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Abstract
Objective Around one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.
Design Mixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.
Setting and participants Three secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).
Analysis Qualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation.
Results Participants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).
Conclusions Clinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.
- acute renal failure
- health informatics
- quality in health care
- nephrology
- qualitative research
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Footnotes
Contributors TF, MB, GM, CG, BY, NK, NS and NSK conceived and designed the study. JS collected the data. JS, TF, GM and NSK analysed the data. JS and NSK drafted the manuscript, with all authors providing critical revisions and approval for the final version. JS and NSK agree to be accountable for all aspects of the work.
Funding This work was supported by funds from Northern Counties Kidney Research Fund (www.nckrf.org.uk). The funder had no role in the design and conduct of the study, including the collection, management, analysis, interpretation of the data, preparation, review or approval of the manuscript, and decision to submit the manuscript for publication.
Competing interests NS received travel funding from Alexion Pharmaceuticals to attend ERA-EDTA 2018 congress. NS is also a grant holder for a project ‘Imaging in Chronic Kidney Disease’, funded by GlaxoSmithKline. No other authors have competing interests to declare.
Patient consent for publication Not required.
Ethics approval All participants provided informed consent to participate. Interview participants provided written consent. Consent for observations was provided verbally by the lead consultant of each unit and individuals being observed. Survey respondents provided consent by returning the survey. The project was reviewed and approved by the National Health Service’s Health Research Authority (https://www.hra.nhs.uk/) (reference 16/HRA/2106). HRA approval brings together the HRA’s assessment of governance and legal compliance with the independent ethical opinion by a Research Ethics Committee. HRA approval is for all project-based research involving the NHS and Health and Social Care that is being led from England.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement The quantitative datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Participants were not asked to provide consent to share their transcripts beyond the research team. The study team would be happy to interrogate the data on behalf of others upon reasonable request to the corresponding author.