The ICE-AKI study: Impact analysis of a Clinical prediction rule and Electronic AKI alert in general medical patients

PLoS One. 2018 Aug 8;13(8):e0200584. doi: 10.1371/journal.pone.0200584. eCollection 2018.

Abstract

Background: Acute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes.

Methods and findings: A controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014-16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981-1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858-0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560-0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation.

Conclusions: In acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness.

Trial registration: Clinicaltrials.org NCT03047382.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / mortality
  • Acute Kidney Injury / pathology*
  • Aged
  • Aged, 80 and over
  • Creatinine / blood
  • Decision Support Techniques*
  • Disease Progression
  • Female
  • Hospital Mortality
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Odds Ratio
  • Risk Factors
  • Severity of Illness Index
  • United Kingdom

Substances

  • Creatinine

Associated data

  • ClinicalTrials.gov/NCT03047382

Grants and funding

Grants from the Small Business Research Initiative (National Institute for Health Research Devices for Dignity HTC partnered with the Department of Health) and the British Renal Society / British Kidney Patient Association, 14-013 (LEH) helped fund integration and implementation of the technology into Patientrack from the Hospital Trust’s electronic servers. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.