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Ostermann M, Lumlertgul N, James MT. Dialysis-Dependent Acute Kidney Injury-A Risk Factor for Adverse Outcomes. JAMA Netw Open 2024; 7:e240346. [PMID: 38457185 DOI: 10.1001/jamanetworkopen.2024.0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nuttha Lumlertgul
- Division of Nephrology, Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Matthew T James
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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McCormack C, Savoy A, Mathew A, Gilmore AM, Cottingham E, Sangani A, Caldwell B, Holden RJ, Weiner M. Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis. APPLIED ERGONOMICS 2024; 115:104177. [PMID: 38016271 PMCID: PMC10863302 DOI: 10.1016/j.apergo.2023.104177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/28/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023]
Abstract
The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance. Referrers and consultants were interviewed about their perceived workflows, barriers, and clinical outcomes to inform a workflow analysis.
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Affiliation(s)
| | - April Savoy
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA; Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
| | - Anna Mathew
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA
| | | | | | - Amee Sangani
- Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
| | - Barrett Caldwell
- Purdue University School of Industrial Engineering, West Lafayette, IN, USA
| | - Richard J Holden
- Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Michael Weiner
- Regenstrief Institute, Inc., Indianapolis, IN, USA; Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
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May HP, Herges JR, Anderson BK, Hanson GJ, Kashani KB, Kattah AG, Cole KC, McCoy RG, Meade LA, Rule AD, Schreier DJ, Tinaglia AG, Barreto EF. Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot. Kidney Med 2023; 5:100734. [PMID: 37964784 PMCID: PMC10641567 DOI: 10.1016/j.xkme.2023.100734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Rationale & Objective Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors. Study Design This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting. Setting & Participants The study included consenting adults with stage 3 AKI discharged home without dialysis. Interventions The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT). Outcomes The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes. Results In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13). Limitations Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis. Conclusions This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants. Trial Registration ClinicalTrials.gov (NCT04505891). Plain-Language Summary Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.
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Affiliation(s)
| | | | | | - Gregory J. Hanson
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C. Cole
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Rozalina G. McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - ACT Study Group
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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Giles C, Novakovic M, Hopman W, Barreto EF, Beaubien-Souligny W, Birks P, Neyra JA, Wald R, Silver SA. The Quality of Discharge Summaries After Acute Kidney Injury. Can J Kidney Health Dis 2023; 10:20543581231199018. [PMID: 37781153 PMCID: PMC10540581 DOI: 10.1177/20543581231199018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/12/2023] [Indexed: 10/03/2023] Open
Abstract
Background Acute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care. Objective The objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries. Design Retrospective chart review. Setting Tertiary care academic center in Ontario, Canada. Patients We examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017. Measurements We reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality. Methods We used multivariable logistic regression to identify predictors of discharge summary quality. Results The median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29). Limitations The single-center study design limits generalizability. Conclusions Most discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.
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Affiliation(s)
- Cameron Giles
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Milica Novakovic
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Wilma Hopman
- Kingston General Hospital Research Institute, Kingston Health Sciences Centre, ON, Canada
| | | | | | - Peter Birks
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, AL, USA
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, ON, Canada
| | - Samuel A. Silver
- Division of Nephrology, Department of Medicine, Queen’s University and Kingston Health Sciences Centre, ON, Canada
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May HP, Krauter AK, Finnie DM, McCoy RG, Kashani KB, Griffin JM, Barreto EF. Acute Kidney Injury Survivor Care Following Hospital Discharge: A Mixed-Methods Study of Nephrologists and Primary Care Providers. Kidney Med 2023; 5:100586. [PMID: 36970221 PMCID: PMC10034506 DOI: 10.1016/j.xkme.2022.100586] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale & Objective Widespread delivery of high-quality care for acute kidney injury (AKI) survivors after hospital discharge requires a multidisciplinary team. We aimed to compare management approaches between nephrologists and primary care providers (PCPs) and explored strategies to optimize collaboration. Study Design Explanatory sequential mixed-methods study using a case-based survey followed by semi-structured interviews. Setting & Participants Nephrologists and PCPs providing AKI survivor care at 3 Mayo Clinic sites and the Mayo Clinic Health System were included. Outcomes Survey questions and interviews elucidated participants' recommendations for post-AKI care. Analytical Approach Descriptive statistics were used to summarize survey responses. Qualitative data analysis used deductive and inductive strategies. A connecting and merging approach was used for mixed-methods data integration. Results 148 of 774 (19%) providers submitted survey responses (24/72 nephrologists and 105/705 PCPs). Nephrologists and PCPs recommended laboratory monitoring and follow-up with a PCP shortly after hospital discharge. Both indicated that the need for nephrology referral, and its timing should be dictated by clinical and non-clinical patient-specific factors. There were opportunities for improvement in medication and comorbid condition management in both groups. Incorporation of multidisciplinary specialists (eg, pharmacists) was recommended to expand knowledge, optimize patient-centered care, and alleviate provider workload. Limitations Survey findings may have been affected by non-response bias and the unique challenges facing clinicians and health systems during the COVID-19 pandemic. Participants were from a single health system, and their views or experiences may differ from those in other health systems or serving different populations. Conclusions A multidisciplinary team-based model of post-AKI care may facilitate implementation of a patient-centered care plan, improve adherence to best practices, and reduce clinician and patient burden. Individualizing care for AKI survivors based on clinical and non-clinical patient-specific factors is needed to optimize outcomes for patients and health systems.
