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Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury.

ABSTRACT: BACKGROUND:Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations. METHODS:We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set. RESULTS:Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients. CONCLUSIONS:Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.

SUBMITTER: Howarth M

PROVIDER: S-EPMC7640650 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury.

Howarth Megan M Bhatt Meha M Benterud Eleanor E Wolska Anna A Minty Evan E Choi Kyoo-Yoon KY Devrome Andrea A Harrison Tyrone G TG Baylis Barry B Dixon Elijah E Datta Indraneel I Pannu Neesh N James Matthew T MT

BMC medical informatics and decision making 20201104 1

<h4>Background</h4>Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expect ...[more]

PMID: 33148237

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Project description:BackgroundElectronic health record (EHR)-based clinical decision support tools can improve the use of evidence-based clinical guidelines for preeclampsia management that can reduce maternal mortality and morbidity. No study has investigated the organizational capabilities that enable hospitals to use EHR-based decision support tools to manage preeclampsia.ObjectiveTo examine the association of organizational capabilities and hospital adoption of EHR-based decision support tools for preeclampsia management.MethodsCross-sectional analyses of hospitals providing obstetric care in 2017. In total, 739 hospitals responded to the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS) and were linked to the 2017 American Hospital Association (AHA) Annual Survey Database and the Area Health Resources File (AHRF). A total of 425 hospitals providing obstetric care across 49 states were included in the analysis. The main outcome was whether a hospital adopted EHR-based clinical decision support tools for preeclampsia management. Hospital organizational capabilities assessed as predictors include EHR functions, adoption of evidence-based clinical treatments, use of quality improvement methods, and dissemination processes to share best patient care practices. Logistic regression estimated the association of hospital organizational capabilities and hospital adoption of EHR-based decision support tools to manage preeclampsia, controlling for hospital structural and patient sociodemographic characteristics.ResultsTwo-thirds of the hospitals (68%) adopted EHR-based decision support tools for preeclampsia, and slightly more than half (56%) of hospitals had a single EHR system. Multivariable regression results indicate that hospitals with a single EHR system were more likely to adopt EHR-based decision support tools for preeclampsia (17.4 percentage points; 95% CI, 1.9 to 33.0; P < .05) than hospitals with a mixture of EHR and paper-based systems. Compared with hospitals having multiple EHRs, on average, hospitals having a single EHR were also more likely to adopt the tools by 9.3 percentage points, but the difference was not statistically significant (95% CI, -1.3 to 19.9). Hospitals with more processes to aid dissemination of best patient care practices were also more likely to adopt EHR-based decision-support tools for preeclampsia (0.4 percentage points; 95% CI, 0.1 to 0.6, for every 1-unit increase in dissemination processes; P < .01).ConclusionStandardized EHRs and policies to disseminate evidence are foundational hospital capabilities that can help advance the use of EHR-based decision support tools for preeclampsia management in the approximately one-third of US hospitals that still do not use them.

Project description:BackgroundThe diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results.ObjectiveThe aim of this study was to report the trial design and implementation experience of a CKD eCDSS in primary care.MethodsThis was a 3-arm pragmatic cluster-randomized trial at an academic general internal medicine practice. Eligible patients had 2 previous estimated-glomerular-filtration-rates by serum creatinine (eGFRCr) <60 mL/min/1.73m2 at least 90 days apart. Randomization occurred at the PCP level. For patients of PCPs in either of the 2 intervention arms, the research team ordered triple-marker testing (serum creatinine, serum cystatin-c, and urine albumin-creatinine-ratio) at the beginning of the study period, to be completed when acquiring labs for regular clinical care. The eCDSS launched for PCPs and patients in the intervention arms during a regular PCP visit subsequent to completing the triple-marker testing. The eCDSS delivered individualized guidance on cardiovascular risk-reduction, potassium and proteinuria management, and patient education. Patients in the eCDSS+ arm also received a pharmacist phone call to reinforce CKD-related education. The primary clinical outcome is blood pressure change from baseline at 6 months after the end of the trial, and the main secondary outcome is provider awareness of CKD diagnosis. We also collected process, patient-centered, and implementation outcomes.ResultsA multidisciplinary team (primary care internist, nephrologists, pharmacist, and informaticist) designed the eCDSS to integrate into the current clinical workflow. All 81 PCPs contacted agreed to participate and were randomized. Of 995 patients initially eligible by eGFRCr, 413 were excluded per protocol and 58 opted out or withdrew, resulting in 524 patient participants (188 usual care; 165 eCDSS; and 171 eCDSS+). During the 12-month intervention period, 53.0% (178/336) of intervention patient participants completed triple-marker labs. Among these, 138/178 (77.5%) had a PCP appointment after the triple-marker labs resulted; the eCDSS was opened for 73.9% (102/138), with orders or education signed for 81.4% (83/102).ConclusionsSuccessful integration of an eCDSS into primary care workflows and high eCDSS utilization rates at eligible visits suggest this tailored electronic approach is feasible and has the potential to improve guideline-concordant CKD care.Trial registrationClinicalTrials.gov NCT02925962; https://clinicaltrials.gov/ct2/show/NCT02925962 (Archived by WebCite at http://www.webcitation.org/78qpx1mjR).International registered report identifier (irrid)DERR1-10.2196/14022.

