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Appl Clin Inform 2025; 16(01): 001-010
DOI: 10.1055/s-0044-1791822
Research Article

Effect of Tiered Implementation of Clinical Decision Support System for Acute Kidney Injury and Nephrotoxin Exposure in Cardiac Surgery Patients

Christopher M. Justice II   #
1   Heart and Vascular Institute, JW Ruby Memorial Hospital, West Virginia University, Morgantown, West Virginia, United States
2   Nurse Anesthesia Program, School of Nursing, West Virginia University, Morgantown, West Virginia, United States
3   Department of Anesthesia, Summersville Regional Medical Center, West Virginia University, Summersville, West Virginia, United States
,
Connor Nevin   #
4   Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
,
Rebecca L. Neely
5   Department of Information Technology, West Virginia University, Morgantown, West Virginia, United States
,
Brian Dilcher
6   Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia, United States
,
Nicole Kovacic-Scherrer
7   School of Pharmacy, West Virginia University, Morgantown, West Virginia, United States
,
Heather Carter-Templeton
8   Department of Adult Health, School of Nursing, West Virginia University, Morgantown, West Virginia, United States
,
Aaron Ostrowski
2   Nurse Anesthesia Program, School of Nursing, West Virginia University, Morgantown, West Virginia, United States
9   Department of Anesthesia, West Virginia University, Morgantown, West Virginia, United States
,
Jacob Krafcheck
1   Heart and Vascular Institute, JW Ruby Memorial Hospital, West Virginia University, Morgantown, West Virginia, United States
,
Gordon Smith
10   Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia, United States
,
Paul McCarthy
11   Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, United States
,
Jami Pincavitch
12   Department of Internal Medicine, West Virginia University, Morgantown, West Virginia, United States
13   Department of Orthopedics, West Virginia University, Morgantown, West Virginia, United States
,
Sandra Kane-Gill
14   Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Robert Freeman
15   Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
,
John A. Kellum
16   Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
,
Roopa Kohli-Seth
17   Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
,
Girish N. Nadkarni
18   Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
19   Division of Data Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
20   The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
,
Khaled Shawwa
21   Section of Nephrology, Department of Internal Medicine, West Virginia University, Morgantown, West Virginia, United States
,
Ankit Sakhuja
17   Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
19   Division of Data Driven and Digital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
20   The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
› Author Affiliations
Funding This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases Grant no.: 5K08DK131286 (A.S.). U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
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Abstract

Background Nephrotoxin exposure may worsen kidney injury and impair kidney recovery if continued in patients with acute kidney injury (AKI).

Objectives This study aimed to determine if tiered implementation of a clinical decision support system (CDSS) would reduce nephrotoxin use in cardiac surgery patients with AKI.

Methods We assessed patients admitted to the cardiac surgery intensive care unit at a tertiary care center from January 2020 to December 2021, and August 2022 to September 2023. A passive electronic AKI alert was activated in July 2020, followed by an electronic nephrotoxin alert in March 2023. In this alert, active nephrotoxic medication orders resulted in a passive alert, whereas new orders were met with an interruptive alert. Primary outcome was discontinuation of nephrotoxic medications within 30 hours after AKI. Secondary outcomes included AKI-specific clinical actions, determined through modified Delphi process and patient-centered outcomes. We compared all outcomes across five separate eras, divided based on the tiered implementation of these alerts.

Results A total of 503 patients met inclusion criteria. Of 114 patients who received nephrotoxins before AKI, nephrotoxins were discontinued after AKI in 6 (25%) patients in pre AKI-alert era, 8 (33%) patients in post AKI-alert era, 7 (35%) patients in AKI-alert long-term follow up era, 7 (35%) patients in pre nephrotoxin-alert era, and 14 (54%) patients in post nephrotoxin-alert era (p = 0.047 for trend). Among AKI-specific consensus actions, we noted a decreased use of intravenous fluids, increased documentation of goal mean arterial pressure of 65 mm Hg or higher, and increased use of bedside point of care echocardiogram over time. Among exploratory clinical outcomes we found a decrease in proportion of stage III AKI, need for dialysis, and length of hospital stay over time.

Conclusion Tiered implementation of CDSS for recognition of AKI and nephrotoxin exposure resulted in a progressive improvement in the discontinuation of nephrotoxins.

Keywords

nephrotoxin - clinical decision support - acute kidney injury - electronic alert - nephrotoxic medication

Protection and Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by West Virginia University Institutional Review Board. Participants were informed of the contents prior to study participation and voluntarily consented to participate.


# equally contributed as first author.


Supplementary Material



Publication History

Received: 29 May 2024

Accepted: 19 September 2024

Article published online:
01 January 2025

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