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Affiliation(s)
- Heather P. May
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn M. Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joan M. Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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Silver SA, Adhikari NK, Jeyakumar N, Luo B, Harel Z, Dixon SN, Brimble KS, Clark EG, Neyra JA, Vijayaraghavan BKT, Garg AX, Bell CM, Wald R. Association of an Acute Kidney Injury Follow-up Clinic With Patient Outcomes and Care Processes: A Cohort Study. Am J Kidney Dis 2022; 81:554-563.e1. [PMID: 36521779 DOI: 10.1053/j.ajkd.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE & OBJECTIVE To determine whether attendance at an acute kidney injury (AKI) follow-up clinic is associated with reduced major adverse kidney events. STUDY DESIGN Propensity-matched cohort study. SETTING & PARTICIPANTS Patients hospitalized with AKI in Ontario, Canada, from February 1, 2013, through September 30, 2017, at a single clinical center, who were not receiving dialysis when discharged. EXPOSURE Standardized assessment by a nephrologist. OUTCOMES Time to a major adverse kidney event, defined as death, initiation of maintenance dialysis, or incident/progressive chronic kidney disease. ANALYTICAL APPROACH Propensity scores were used to match each patient who attended an AKI follow-up clinic to 4 patients who received standard care. Cox proportional hazards models were fit to assess the association between the care within an AKI follow-up clinic and outcomes. To avoid immortal time bias, we randomly assigned index dates to the comparator group. RESULTS We matched 164 patients from the AKI follow-up clinic to 656 patients who received standard care. During a mean follow-up of 2.2±1.3 (SD) years, care in the AKI follow-up clinic was not associated with a reduction in major adverse kidney events relative to standard care (22.1 vs 24.7 events per 100 patient-years; HR, 0.91 [95% CI, 0.75-1.11]). The AKI follow-up clinic was associated with a lower risk of all-cause mortality (HR, 0.71 [95% CI, 0.55-0.91]). Patients aged at least 66 years who attended the AKI follow-up clinic were more likely to receive β-blockers (HR, 1.34 [95% CI, 1.02-1.77]) and statins (HR, 1.35 [95% CI, 1.05-1.74]), but not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (HR, 1.21 [95% CI, 0.94-1.56]). LIMITATIONS Single-center study and residual confounding. CONCLUSIONS Specialized postdischarge follow-up for AKI survivors was not associated with a lower risk of major adverse kidney events but was associated with a lower risk of death and increased prescriptions for some cardioprotective medications.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada.
