Personalized Recommendations for Acute Kidney Injury (AKI) Care Using a Kidney Action Team: A Randomized Trial

项目摘要 该提案的总体目标是确定快速响应式、个性化 急性肾损伤（阿基）患者的检查和治疗建议，由 远程肾脏行动小组将改善住院人群的临床结果。阿基是常见的 住院患者的并发症，并与住院死亡风险的急剧增加有关， 长期慢性肾脏疾病和费用。阿基治疗的国际指南关注最佳实践 这包括药物剂量的适当管理，避免肾毒性暴露， 血液动力学和电解质平衡。然而，多项研究和我们的初步数据表明， 在各种医院环境中经常被遗漏，并且很少采取诊断和治疗措施 或者不合适未能采用最佳做法与发病率和死亡率增加有关 阿基患者中。 我们的团队广泛关注提高供应商对阿基的认识和认可。我们 简单的电子阿基警报系统的随机试验已经证明了关于 此类警报的有效性，因为警报中的患者的临床结局没有改善 组然而，该警报纯粹是信息性的，没有提供任何可采取行动的建议。因为 阿基患者和阿基病因、诊断和治疗计划的异质性应高度 个性化，并考虑到护理的许多方面，包括诊断检查，酸/碱管理， 电解质管理、血液动力学管理和药物管理。 这项建议旨在根据我们以往的经验，以确定是否提供供应商迅速 针对个体患者个性化的可操作项目可能对阿基的护理更有益 患者在两个医疗中心和八家医院，我们将招募和培训肾脏行动小组- 作为阿基的快速反应小组-由高级执业医师、药剂师和 肾病学家在轴辐式设计中，集中的肾脏行动小组将使个性化的 基于电子病历审查的阿基诊断和治疗建议。肾脏行动小组 将为所有患者创建建议，但仅在随机分配到干预的患者中提供。 该实验设计将确定：1）用于阿基诊断的实时个性化建议是否 和治疗改善改善患者的结果; 2）哪些患者和提供者最有可能受益 从这种类型的电子咨询和3）是否完全自动化的规则引擎可以成功地模仿人类- 衍生的建议。这样一个自动化系统，如果成功的话，将提供一个高度普遍化的 将其纳入其他卫生系统的模式。

Project Summary The overarching goal of this proposal is to determine whether rapid response-style, personalized recommendations for the workup and treatment of patients with Acute Kidney Injury (AKI), as delivered by a remote Kidney Action Team, will improve clinical outcomes in a hospitalized population. AKI is a common complication in hospitalized patients and is associated with dramatic increases in the risk of inpatient mortality, long-term chronic kidney disease, and cost. International guidelines for AKI treatment focus on best practices that include appropriate management of drug dosing, avoidance of kidney-toxic exposures, and careful hemodynamic and electrolyte balance. However, multiple studies and our preliminary data suggest that AKI is often missed in a variety of hospital settings and that diagnostic and therapeutic actions are infrequently taken or inappropriate. Failure to engage in best practices is associated with increased morbidity and mortality among AKI patients. Our group focuses extensively on increasing provider awareness and recognition of AKI. Our randomized trials of simple electronic AKI alert systems have demonstrated clinical equipoise regarding the effectiveness of such alerting, as there was no improvement in clinical outcomes among those in the alert group. However, the alert was purely informational and provided no actionable recommendations. Because of the heterogeneity of both the AKI patient and AKI etiology, diagnostic and treatment plans should be highly individualized and consider many facets of care, including diagnostic workup, acid/base management, electrolyte management, hemodynamic management, and medication management. This proposal seeks to build on our prior experience to determine whether offering providers prompt and actionable items that are personalized to individual patients may be more beneficial in the care of AKI patients. Across two medical centers and eight hospitals, we will recruit and train Kidney Action Teams – acting as a rapid response team for AKI – consisting of an advanced practitioner, a pharmacist and a nephrologist. In a hub-and-spoke design, centralized Kidney Action Teams will make personalized recommendations on AKI diagnosis and treatment based on electronic chart review. Kidney Action Team recommendations will be created for all patients but delivered only in those randomized to the intervention. This experimental design will determine: 1) whether real-time personalized recommendations for AKI diagnosis and treatment improve improve patient outcomes; 2) which patients and providers are most likely to benefit from e-consults of this type and 3) whether a fully automated rules engine can successfully mimic human- derived recommendations. Such an automated system, if successful, would provide a highly generalizable model for integration into other health systems.