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

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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.