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Nivethika Jeyakumar
- ICES, University of Toronto, Toronto, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Bin Luo
- ICES, University of Toronto, Toronto, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Ziv Harel
- ICES, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie N Dixon
- ICES, University of Toronto, Toronto, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - K Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | | | - Amit X Garg
- ICES, University of Toronto, Toronto, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Chaim M Bell
- ICES, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Mount Sinai Hospital University of Toronto, Toronto, Ontario, Canada
| | - Ron Wald
- ICES, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Zheng F, Wang D, Zhang X. The impact of clinical pharmacist-physician communication on reducing drug-related problems: a mixed study design in a tertiary teaching Hospital in Xinjiang, China. BMC Health Serv Res 2022; 22:1157. [PMID: 36104805 PMCID: PMC9472438 DOI: 10.1186/s12913-022-08505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Background The incidence of drug-related problems (DRPs) has caused serious health hazards and economic burdens among polymedicine patients. Effective communication between clinical pharmacists and physicians has a significant impact on reducing DRPs, but the evidence is poor. This study aimed to explore the impact of communication between clinical pharmacists and physicians on reducing DRPs. Methods A semistructured interview was conducted to explore the communication mode between clinical pharmacists and physicians based on the interprofessional approach of the shared decision-making model and relational coordination theory. A randomized controlled trial (RCT) was used to explore the effects of communication intervention on reducing DRPs. Logistic regression analysis was used to identify the influencing factors of communication. Results The mode of communication is driven by clinical pharmacists between clinical pharmacists and physicians and selectively based on different DRP types. Normally, the communication contents only cover two (33.8%) types of DRP contents or fewer (35.1%). The communication time averaged 5.8 minutes. The communication way is predominantly face-to-face (91.3%), but telephone or other online means (such as WeChat) may be preferred for urgent tasks or long physical distances. Among the 367 participants, 44 patients had DRPs. The RCT results indicated a significant difference in DRP incidence between the control group and the intervention group after the communication intervention (p = 0.02), and the incidence of DRPs in the intervention group was significantly reduced (15.6% vs. 0.07%). Regression analysis showed that communication time had a negative impact on DRP incidence (OR = 13.22, p < 0.001). Conclusion The communication mode based on the interprofessional approach of the shared decision-making between clinical pharmacists and physicians in medication decision-making could significantly reduce the incidence of DRPs, and the length of communication time is a significant factor. The longer the communication time is, the fewer DRPs that occur. Trial registration This trial was approved by the ethics committee of The First Affiliated Hospital of Medical College of Xinjiang Shihezi University Hospital (kj2020–087-03) and registered in the China clinical trial registry (https://www.chictr.org.cn, number ChiCTR2000035321 date: 08/08/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08505-1.
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Madan S, Norman PA, Wald R, Neyra JA, Meraz-Muñoz A, Harel Z, Silver SA. Use of Guideline-Based Therapy for Diabetes, Coronary Artery Disease, and Chronic Kidney Disease After Acute Kidney Injury: A Retrospective Observational Study. Can J Kidney Health Dis 2022; 9:20543581221103682. [PMID: 35721395 PMCID: PMC9201307 DOI: 10.1177/20543581221103682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background Survivors of acute kidney injury (AKI) are at a high risk for cardiovascular complications. An underrecognition of this risk may contribute to the low utilization of relevant guideline-based therapies in this population. Objective We sought to assess accordance with guideline-based recommendations for survivors of AKI with diabetes, coronary artery disease (CAD), and preexisting chronic kidney disease (CKD) in a post-AKI clinic, and identify factors that may be associated with guideline accordance. Design Retrospective cohort study. Setting Post-AKI clinics at 2 tertiary care centers in Ontario, Canada. Patients We included adult patients seen in both post-AKI clinics between 2013 and 2019 who had at least 2 clinic visits within 24 months of an index AKI hospitalization. Measurements We assessed accordance to recommendations from the most recent North American and international guidelines available at the time of study completion for diabetes, CAD, and CKD. Methods We compared guideline accordance between visits using the Cochran Mantel Haenszel test. We used multivariable Poisson regression to identify prespecified factors associated with accordance. Results Of 213 eligible patients, 192 (90%) had Kidney Disease Improving Global Outcomes Stage 2-3 AKI, 91 (43%) had diabetes, 76 (36%) had CAD, and 88 (41%) had preexisting CKD. From the first clinic visit to the second, there was an increase in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-I/ARB) use across all disease groups-from 33% to 46% (P = .028) in patients with diabetes, from 30% to 57% (P = .002) in patients with CAD, and from 16% to 35% (P < .001) in patients with preexisting CKD. Statin use increased in patients with preexisting CKD from 64% to 71% (P = .034). Every 25 μmol/L rise in the discharge serum creatinine was associated with a 19% (95% confidence interval [CI], 8%-28%) and 12% (95% CI, 2%-21%) lower likelihood of being on an ACE-I/ARB in patients with diabetes and preexisting CKD, respectively. Limitations The study lacked a comparison group that received usual care. The small sample and multiple comparisons make false positives possible. Conclusion There is room to improve guideline-based cardiovascular risk factor management in survivors of AKI, particularly ACE-I/ARB use in patients with an elevated discharge serum creatinine.
