In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available ...through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
Aims
To summarize and extend the main conclusions and recommendations relevant to drug management during acute kidney disease (AKD) as agreed at the 16th Acute Disease Quality Initiative (ADQI) ...consensus conference.
Methods
Using a modified Delphi method to achieve consensus, experts attending the 16th ADQI consensus conference reviewed and appraised the existing literature on drug management during AKD and identified recommendations for clinical practice and future research. The group focussed on drugs with one of the following characteristics: (i) predominant renal excretion; (ii) nephrotoxicity; (iii) potential to alter glomerular function; and (iv) presence of metabolites that are modified in AKD and may affect other organs.
Results
We recommend that medication reconciliation should occur at admission and discharge, at AKD diagnosis and change in AKD phase, and when the patient's condition changes. Strategies to avoid adverse drug reactions in AKD should seek to minimize adverse events from overdosing and nephrotoxicity and therapeutic failure from under‐dosing or incorrect drug selection. Medication regimen assessment or introduction of medications during the AKD period should consider the nephrotoxic potential, altered renal and nonrenal elimination, the effects of toxic metabolites and drug interactions and altered pharmacodynamics in AKD. A dynamic monitoring plan including repeated serial assessment of clinical features, utilization of renal diagnostic tests and therapeutic drug monitoring should be used to guide medication regimen assessment.
Conclusions
Drug management during different phases of AKD requires an individualized approach and frequent re‐assessment. More research is needed to avoid drug associated harm and therapeutic failure.
Abstract Purpose The purpose was to determine if the implementation of an evidence-based nonpharmacologic protocol reduced the percentage of time patients spent delirious in a medical intensive care ...unit (MICU) that already uses a sedation and mobility protocol. Materials and methods This was a prospective, pre-post quality improvement project of MICU patients conducted from September 2013 to April 2014. Evidence-based effective nonpharmacologic interventions with nursing education were bundled into the project protocol: music, opening/closing of blinds, reorientation/cognitive stimulation, and eye/ear care. Results Patients were evaluated between September 2013 and April 2014, with 230 and 253 patients being included in the each phase. There was a 50.6% reduction (16.1% vs 9.6%, P < .001) in time spent delirious in the MICU. Incidence of delirium developed was decreased (15.7% vs 9.4%, P = .04). The protocol reduced the odds of developing delirium by 57% (odds ratio, 0.43; P = .005) after controlling for age, Acute Physiology and Chronic Health Evaluation II, mechanical ventilation, and dementia. Conclusions The implementation of a nonpharmacologic delirium prevention protocol resulted in a significant decrease in the percentage of time spent delirious in the MICU while reducing the risk of delirium development. Additional studies with more rigorous study designs need to be completed to further the research of nonpharmacologic interventions with appropriate sedation and mobility protocols.
OBJECTIVE:Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to ...alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment.
DATA SOURCES:PubMed, SCOPUS, Embase, and CINAHL.
STUDY SELECTION:We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; “what interventions have been attempted and resulted in the success of reducing alarm fatigue?” and 3-secondary key questions; “what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?”
DATA EXTRACTION:Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool.
DATA SYNTHESIS:We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of “alarm fatigue.” For our primary key question 1, the relevant studies focused on three main areasquality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly.
CONCLUSIONS:There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.
Quality Improvement Goals for Acute Kidney Injury Kashani, Kianoush; Rosner, Mitchell Howard; Haase, Michael ...
Clinical journal of the American Society of Nephrology,
06/2019, Letnik:
14, Številka:
6
Journal Article
Recenzirano
Odprti dostop
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.
Drugs are the third to fifth leading cause of acute kidney injury (AKI) in critically ill patients following sepsis and hypotension. Susceptibilities and exposures for development of AKI have been ...identified, and some are modifiable allowing for the possibility of AKI prevention or mitigation of AKI severity. Using drug therapies for prevention of AKI has been attempted but with little success in human studies, so we must rely on risk-assessment strategies for prevention. The purpose of this article is to review the risk factors, risk-assessment strategies, prevention, and management of drug-induced AKI with emphasis on risk assessment.
Background. Acute kidney injury (AKI) is a recognized complication of cardiac surgery; however, the variability in costs and outcomes reported are due, in part, to different criteria for diagnosing ...and classifying AKI. We determined costs, resource use and mortality rate of patients. We used the serum creatinine component of the RIFLE system to classify AKI. Methods. A retrospective cohort study was conducted from the electronic data repository at the University of Pittsburgh Medical Center of patients who underwent cardiac surgery and had an elevation (≥0.5 mg/dl) of serum creatinine postoperatively. Data were compared to age- and APACHE III-matched controls. Cost, mortality and resource use of AKI patients were determined postoperatively for each of the three RIFLE classes on the basis of changes in serum creatinine. Results. Of the 3741 admissions, 258 (6.9%) had AKI and were classified as RIFLE-R 138 (3.7%), RIFLE-I 70 (1.9%) and RIFLE-F 50 (1.3%). Total and departmental level costs, length of stay (LOS) and requirement for renal replacement therapy (RRT) were higher in AKI patients compared to controls. Statistically significant differences in all costs, mortality rate and requirement for RRT were seen in the patients stratified into RIFLE-R, RIFLE-I and RIFLE-F. Even patients with the smallest change in serum creatinine, namely RIFLE-R, had a 2.2-fold greater mortality, a 1.6-fold increase in ICU LOS and 1.6-fold increase in total postoperative costs compared to controls. Discussion. Costs, LOS and mortality are higher in postoperative cardiac surgery patients who develop AKI using RIFLE criteria, and these values increase as AKI severity worsens.
The Impact of Mortality on Total Costs Within the ICU Kramer, Andrew A; Dasta, Joseph F; Kane-Gill, Sandra L
Critical care medicine,
2017-September, 2017-Sep, 2017-09-00, 20170901, Letnik:
45, Številka:
9
Journal Article
Recenzirano
OBJECTIVES:The high cost of critical care has engendered research into identifying influential factors. However, existing studies have not considered patient vital status at ICU discharge. This study ...sought to determine the effect of mortality upon the total cost of an ICU stay.
DESIGN:Retrospective cohort study.
SETTING:Twenty-six ICUs at 13 hospitals in the United States.
PATIENTS:58,344 admissions from January 1, 2012, to June 30, 2016, obtained from a commercial ICU database.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:The median observed cost of a unit stay was $9,619 (mean = $16,353). A multivariable regression model was developed on the log of total costs for a unit stay, using severity of illness, unit admitting diagnosis, mortality in the unit, daily unit occupancy (occupying a bed at midnight), and length of mechanical ventilation. This model had an r of 0.67 and a median difference between observed and expected costs of $437. The first few days of care and the first day receiving mechanical ventilation had the largest effect on total costs. Patients dying before unit discharge had 12.4% greater costs than survivors (p < 0.01; 99% CI = 9.3–15.5%) after multivariable adjustment. This effect was most pronounced for patients with an extended ICU stay who were receiving mechanical ventilation.
CONCLUSIONS:While the largest drivers of ICU costs at the patient level are day 1 room occupancy and day 1 mechanical ventilation, mortality before unit discharge is associated with substantially higher costs. The increase was most evident for patients with an extended ICU stay who were receiving mechanical ventilation. Studies evaluating costs among ICUs need to take mortality into account.
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