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Randomized Controlled Trial
. 2020 Jan;87(1):118-124.
doi: 10.1038/s41390-019-0550-1. Epub 2019 Aug 27.

Acute kidney injury risk-based screening in pediatric inpatients: a pragmatic randomized trial

Sara L Van Driest  1 , Li Wang  2 , Michael F McLemore  3 , Brian C Bridges  4 , Geoffrey M Fleming  4 , Tracy L McGregor  4 , Deborah P Jones  4 , Jana Shirey-Rice  5 , Cheryl L Gatto  5 , James C Gay  4 , Daniel W Byrne  2 , Asli Weitkamp  6 , Dan M Roden  7 , Gordon Bernard  7
Affiliations
Randomized Controlled Trial

Acute kidney injury risk-based screening in pediatric inpatients: a pragmatic randomized trial

Sara L Van Driest et al. Pediatr Res. 2020 Jan.

Abstract

Background: Pediatric acute kidney injury (AKI) is common and associated with increased morbidity, mortality, and length of stay. We performed a pragmatic randomized trial testing the hypothesis that AKI risk alerts increase AKI screening.

Methods: All intensive care and ward admissions of children aged 28 days through 21 years without chronic kidney disease from 12/6/2016 to 11/1/2017 were included. The intervention alert displayed if calculated AKI risk was > 50% and no serum creatinine (SCr) was ordered within 24 h. The primary outcome was SCr testing within 48 h of AKI risk > 50%.

Results: Among intensive care admissions, 973/1909 (51%) were randomized to the intervention. Among those at risk, more SCr tests were ordered for the intervention group than for controls (418/606, 69% vs. 361/597, 60%, p = 0.002). AKI incidence and severity were the same in intervention and control groups. Among ward admissions, 5492/10997 (50%) were randomized to the intervention, and there were no differences between groups in SCr testing, AKI incidence, or severity of AKI.

Conclusions: Alerts based on real-time prediction of AKI risk increased screening rates in intensive care but not pediatric ward settings. Pragmatic clinical trials provide the opportunity to assess clinical decision support and potentially eliminate ineffective alerts.

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Conflict of interest statement

Disclosure: The authors have no financial relationships relevant to this article to disclose, and no potential/perceived conflicts of interest relevant to this article to disclose.

Figures

Figure 1.
Figure 1.. Acute Kidney Injury Risk Alert.
The alert was shown at the end of order entry if the admission was randomized to the intervention group, the calculated acute kidney injury risk exceeded 50%, the alert had not been acknowledged in the prior 24 hours, and no serum creatinine test result was available from the prior 24 hours or scheduled to be obtained within 24 hours. BMP – basic metabolic profile, including serum sodium, potassium, chloride, carbon dioxide, glucose, blood urea nitrogen, calcium and creatinine.
Figure 2.
Figure 2.. Study Cohorts.
Admissions to the PICU and inpatient ward were included. Individuals with known CKD were excluded. Admissions were assigned to the ward or PICU cohorts for AKI risk calculation and for study analysis based on patient location. Admissions that remained in ward units for the duration of the hospitalization were assigned to the ward cohort (n=10,822). Those initially admitted to the PICU were assigned to the PICU cohort and retained in the ICU cohort for the duration of the admission, even if the patient was transferred to the inpatient ward (N=1,734). Admissions initially located in the inpatient ward but then transferred to the ICU (N=175) were included in the ward cohort from admission until transfer to the ICU (the duration of their ward stay), then included in the ICU cohort from transfer until discharge. The primary outcome (SCr screening within 48 hours of AKI risk >50%) was evaluated among those identified as at risk for AKI (AKI risk >50%). LOS and mortality were assessed among those at risk, and among all randomized patients. AKI incidence and AKI severity were assessed in those admissions with at least 2 SCr measurements, enabling determination of AKI status. aAdmissions to the ward later transferred to the PICU had risk calculation based on the ward model until transfer, and data through the time of transfer are included in the ward cohort; after transfer to the PICU, risk was calculated using the PICU model, and the portion of the admission from transfer through discharge is included in the PICU cohort. bAdmissions were included for assessment of AKI outcomes based on presence of 2 SCr measurements, regardless of AKI risk. CKD - Chronic Kidney Disease; PICU - Pediatric Intensive Care Unit; SCr – Serum Creatinine; LOS – Length of Stay; AKI - Acute Kidney Injury.
Figure 3.
Figure 3.. Reasons Given for Declining to Follow CDS Recommendation.
The count of each type of reason given is shown in the graph. A. For the pediatric ICU, reasons were entered for a total of 20 of CDS alert instances. B. For the pediatric ward, reasons were given for a total of 97 CDS alert instances. *Other reasons included one instance each of “aware,” nephrology involved, and care per protocol.
See this image and copyright information in PMC

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