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Affiliation(s)
- Sunchit Madan
- Division of Nephrology, St. Joseph’s
Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Patrick A. Norman
- Kingston General Health Research
Institute, Kingston, ON, Canada
- Department of Public Health Sciences,
Queen’s University, Kingston, ON, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s
Hospital, University of Toronto, ON, Canada
| | - Javier A. Neyra
- Division of Nephrology, Bone and
Mineral Metabolism, Department of Internal Medicine, University of Kentucky,
Lexington, USA
| | | | - Ziv Harel
- Division of Nephrology, St. Michael’s
Hospital, University of Toronto, ON, Canada
| | - Samuel A. Silver
- Division of Nephrology, Kingston Health
Sciences Centre, Queen’s University, Kingston, ON, Canada
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Goswami EAS, Sexton E, Fadrowski JJ. Pediatric Nurse and Pharmacist Knowledge of Acute Kidney Injury. Hosp Pediatr 2021; 11:871-877. [PMID: 34301718 DOI: 10.1542/hpeds.2020-005773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In this study, we assessed the knowledge and experience of pediatric pharmacists and nurses at a US tertiary-care pediatric center regarding the risk factors for, recognition of, and best practices for managing an acute kidney injury (AKI) in children. METHODS The authors developed a survey to assess the attitudes and knowledge of nurses and pharmacists regarding AKI in hospitalized children, which was reviewed by a small multidisciplinary group for content and length. The final 16-item survey consisted of demographic, self-assessment and attitude, and knowledge questions. All pediatric pharmacists and nurses at the study site received a voluntary online survey via e-mail. Data were analyzed by using descriptive statistics. RESULTS A survey was sent to 620 nurses and 50 pharmacists; 148 (25%) and 22 (44%), respectively, completed it. Most respondents were <35 years old and had ≤10 years of experience in both their professions and pediatrics. A total of 72% of pediatric nurses felt identification of AKI was within their scope of practice, and ∼60% felt confident in their ability to do so. More than 80% of pediatric pharmacists felt confident in their abilities to adjust medication doses in pediatric patients with AKI, but <60% felt confident in their ability to estimate the glomerular filtration rate in these patients. Nurses and pharmacists were able to correctly identify specific AKI criteria 60% to 70% and 70% to 90% of the time, respectively. CONCLUSIONS Although pediatric nurses and pharmacists have knowledge of AKI prevention and mitigation, gaps exist, and there is a desire for education in recognition of their key roles in the clinical team.
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Affiliation(s)
| | | | - Jeffrey J Fadrowski
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Schütze A, Hohmann C, Haubitz M, Radziwill R, Benöhr P. Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:587-597. [PMID: 34244750 DOI: 10.1093/ijpp/riab033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/25/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs). METHODS A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling. KEY FINDINGS In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001). CONCLUSIONS Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.
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Affiliation(s)
- Alexander Schütze
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany.,Institute of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Philipps-University Marburg, Marburg, Germany
| | - Carina Hohmann
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
| | - Marion Haubitz
- Department of Nephrology, Klinikum Fulda gAG, Fulda, Germany
| | | | - Peter Benöhr
- Department of Nephrology, Klinikum Fulda gAG, Fulda, Germany
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Ravn-Nielsen LV, Burghle A, Christensen PM, Coric F, Graabæk T, Henriksen JP, Karlsdóttir F, Rosholm JU, Pottegård A. Multidisciplinary telephone conferences about medication therapy after discharge of older inpatients: a feasibility study. Int J Clin Pharm 2021; 43:1381-1393. [PMID: 33847841 DOI: 10.1007/s11096-021-01265-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/01/2021] [Indexed: 11/28/2022]
Abstract
Background Studies have shown poor post-discharge implementation by the general practitioner of changes made to patients' medication during admission. Objective To assess the feasibility of conducting telephone conferences delivering information about changes in older patients' medications from hospital to general practitioners. Setting Two departments of geriatric medicine in a Danish routine healthcare setting. Method Older polypharmacy patients (≥ 65 years and ≥ 5 prescriptions) consecutively admitted were eligible for inclusion. Telephone conferences based on a review of these patient's medication therapy during hospital stay were arranged between a pharmacist and a geriatrician from the hospital, and a general practitioner. Interviews were conducted with pharmacists, geriatricians, and general practitioners about their perspectives on the feasibility of telephone conferences. Interviews were analyzed using systematic text condensation. Main outcome measure The proportion of telephone conferences conducted and perspectives on the feasibility of the study. Results A total of 113 patients were included and 82 patients (75%) were eligible for telephone conferences. A total of 40 (49%) telephone conferences were conducted. The main reasons for conferences not being conducted were general practitioners not wanting to participate or not returning the calls from the pharmacists. Three themes emerged from the qualitative analysis: considerations on planning and running the project, Barriers, facilitators, and implications of the telephone conference, and Actual and desirable cross-sectorial communication. Conclusion Telephone conferences were only possible for half of the patients. The participating general practitioners, pharmacists and geriatricians expressed varied benefit and agreed that telephone conferences were mainly relevant for complex patients.
