Association Between Implementation of an e-Alert for Detection of Acute Kidney Injury and Processes of Care and Outcomes: A Systematic Review and Meta-Analysis
CCCF ePoster library. Lachance P. Oct 31, 2016; 150880; 3
Dr. Philippe Lachance
Dr. Philippe Lachance
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Topic: Systematic Review, Meta-analysis, or Meta-synthesis

Association Between Implementation of an e-Alert for Detection of Acute Kidney Injury and Processes of Care and Outcomes: A Systematic Review and Meta-Analysis


Lachance Philippe MD MSc 1, Villeneuve Pierre-Marc MD 1, Rewa Oleksa MD 1, Wilson Francis MD MSCE 2, Selby Nicholas M MD 3, Featherstone Robin MLIS 4, Bagshaw Sean M MD MSc 1,5 

1 Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada, 2 Program of Applied Translational Research, Yale University School of Medicine, New Haven, USA, 3 Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK, 4 Alberta Research Center for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Canada,  5 Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada 


Grant acknowledgements:
Dr. Bagshaw holds a Canada Research Chair in Critical Care Nephrology.

Abstract:

INTRODUCTION Acute kidney injury (AKI) is a common complication in hospitalized patients. It imposes significant risk for major morbidity and mortality. Recently, a number of studies have evaluated the implementation of automated electronic alerts (e-alerts) to warn healthcare providers of early or impending AKI in hospitalized patients. The impact of e-alerts on patient-centered and health services outcomes remains uncertain1-3.

OBJECTIVES: 1)Describe the definitions and methods utilized for designing and implementing an electronic alert in AKI; Determine the impact of electronic alerting for AKI on 2) quality of care indicators and processes of care 3) patient-centered clinical outcomes and 4) health services use.
 
METHODS: We performed a systematic review and meta-analysis. We searched electronic databases and grey literature for original studies and abstracts published between 1990 and 2016. Two independent reviewers appraised quality of retrieved studies.  The detailed structure and target of each alert were also analyzed. We evaluated the impact of e-alerts on selected patient-centered outcomes including hospital mortality, receipt of renal replacement therapy (RRT) and worsening AKI (defined as achieve KDIGO stage 3 AKI or equivalent). We also evaluated the impact on health services outcomes (ICU admission, ICU and hospital lengths of stay) and selected care processes in response to alerting (ordering of investigations; fluid and/or diuretic administration). Pooled analysis using a random effect model was used when possible. Data were described with OR (95% CI).

RESULTS: Our search yielded 6472 citations; of which seven unique studies (n=14347 patients) fulfilled all eligibility and were included. One study was a randomized control trial, one use historical control, 3 were before and after studies and 2 were time series studies. 6 studies were high quality and 1 moderate. Most alerts were automated and used the electronic medical record. They were mildly intrusive and most of them were not linked to clear clinical decision support. E-alerts had no impact on mortality [OR 0.98, 95%CI 0.89-1.08; n=6 studies; n=11766 patients; I2 = 0%)], receipt of RRT [1.04, 95% CI 0.56-1.96; n=4 studies; n=11577 patients; I2 = 86%)],], and worsening AKI[1.04, 95% CI 0.9-1.21; n=3 studies; n=9194 patients; I2 = 24%)],]. There was no significant difference in fluid therapy [2.18 95% CI 0.46-10.31; n=2 studies; n=4378 patients; I2 = 99%)]. Pooled estimates were not available for the other prespecified outcomes mentioned above.

CONCLUSION: Our systematic review synthesizing evidence from 7 good quality studies did not show e-alerts for AKI were associated with improved survival, reduced RRT utilization, or reduced risk of worsening AKI. Similarly, e-alerts were not found to impact selected processes of care.  Given the widespread implementation of electronic medical records and adoption of automated alerting systems, further evaluation is urgent needed to understand the aspects of e-alerts for AKI most likely to impact care processes and improve outcomes, such as intrusiveness or integrated clinical decision support.
 


References:

1. Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg Med 2010;56(6):623-9.
2. Colpaert K, Hoste EA, Steurbaut K, et al. Impact of real-time electronic alerting of acute kidney injury on therapeutic intervention and progression of RIFLE class. Crit Care Med 2012;40(4):1164-70.
3. Wilson FP, Shashaty M, Testani J, et al. Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial. Lancet 2015;385(9981):1966-74.
 



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