Electronic Alerts for AKI Show Little Benefit, and Possible Harms

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Electronic health record alerts have only a modest impact on care processes for acute kidney injury (AKI), and no impact on important disease outcomes—with a possible increase in adverse outcomes in some settings, according to conclusions from a randomized trial in the British Medical Journal.

The double-blind, multi-center trial was carried out at six hospitals, including four teaching hospitals, in a New England university-affiliated health system. The intervention was a “pop-up” alert in the electronic health record of patients meeting KDIGO (Kidney Disease Improving Global Outcomes) criteria for AKI.

At intervention hospitals, the alert was triggered whenever the

Electronic health record alerts have only a modest impact on care processes for acute kidney injury (AKI), and no impact on important disease outcomes—with a possible increase in adverse outcomes in some settings, according to conclusions from a randomized trial in the British Medical Journal.

The double-blind, multi-center trial was carried out at six hospitals, including four teaching hospitals, in a New England university-affiliated health system. The intervention was a “pop-up” alert in the electronic health record of patients meeting KDIGO (Kidney Disease Improving Global Outcomes) criteria for AKI.

At intervention hospitals, the alert was triggered whenever the chart was opened by a provider with authority to change or enter new orders—including physicians, trainees, nurse practitioners, and physician’s assistants. The alert prompted providers to enter AKI onto a patient’s problem list and included a link to a standard AKI order set. At usual-care control hospitals, the system generated “silent” alerts that were not visible to providers but were tracked by the researchers.

A primary composite outcome of AKI progression, dialysis initiation, or death within 14 days was compared for patients at intervention and control hospitals. Secondary outcomes included the frequency of various care practices for AKI and the effects of the alerts at each study hospital.

The analysis included 6030 patients admitted over 22 months. There was no significant difference in rates of the primary outcome at intervention versus usual care hospitals: 21.3% and 20.9%, respectively.

At the two non-teaching hospitals, accounting for 13% of patients, the risk of the primary outcome was higher in the alert group: relative risk 1.49. The difference appeared to be mainly driven by deaths: 15.6% in the alert group versus 8.6% in the usual-care group.

Rates of kidney consultations were similar between the groups. Some small increases in process measures in the alert group were observed, including orders for intravenous fluids and urinalysis.

It is often assumed that increased recognition of AKI in hospitalized patients will lead to improvements in care and thus in clinical outcomes, the authors noted. Thus, many health systems have introduced electronic alerts for AKI, despite limited evidence of their impact on patient outcomes.

The new trial shows no improvement in clinical outcomes in AKI patients at hospitals with electronic health record alerts and limited effects on care processes. The study also provides evidence of possible harms associated with AKI alerts in some settings, which remains unexplained.

“This study argues against the implementation of informational alerts for acute kidney injury and for a reconsideration of the alerts currently used,” the authors state [Wilson FP, et al. Electronic health record alerts for acute kidney injury: Multicenter, randomized clinical trial. BMJ 2021;372:m4786. doi: 10.1136/bmj.m4786; https://www.bmj.com/content/372/bmj.m4786].

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