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Affiliation(s)
- Lene Vestergaard Ravn-Nielsen
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark. .,Open Patient Data Explorative Network, OPEN, Odense University Hospital, Odense, Denmark.
| | - Alaa Burghle
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark.,Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | - Faruk Coric
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark
| | - Trine Graabæk
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark.,Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | - Fjóla Karlsdóttir
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark
| | | | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, 5000, Odense C, Denmark.,Department of Public Health, Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
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12
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Powell C, Breen L, Fylan B, Ismail H, Alderson SL, Gale CP, Gardner P, Farrin AJ, Alldred DP. Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT): protocol for a process evaluation of a cluster randomised control trial. BMJ Open 2020; 10:e040493. [PMID: 33234644 PMCID: PMC7689064 DOI: 10.1136/bmjopen-2020-040493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION A key priority for the UK National Health Service and patients is to ensure that medicines are used safely and effectively. However, medication changes are not always optimally communicated and implemented when patients transfer from hospital into community settings. Heart failure is a common reason for admission to hospital. Patients with heart failure have a high burden of morbidity, mortality and complex pharmacotherapeutic regimens. The Improving the Safety and Continuity Of Medicines management at Transitions of care programme comprises a cluster randomised controlled trial which will test the effectiveness of a complex behavioural intervention aimed at improving medications management at the interface between hospitals discharge and community care. We will conduct a rigorous process evaluation to inform interpretation of the trial findings, inform implementation of the intervention on a wider scale and aid dissemination of the intervention. METHODS AND ANALYSIS The process evaluation will be conducted in six purposively selected intervention sites (ie, hospital trusts and associated community pharmacies) using a mixed-methods design. Fidelity and barriers/enablers of implementation of the Medicines at Transitions Intervention (MaTI) will be explored using observation, interviews (20 patients, 40 healthcare professionals), surveys and routine trial data collection on adherence to MaTI. A parallel mixed analysis will be applied. Qualitative data will be thematically analysed using Framework analysis and survey data will be analysed descriptively. Data will be synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research where appropriate. The process evaluation commenced on June 2018 and is due to end on February 2021. ETHICS AND DISSEMINATION Approved by Research Ethics Committee and the UK Health Research Authority REC: 18/YH/0017/IRAS: 231 431. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media. TRIAL REGISTRATION NUMBER ISRCTN66212970.
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Affiliation(s)
- Catherine Powell
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Liz Breen
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
- Bradford Institute for Health Research, NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Beth Fylan
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
- Bradford Institute for Health Research, NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Hanif Ismail
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Sarah L Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter Gardner
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - David P Alldred
- Wolfson Centre for Applied Health Research, Bradford, UK
- Bradford Institute for Health Research, NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- School of Healthcare, University of Leeds, Leeds, UK
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13
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Howarth M, Bhatt M, Benterud E, Wolska A, Minty E, Choi KY, Devrome A, Harrison TG, Baylis B, Dixon E, Datta I, Pannu N, James MT. Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury. BMC Med Inform Decis Mak 2020; 20:287. [PMID: 33148237 PMCID: PMC7640650 DOI: 10.1186/s12911-020-01303-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/22/2020] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations.
Methods We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set.
Results Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients. Conclusions Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.
