预防对比剂相关性急性肾损伤干预后的持续改善：一项随机对照试验
Sustained Improvements After Intervention to Prevent Contrast-Associated Acute Kidney Injury: A Randomized Controlled Trial.
作者信息
Matheny Michael E, Carpenter-Song Elizabeth, Ricket Iben M, Solomon Richard J, Stabler Meagan E, Davis Sharon E, Zubkoff Lisa, Westerman Dax M, Dorn Chad, Cox Kevin C, Minter Freneka F, Jneid Hani, Currier Jesse W, Athar S Ahmed, Girotra Saket, Leung Calvin, Helton Thomas J, Agarwal Ajay, Vidovich Mladen I, Plomondon Mary E, Waldo Stephen W, Aschbrenner Kelly A, McKay Virginia, O'Malley A James, Brown Jeremiah R
机构信息
Department of Biomedical Informatics Vanderbilt University Medical Center Nashville TN USA.
Geriatric Research Education and Clinical Care Center Tennessee Valley Healthcare System VA Nashville TN USA.
出版信息
J Am Heart Assoc. 2025 May 20;14(10):e038920. doi: 10.1161/JAHA.124.038920. Epub 2025 May 15.
BACKGROUND
In the IMPROVE AKI (A Cluster-Randomized Trial of Team-Based Coaching Interventions to Improve Acute Kidney Injury) trial, a combination of team-based coaching and data-driven surveillance dashboards reduced the odds of AKI following cardiac catheterization by 46%. The objective of this study was to determine if improvements in AKI outcomes would be sustained after completion of the active intervention.
METHODS AND RESULTS
A 2×2 factorial cluster-randomized trial with an 18-month active intervention phase (October 2019-March 2021) and an 18-month sustainability phase (April 2021-September 2022) conducted among cardiac catheterization laboratories in 20 Veterans Affairs sites. Interventions included team-based coaching in a virtual learning collaborative or technical assistance, with and without access to an automated surveillance reporting dashboard. Data were collected on procedures involving adult patients undergoing diagnostic coronary angiography or percutaneous coronary interventions and not receiving chronic dialysis. The main outcome was AKI within 7 days of cardiac catheterization among all participants and those with preexisting chronic kidney disease. In addition, survey and focused interview data were collected to understand barriers and facilitators to sustaining AKI improvements. In this phase, 440 of 4160 patients experienced AKI, including 216 of 1260 patients with chronic kidney disease. Compared with technical assistance alone, we observed a reduction in AKI among virtual learning collaborative + automated surveillance reporting sites (adjusted odds ratio, 0.60 [95% CI, 0.42-0.86]). Sites had implemented standardized orders (11), oral and intravenous hydration standing orders (13), and contrast limiting protocols (10).
CONCLUSIONS
Team-based coaching coupled with data-driven surveillance dashboards reduced AKI by 40% during the 18 months after active participation in the trial. Process improvement education, care process standardization, and automated outcome feedback may be effective and durable methods for reducing AKI.
REGISTRATION
URL: https://clinicaltrials.gov/; Unique Identifier: NCT03556293.
背景
在IMPROVE AKI（一项基于团队的指导干预以改善急性肾损伤的整群随机试验）试验中，基于团队的指导与数据驱动的监测仪表板相结合，使心脏导管插入术后发生急性肾损伤的几率降低了46%。本研究的目的是确定在积极干预结束后，急性肾损伤结局的改善是否会持续。
方法与结果
在20个退伍军人事务部站点的心脏导管插入实验室进行了一项2×2析因整群随机试验，包括一个为期18个月的积极干预期（2019年10月至2021年3月）和一个为期18个月的可持续性阶段（2021年4月至2022年9月）。干预措施包括在虚拟学习协作中进行基于团队的指导或技术援助，有无自动化监测报告仪表板的使用权限。收集了涉及接受诊断性冠状动脉造影或经皮冠状动脉介入治疗且未接受慢性透析的成年患者的手术数据。主要结局是所有参与者以及患有慢性肾脏病的参与者在心脏导管插入术后7天内发生急性肾损伤。此外，收集了调查和重点访谈数据，以了解维持急性肾损伤改善的障碍和促进因素。在此阶段，4160例患者中有440例发生急性肾损伤，其中1260例慢性肾脏病患者中有216例。与仅接受技术援助相比，我们观察到虚拟学习协作+自动化监测报告站点的急性肾损伤发生率降低（调整后的比值比，0.60[95%CI，0.42-0.86]）。各站点实施了标准化医嘱（11个）、口服和静脉补液常规医嘱（13个）以及造影剂限制方案（10个）。
结论
在积极参与试验后的18个月内，基于团队的指导与数据驱动的监测仪表板相结合使急性肾损伤降低了40%。过程改进教育、护理过程标准化和自动化结局反馈可能是降低急性肾损伤的有效且持久的方法。
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