Electronic Alerts for Acute Kidney Injury

Abstract

Background: Acute kidney injury (AKI) often takes a complicated course if diagnosed late and undertreated. Electronic alerts that provide an early warning of AKI are intended to support treating physicians in making the diagnosis of AKI and treating it appropriately. The available evidence on the effects of such alert systems is inconsistent.

Methods: We employed the PRISMA recommendations for systematic literature reviews to identify relevant articles in the PubMed, Scopus, and Web of Science databases. All of the studies that were retrieved were independently assessed by two of the authors with respect to the methods of computer-assisted electronic alert systems and their effects on process indicators and clinical endpoints.

Results: 16 studies with a total of 32 842 patients were identified. 8.5% of admitted patients had community-acquired or hospital-acquired AKI, with an in-hospital mortality of 22.8%. Fifteen electronic alert systems were in use throughout the participating hospitals. In 13 of 15 studies, alarm activation was accompanied by concrete treatment recommendations. A randomized controlled trial in which no such recommendations were given did not reveal any benefit of the alert system for the patients. In controlled but non-randomized trials, however, the provision of concrete treatment recommendations when the alert was activated led to more frequent implementation of diagnostic or therapeutic measures, less loss of renal function, lower in-hospital mortality, and lower mortality after discharge compared to control groups without an electronic alert for AKI.

Conclusion: Non-randomized controlled trials of electronic alerts for AKI that were coupled with treatment recommendations have yielded evidence of improved care processes and treatment outcomes for patients with AKI. This review is limited by the low number of randomized trials and the wide variety of endpoints used in the studies that were evaluated.

Figure 1

Principle of an electronic early warning alerting system for acute kidney injury The detection element of an electronic alerting system is an algorithm built into the laboratory program, which can be used to compare current serum creatinine measurements with previously taken ones. Wherever possible, serum creatinine measurements are considered before inpatient admission and patients needing chronic dialysis are excluded. During the alerting process, treating phsycians can be informed about a reduction in renal function in various ways. One way is a simple list of affected patients with or without mention of the severity grade of their AKI. Another way is by using technically sophisticated early warning systems that will disrupt doctors‘ routine practice briefly and are linked to concrete recommendations to treating physicians. Use and benefit of the AKI alerting system should be checked at regular intervals, and feedback should be given to users (13). AKI, acute kidney injury

Figure 2

Flowchart showing study selection process

Figure 3

Typical characteristics of AKI alerting systems *Proportion of studies among those studies that reported relevant endpoints.

Figure 4

Effect of AKI alerting systems with linked concrete treatment recommendations on process indicators in controlled, non-randomized studies: Significant improvement in process indicators in the alert groups in 7 of 8 controlled, non-randomized studies (87.5%), in which an AKI alerting system was linked to concrete treatment recommendations or specialist treatment and relevant process indicators were reported * Bundles of measures can include the separately listed individual measures. AKI, acute kidney injury