Project description:BackgroundHospitals across Australia are implementing Clinical Information Systems, e.g. Electronic Medication Management Systems (EMMS) at a rapid pace to moderate health services. The benefits of the EMMS depend on the acceptance of the system by the clinicians. The study hospital used a unique patient-centric implementation strategy that was based on the guiding principle of "one patient, one chart" to avoid a patient being on a hybrid medication chart. This paper aims to study the factors facilitating or hindering the adoption of the EMMS as viewed by clinicians and the implementation team.MethodsFour focus groups (FG), one each for (1) doctors, (2) nurses, (3) pharmacists, and (4) implementation team, were conducted. A guide for the FG was based on the Unified Theory of Acceptance and Use of Technology (UTAUT).ResultsA total of 23 unique subthemes were identified and were grouped into five main themes (1) implementation strategy, (2) organisational outcome of EMMS, (3) individual impact of EMMS, (4) IT product, and (5) organisational culture. Clinicians reported improvement in their workflow efficiency post-EMMS implementation. They also reported some challenges in using the EMMS that centered around the area of infrastructure, technical and design issues. Additionally, the implementation team highlighted two crucial factors influencing the success of EMMS implementation, namely: (1) the patient-centric implementation strategy, and (2) the organisation readiness.ConclusionOverall, this study outlines the implementation process of the EMMS in a large healthcare facility from the clinicians' and the implementation team's perspectives using UTAUT model. The result suggests that clinicians' acceptance of the EMMS was highly influenced by the unique implementation strategy (namely, patient-centric approach and clinical leadership in the implementation team). Whereas the level of adoption of EMMS by clinicians was determined by their level of perceived and realised benefits. On the other hand, a number of barriers to the adoption of EMMS were discovered, namely, general training instead of customised training based on local needs, technical and design issues and lack of availability of computer systems. It is suggested that promptly resolving these issues can improve the adoption of the EMMS.

Project description:BACKGROUND:Hospital-acquired acute kidney injury (AKI) is associated with increased mortality and resource consumption. Little is known about the association of AKI with short-term hospital readmissions. STUDY DESIGN:Retrospective cohort study. SETTING & PARTICIPANTS:We investigated whether adult survivors of hospital-acquired AKI were at increased odds for early hospital readmission. PREDICTOR:The peak-to-nadir serum creatinine difference during the index hospitalization was used to define AKI according to the KDIGO (Kidney Disease: Improving Global Outcomes) classification and staging system. MEASUREMENTS:Multivariable logistic regression analyses examined the association of AKI with 30-, 60-, and 90-day hospital readmission, adjusting for age, sex, race, Charlson-Deyo comorbidity index score, acute hospital-related factors, common causes of hospitalization, and baseline estimated glomerular filtration rate. RESULTS:3,345 (15%) of 22,001 included patients experienced AKI during the index hospitalization. Compared to the non-AKI group, the AKI group had a significantly higher 30-day hospital readmission rate (11% vs 15%; P<0.001), which persisted at 60 and 90 days. The AKI group also was more likely to be readmitted to the hospital within 30 days for cardiovascular-related conditions, mainly heart failure (P<0.001) and acute myocardial infarction (P=0.01). AKI associated independently with higher odds of 30-day hospital readmission (OR, 1.21; 95% CI, 1.08-1.36), which persisted at 60 (OR, 1.15; 95% CI, 1.03-1.27) and 90 days (adjusted OR, 1.13; 95% CI, 1.02-1.25). Results were attenuated in a propensity score-matched cohort of 5,912 patients. LIMITATIONS:Single-center study of mild forms of AKI; ascertainment bias and outcome misclassification due to the use of administrative codes. CONCLUSIONS:Our results suggest that survivors of hospital-acquired AKI experience higher odds of early hospital readmission. Transitions of care services may be warranted for such patients to prevent readmissions and reduce health care costs.