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Affiliation(s)
- Megan Howarth
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Meha Bhatt
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Eleanor Benterud
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Anna Wolska
- Alberta Health Services, Calgary, AB, Canada
| | - Evan Minty
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Kyoo-Yoon Choi
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea Devrome
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tyrone G Harrison
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Barry Baylis
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Elijah Dixon
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Indraneel Datta
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Neesh Pannu
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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14
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Elvey R, Howard SJ, Martindale AM, Blakeman T. Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation. BMJ Open 2020; 10:e036077. [PMID: 32792434 PMCID: PMC7430404 DOI: 10.1136/bmjopen-2019-036077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/28/2020] [Accepted: 05/17/2020] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES We sought to understand the factors influencing the implementation of a primary care intervention to improve post-discharge care following acute kidney injury (AKI). DESIGN Qualitative study using semi-structured interviews and thematic analysis. SETTING General practices in one Clinical Commissioning Group area in England. PARTICIPANTS A total of 18 healthcare staff took part in interviews. Participants were practice pharmacists, general practitioners, practice managers and administrators involved in implementing the intervention. RESULTS We identified three main factors influencing implementation: differentiation of the new intervention from other practice work; development of skill mix and communication across organisations. Overall, post-AKI processes of care were deemed straightforward to embed into existing practice. However, it was also important to separate the intervention from other work in general practice. Dedicating staff time to proactively identify AKI on discharge summaries and to coordinate the provision of care enabled implementation of the intervention. The post-AKI intervention provided an opportunity for practice pharmacists to expand their primary care role. Working in a new setting also brought challenges; time to develop trusting relationships including an understanding of boundaries of clinical expertise influenced pharmacists' roles. Unclear and inconsistent information on discharge summaries contributed to concerns about additional work in primary care. CONCLUSIONS The research highlights challenges around post-discharge management in the primary care context. Coordination and communication were key factors for improving follow-up care following AKI. Further consideration is required to understand patient experiences of the interface between secondary and primary care. The issues pertaining to discharge care following AKI are relevant to practitioners and commissioners as they work to improve transitions of care for vulnerable patient populations.
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Affiliation(s)
- Rebecca Elvey
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Salford Royal NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | - Susan J Howard
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Salford Royal NHS Foundation Trust, Salford, UK
| | - Anne-Marie Martindale
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Salford Royal NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Salford Royal NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre (MAHSC), Manchester, UK
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15
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Silver SA, Nadim MK, O'Donoghue DJ, Wilson FP, Kellum JA, Mehta RL, Ronco C, Kashani K, Rosner MH, Haase M, Lewington AJP. Community Health Care Quality Standards to Prevent Acute Kidney Injury and Its Consequences. Am J Med 2020; 133:552-560.e3. [PMID: 31830434 PMCID: PMC7724764 DOI: 10.1016/j.amjmed.2019.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/22/2019] [Accepted: 10/27/2019] [Indexed: 12/29/2022]
Abstract
As the incidence of acute kidney injury (AKI) increases, prevention strategies are needed across the health care continuum, which begins in the community. Recognizing this knowledge gap, the 22nd Acute Disease Quality Initiative (ADQI) was tasked to discuss the evidence for quality-of-care measurement and care processes to prevent AKI and its consequences in the community. Using a modified Delphi process, an international and interdisciplinary group provided a framework to identify and monitor patients with AKI in the community. The recommendations propose that risk stratification involve both susceptibilities (eg, chronic kidney disease) and exposures (eg, coronary angiography), with the latter triggering a Kidney Health Assessment. This assessment should include blood pressure, serum creatinine, and urine dipstick, followed by a Kidney Health Response to prevent AKI that encompasses cessation of unnecessary medications, minimization of nephrotoxins, patient education, and ongoing monitoring until the exposure resolves. These recommendations give community health care providers and health systems a starting point for quality improvement initiatives to prevent AKI and its consequences in the community.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ont, Canada.
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles
| | - Donal J O'Donoghue
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Francis P Wilson
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Conn
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Penn
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego
| | - Claudio Ronco
- Department of Nephrology, Dialysis, and Transplantation, International Renal Research Institute, St Bortolo Hospital, Vicenza, Italy
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, & MVZ Diaverum Potsdam, Germany
| | - Andrew J P Lewington
- Renal Department, St. James's University Hospital, Leeds, UK; NIHR Diagnostic Evidence Co-operative, Leeds, UK
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16
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James MT, Bhatt M, Pannu N, Tonelli M. Long-term outcomes of acute kidney injury and strategies for improved care. Nat Rev Nephrol 2020; 16:193-205. [PMID: 32051567 DOI: 10.1038/s41581-019-0247-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2019] [Indexed: 12/19/2022]
Abstract
Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development of chronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin-angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management.
