A Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report

doi:10.1053/j.ajkd.2010.05.024

American Journal of Kidney Diseases

Volume 56, Issue 5, November 2010, Pages 832-841

https://doi.org/10.1053/j.ajkd.2010.05.024 Get rights and content

Background

Frequently, prescribers fail to account for changing kidney function when prescribing medications. We evaluated the use of a computerized provider order entry intervention to improve medication management during acute kidney injury.

Study Design

Quality improvement report with time series analyses.

Setting & Participants

1,598 adult inpatients with a minimum 0.5-mg/dL increase in serum creatinine level over 48 hours after an order for at least one of 122 nephrotoxic or renally cleared medications.

Quality Improvement Plan

Passive noninteractive warnings about increasing serum creatinine level appeared within the computerized provider order entry interface and on printed rounding reports. For contraindicated or high-toxicity medications that should be avoided or adjusted, an interruptive alert within the system asked providers to modify or discontinue the targeted orders, mark the current dosing as correct and to remain unchanged, or defer the alert to reappear in the next session.

Outcomes & Measurements

Intervention effect on drug modification or discontinuation, time to modification or discontinuation, and provider interactions with alerts.

Results

The modification or discontinuation rate per 100 events for medications included in the interruptive alert within 24 hours of increasing creatinine level improved from 35.2 preintervention to 52.6 postintervention (P < 0.001); orders were modified or discontinued more quickly (P < 0.001). During the postintervention period, providers initially deferred 78.1% of interruptive alerts, although 54% of these eventually were modified or discontinued before patient death, discharge, or transfer. The response to passive alerts about medications requiring review did not significantly change compared with baseline.

Limitations

Single tertiary-care academic medical center; provider actions were not independently adjudicated for appropriateness.

Conclusions

A computerized provider order entry–based alerting system to support medication management after acute kidney injury significantly increased the rate and timeliness of modification or discontinuation of targeted medications.

Section snippets

Setting

Vanderbilt University Hospital (Nashville, TN) is an academic tertiary-care facility with more than 500 adult beds and 34,000 admissions annually. During the past decade, Vanderbilt University Hospital care providers have used locally developed and maintained inpatient computerized provider order entry and inpatient/outpatient electronic medical record systems with extensive integrated decision support.30, 31, 32 Existing clinical decision support includes other alerts about drug safety and

Results

The pre- and postintervention periods were not statistically different for patient age, sex, admitting service, need for intensive care unit care, and median number of target drug orders, although patient ethnicities differed slightly (Table 1). Data analyzed in the preintervention period included 914 patients with 1,920 orders for a target drug in the setting of an initial creatinine level increase. Excluded were 39 patients identified as receiving dialysis and 158 patients who died,

Discussion

We developed an alerting system integrated with computerized provider order entry to continuously monitor and inform health care providers about medication safety in the setting of AKI. The intervention significantly improved provider response to increasing creatinine levels, increasing the frequency at which nephrotoxic and renally cleared medications were modified or discontinued. The greatest effect occurred for medications with the highest potential for toxicity. Response rates showed a

Acknowledgements

The authors thank Mark Sullivan, Cori Nelsen, and Titus Daniels for clinical expertise and Randolph Miller for review and insight. Preliminary results were presented as a poster at the 2008 AMIA Annual Symposium, November 8-12, 2008 in Washington, DC.

Support: The authors were funded in part by National Library of Medicine grants T15 LM007450-08 (A.B.M. and C.S.G.), R01 LM009965-02 (A.B.M., J.F.P., L.R.W., and I.D.), and R03 LM009238-02 (J.F.P).

Financial Disclosure: The authors declare that they

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Our study provides a contribution to the published literature of quality improvement projects that leverage information in the electronic health record to improve outcomes in adult patients with, or at-risk for, AKI. Early studies reported on programs that would alert physicians to adjust medications or assess fluid status in patients with AKI.18,19 In these studies, physician response and intervention time decreased after the AKI alert was put in place.
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: Originally published online as doi:10.1053/j.ajkd.2010.05.024 on August 16, 2010.

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Original InvestigationPathogenesis and Treatment of Kidney DiseaseA Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report

Background

Study Design

Setting & Participants

Quality Improvement Plan

Outcomes & Measurements

Results

Limitations

Conclusions

Section snippets

Setting

Results

Discussion

Acknowledgements

Kidney Int

Am J Med

Am J Kidney Dis

Medicine

Am J Med

J Am Med Inform Assoc

Am J Med Sci

J Biomed Inform

J Am Med Inform Assoc

J Am Med Inform Assoc

J Am Med Inform Assoc

J Am Med Inform Assoc

Drug prescribing for patients with changing renal function

Am J Hosp Pharm

Acquired renal insufficiency in critically ill patients

Crit Care Med

Acute renal failure in critically ill patients: a multinational, multicenter study

JAMA

Incidence and mortality of acute renal failure in Medicare beneficiaries, 1992 to 2001

J Am Soc Nephrol

Diagnosis, epidemiology and outcomes of acute kidney injury

Clin J Am Soc Nephrol

Nephrology: 3. Safe drug prescribing for patients with renal insufficiency

CMAJ

Considerations in the use of drugs in patients with renal failure

J Clin Pharmacol

Iatrogenic renal disease

Arch Intern Med

Guided medication dosing for inpatients with renal insufficiency

JAMA

Evaluation of a computer-assisted antibiotic-dose monitor

Ann Pharmacother

Original Investigation
Pathogenesis and Treatment of Kidney Disease
A Computerized Provider Order Entry Intervention for Medication Safety During Acute Kidney Injury: A Quality Improvement Report