Project description:Purpose of programDifferent models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta, Canada, with the goal of preventing contrast-associated acute kidney injury (CA-AKI) following coronary angiography and intervention. This report describes the change management approaches used by the initiative and end-user's feedback on these processes.Sources of information and methodsThe Canada Health Infoway Change Management model was used to address 6 activities relevant to project implementation: governance and leadership, stakeholder engagement, communications, workflow analysis and integration, training and education, and monitoring and evaluation. Health care providers and invasive cardiologists from all sites completed preimplementation, usability, and postimplementation surveys to assess integration and change success.Key findingsPrior to implementation, 67% of health providers were less than satisfied with processes to determine appropriate contrast dye volumes, 47% were less than satisfied with processes for administering adequate intravenous fluids, and 68% were less than satisfied with processes to ensure follow-up of high-risk patients. 48% of invasive cardiologists were less than satisfied with preprocedural identification of patients at risk of acute kidney injury (AKI). Following implementation, there were significant increases among health providers in the odds of satisfaction with processes for identifying those at high risk of AKI (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.36-6.66, P = .007), quantifying the appropriate level of contrast dye for each patient (OR 6.98, 95% CI 3.06-15.91, P < .001), determining the optimal amount of IV fluid for each patient (OR 1.86, 95% CI 0.88-3.91, P = .102), and following up of kidney function of high risk patients (OR 5.49, 95%CI 2.45-12.30, P < .001). There were also significant increases among physicians in the odds of satisfaction with processes for identifying those at high risk of AKI (OR 19.53, 95% CI 3.21-118.76, P = .001), quantifying the appropriate level of contrast dye for each patient (OR 26.35, 95% CI 4.28-162.27, P < .001), and for following-up kidney function of high-risk patients (OR 7.72, 95% CI 1.62-36.84.30, P = .010). Eighty-nine percent of staff perceived the initiative as being successful in changing clinical practices to reduce the risk of CA-AKI. Physicians uniformly agreed that the system was well-integrated into existing workflows, while 42% of health providers also agreed.ImplicationsThe Canada Health Infoway Change Management model was an effective framework for guiding implementation of an electronic decision support tool and audit and feedback intervention to improve processes for AKI prevention within cardiac catheterization units.

Project description:BACKGROUND:Mobile health (mHealth) technologies are increasingly used in various medical fields. However, the potential of mHealth to improve patient care in radiotherapy by acquiring electronic patient reported outcome measures (ePROMs) during treatment has been poorly studied so far. OBJECTIVE:The aim of this study was to develop and implement a novel Web app (PROMetheus) for patients undergoing radiotherapy. Herein, we have reported our experience with a focus on feasibility, patient acceptance, and a correlation of ePROMs with the clinical course of the patients. METHODS:In the period between January and June 2018, 21 patients used PROMetheus to score side effects, symptoms, and quality of life-related parameters during and after their treatment. Items of the Patient Reported Outcome version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) were chosen based on the primary site of disease, 27 items for head and neck tumors, 21 items for thoracic tumors, and 24 items for pelvic tumors. RESULTS:In total, 17 out of the 21 patients (81%) regularly submitted ePROMs and more than 2500 data points were acquired. An average of 5.2, 3.5, and 3.3 min was required to complete the head and neck, thorax, and pelvis questionnaires, respectively. ePROMS were able to detect the occurrence of both expected and unexpected side effects during the treatment. In addition, a gradual increase in the severity of side effects over the course the treatment and their remission afterward could be observed with ePROMs. In total, 9 out of the 17 patients (53%), mostly those with head and neck and thoracic cancers, reported PRO-CTCAE grade III or IV fatigue with severe impairments of activities of daily life. CONCLUSIONS:This study shows the successful implementation of an ePROM system and a high patient acceptance. ePROMs have a great potential to improve patient care in radiotherapy by providing a comprehensive documentation of symptoms and side effects, especially of ones that are otherwise underreported.

Dataset Information

Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury.

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Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury.

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