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. 2019 Jul 31:2:67.
doi: 10.1038/s41746-019-0100-6. eCollection 2019.

Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions

Alistair Connell  1   2 , Hugh Montgomery  1 , Peter Martin  3 , Claire Nightingale  3   4 , Omid Sadeghi-Alavijeh  5 , Dominic King  2 , Alan Karthikesalingam  2 , Cian Hughes  2 , Trevor Back  2 , Kareem Ayoub  2 , Mustafa Suleyman  2 , Gareth Jones  5 , Jennifer Cross  5 , Sarah Stanley  5 , Mary Emerson  5 , Charles Merrick  5 , Geraint Rees  6 , Chris Laing #  5   7 , Rosalind Raine #  3
Affiliations

Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions

Alistair Connell et al. NPJ Digit Med. .

Abstract

We developed a digitally enabled care pathway for acute kidney injury (AKI) management incorporating a mobile detection application, specialist clinical response team and care protocol. Clinical outcome data were collected from adults with AKI on emergency admission before (May 2016 to January 2017) and after (May to September 2017) deployment at the intervention site and another not receiving the intervention. Changes in primary outcome (serum creatinine recovery to ≤120% baseline at hospital discharge) and secondary outcomes (30-day survival, renal replacement therapy, renal or intensive care unit (ICU) admission, worsening AKI stage and length of stay) were measured using interrupted time-series regression. Processes of care data (time to AKI recognition, time to treatment) were extracted from casenotes, and compared over two 9-month periods before and after implementation (January to September 2016 and 2017, respectively) using pre-post analysis. There was no step change in renal recovery or any of the secondary outcomes. Trends for creatinine recovery rates (estimated odds ratio (OR) = 1.04, 95% confidence interval (95% CI): 1.00-1.08, p = 0.038) and renal or ICU admission (OR = 0.95, 95% CI: 0.90-1.00, p = 0.044) improved significantly at the intervention site. However, difference-in-difference analyses between sites for creatinine recovery (estimated OR = 0.95, 95% CI: 0.90-1.00, p = 0.053) and renal or ICU admission (OR = 1.06, 95% CI: 0.98-1.16, p = 0.140) were not significant. Among process measures, time to AKI recognition and treatment of nephrotoxicity improved significantly (p < 0.001 and 0.047 respectively).

Keywords: Acute kidney injury; Outcomes research.

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Conflict of interest statement

Competing interestsC.L., H.M., G.R. and R.R. are paid clinical advisors to DeepMind. The clinical research fellowship of A.C. was part-funded by DeepMind, where he has been a full-time employee since May 2018. DeepMind remained independent from the collection and analysis of all data. C.L. was a member of the NICE clinical guideline 169 development group referenced in the article. H.M. co-holds a patent on a fluid delivery device which might ultimately help in preventing some (dehydration-related) cases of AKI occurring.

Figures

Fig. 1
Fig. 1
Weekly recovery rate at RFH and BGH before and after implementation of the care pathway. RFH Royal Free Hospital, BGH Barnet General Hospital. Individual data points reflect the rate of each outcome for a single week. Solid lines indicate fitted values from the modelling functions
Fig. 2
Fig. 2
Time to recognition of acute kidney injury (AKI). Kaplan–Meier curves for recognition of AKI after entry to the Emergency Department, before and after the implementation of the care pathway. The vertical dashed line represents the median time of creatinine result release across both time periods
Fig. 3
Fig. 3
Defining the final evaluation sample
See this image and copyright information in PMC

References

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