantown, West Virginia, United States.
Nurse Anesthesia Program, School of Nursing, West Virginia University, Morgantown, West Virginia, United States.
Appl Clin Inform. 2025 Jan;16(1):1-10. doi: 10.1055/s-0044-1791822. Epub 2025 Jan 1.
Nephrotoxin exposure may worsen kidney injury and impair kidney recovery if continued in patients with acute kidney injury (AKI).
This study aimed to determine if tiered implementation of a clinical decision support system (CDSS) would reduce nephrotoxin use in cardiac surgery patients with AKI.
We assessed patients admitted to the cardiac surgery intensive care unit at a tertiary care center from January 2020 to December 2021, and August 2022 to September 2023. A passive electronic AKI alert was activated in July 2020, followed by an electronic nephrotoxin alert in March 2023. In this alert, active nephrotoxic medication orders resulted in a passive alert, whereas new orders were met with an interruptive alert. Primary outcome was discontinuation of nephrotoxic medications within 30 hours after AKI. Secondary outcomes included AKI-specific clinical actions, determined through modified Delphi process and patient-centered outcomes. We compared all outcomes across five separate eras, divided based on the tiered implementation of these alerts.
A total of 503 patients met inclusion criteria. Of 114 patients who received nephrotoxins before AKI, nephrotoxins were discontinued after AKI in 6 (25%) patients in pre AKI-alert era, 8 (33%) patients in post AKI-alert era, 7 (35%) patients in AKI-alert long-term follow up era, 7 (35%) patients in pre nephrotoxin-alert era, and 14 (54%) patients in post nephrotoxin-alert era ( = 0.047 for trend). Among AKI-specific consensus actions, we noted a decreased use of intravenous fluids, increased documentation of goal mean arterial pressure of 65 mm Hg or higher, and increased use of bedside point of care echocardiogram over time. Among exploratory clinical outcomes we found a decrease in proportion of stage III AKI, need for dialysis, and length of hospital stay over time.
Tiered implementation of CDSS for recognition of AKI and nephrotoxin exposure resulted in a progressive improvement in the discontinuation of nephrotoxins.
对于急性肾损伤（AKI）患者，如果持续接触肾毒素，可能会加重肾损伤并妨碍肾脏恢复。
本研究旨在确定临床决策支持系统（CDSS）的分层实施是否会减少心脏手术合并AKI患者的肾毒素使用。
我们评估了2020年1月至2021年12月以及2022年8月至2023年9月期间在一家三级医疗中心心脏外科重症监护病房住院的患者。2020年7月启动了被动电子AKI警报，随后于2023年3月启动了电子肾毒素警报。在该警报中，如果有正在使用的肾毒性药物医嘱，则会触发被动警报，而新的医嘱则会触发中断性警报。主要结局是在AKI发生后30小时内停用肾毒性药物。次要结局包括通过改良德尔菲法确定的AKI特异性临床措施以及以患者为中心的结局。我们比较了基于这些警报分层实施划分的五个不同时期的所有结局。
共有503例患者符合纳入标准。在114例AKI发生前接受肾毒素治疗的患者中，在AKI前警报时代，6例（25%）患者在AKI发生后停用了肾毒素；在AKI后警报时代，8例（33%）患者停用；在AKI警报长期随访时代，7例（35%）患者停用；在肾毒素前警报时代，7例（35%）患者停用；在肾毒素后警报时代，14例（54%）患者停用（趋势检验P = 0.047）。在AKI特异性共识措施方面，我们注意到随着时间的推移，静脉输液的使用减少，目标平均动脉压记录为65 mmHg或更高的情况增加，以及床旁即时超声心动图的使用增加。在探索性临床结局方面，我们发现随着时间的推移，III期AKI的比例、透析需求和住院时间均有所下降。
用于识别AKI和肾毒素暴露的CDSS分层实施导致肾毒素停用情况逐步改善。
