Quality Improvement Goals for Acute Kidney Injury

Abstract

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.

Keywords: ADQI; Acute Disease; Acute Kidney Injury; Emergency Service, Hospital; Goals; Health Care Costs; Incidence; Inpatients; Management; Nurse Practitioners; Patient Discharge; Pharmacists; Prevention; Quality Improvement; Quality of Health Care; acute renal failure; hospitalization.

Figure 1.

Seven steps need to be taken for a successful quality improvement project. Supplemental Appendix 1 provides definitions, templates, and examples. DMAIC, Define, Measure, Analyze, Implement, Control; PDSA, Plan, Do, Study, Act. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.

Figure 2.

AKI quality care in a continuity. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.

Figure 3.

KHA and response. KHA includes AKI history, BP, CKD, serum Creatinine level, Drug list, and urine Dipstick (ABCD). Exposures include Nephrotoxic Medications, Imaging, Surgery, Sickness (NISS). KHR (4Ms) that encompasses Medication review to withhold unnecessary medications (e.g., nonsteroidal anti-inflammatory drugs [16,17]), the Minimization of nephrotoxic exposures (e.g., intravenous contrast [18]), Messaging the healthcare team and patient to alert the high risk of AKI, and Monitoring for AKI and its consequences. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.

Figure 4.

Factors related to quality indicators and reporting can be divided in structure, process, and outcome in community, hospital, and after initiation of KRT. Clearly, different levels exist depending on resource possibilities. For example, resource-sufficient areas may have access electronic medical records, allowing system-driven identification and prevention and more detailed outcome reporting of patients with AKI. Embedded in these is a basic level of quality measures and level of reporting that should be feasible in both resource-limited and research-sufficient areas (white boxes). AE, adverse event; EMR, Electronical Medical Record; ICU, intensive care unit; Scr, serum creatinine; QoL, quality of life; KRT, kidney replacement therapy. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.

Figure 5.

Schematic for AKI/AKD follow-up. The figure displays a potential paradigm for the care of patients who experience AKI/AKD. The degree of nephrology-based follow-up increases as the duration and severity of AKI/AKID increases. The timing and nature of follow up are suggestions as there is limited data to inform this process. Future research effort should work to clarify the timing and health care providers who should be providing AKI/AKD follow-up. The items in each bucket follow the “OR” rule; therefore, each patient should follow the most severe bucket if even meet one criteria of that bucket (e.g., patient with CKD stage 4 regardless of severity of AKI should be followed by nephrologist in 1 week). Reprinted from Acute disease quality initiative (ADQI) (12), with permission.