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Affiliation(s)
- Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Meha Bhatt
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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Phipps DL, Blakeman TM, Morris RL, Ashcroft DM. Mapping the territory of renal care: a formative analysis of the cognitive work involved in managing acute kidney injury. ERGONOMICS 2019; 62:1117-1133. [PMID: 31111790 DOI: 10.1080/00140139.2019.1620968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 05/09/2019] [Indexed: 06/09/2023]
Abstract
The design and evaluation of healthcare work systems requires an understanding of the cognitive work involved in healthcare tasks. Previous studies suggest that a formative approach would be particularly useful to examine healthcare activities for this purpose. In the present study, methods from cognitive work analysis and cognitive task analysis are combined in a formative examination of managing acute kidney injury, an activity that occurs across primary and secondary healthcare settings. The analyses are informed by interviews with healthcare practitioners and a review of practice guidelines. The findings highlight ways in which the task setting influenced practitioners' activity, and ways in which practitioners approached the activity (for example, how they used data to make decisions). The approach taken provided a rich understanding of the cognitive work involved, as well as generating suggestions for the design of work systems to support the clinical task. Practitioner summary: Healthcare tasks often require decision-making in complex and dynamic circumstances, potentially involving collaboration across different practitioner roles and locations. We demonstrate the use of a formative analysis to understand the cognitive work in managing a clinical syndrome across primary and secondary care settings, and consider the implications for work design.
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Affiliation(s)
- Denham L Phipps
- a School of Health Sciences, The University of Manchester , Manchester , UK
- b NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester , Manchester , UK
| | - Thomas M Blakeman
- a School of Health Sciences, The University of Manchester , Manchester , UK
- c NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester, The University of Manchester , Manchester , UK
| | - Rebecca L Morris
- a School of Health Sciences, The University of Manchester , Manchester , UK
- b NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester , Manchester , UK
| | - Darren M Ashcroft
- a School of Health Sciences, The University of Manchester , Manchester , UK
- b NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester , Manchester , UK
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18
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Fylan B, Marques I, Ismail H, Breen L, Gardner P, Armitage G, Blenkinsopp A. Gaps, traps, bridges and props: a mixed-methods study of resilience in the medicines management system for patients with heart failure at hospital discharge. BMJ Open 2019; 9:e023440. [PMID: 30782879 PMCID: PMC6377507 DOI: 10.1136/bmjopen-2018-023440] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Poor medicines management places patients at risk, particularly during care transitions. For patients with heart failure (HF), optimal medicines management is crucial to control symptoms and prevent hospital readmission. This study explored the concept of resilience using HF as an example condition to understand how the system compensates for known and unknown weaknesses. METHODS We explored resilience using a mixed-methods approach in four healthcare economies in the north of England. Data from hospital site observations, healthcare staff and patient interviews, and documentary analysis were collected between June 2016 and March 2017. Data were synthesised and analysed using framework analysis. RESULTS Interviews were conducted with 45 healthcare professionals, with 20 patients at three time points and 189 hours of observation were undertaken. We identified four primary inter-related themes concerning organisational resilience. These were named as gaps, traps, bridges and props. Gaps were discontinuities in processes that had the potential to result in poorly optimised medicines. Traps were features of the system that could produce errors or unintended adverse medication events. Bridges were features of the medicines management system that promoted safety and continuity which ensured that, despite varying conditions, care could be delivered successfully. Props were informal, temporary or impromptu actions taken by patients or healthcare staff to avoid potential adverse events. CONCLUSION The numerous opportunities for HF patient safety to be compromised and for suboptimal medicines management during this common care transition are mitigated by system resilience. Cross-organisational bridges and temporary fixes or 'props' put in place by patients and carers, healthcare teams and organisations are critical for safe and optimal care to be delivered in the face of continued system pressures.
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Affiliation(s)
- Beth Fylan
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- Yorkshire Quality & Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Iuri Marques
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Hanif Ismail
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Liz Breen
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Peter Gardner
- School of Psychology, University of Leeds, Leeds, UK
| | - Gerry Armitage
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- Bradford District Care Trust, Bradford, UK
| | - Alison Blenkinsopp
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
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19
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Abstract
OBJECTIVE To develop and validate an interprofessional collaboration competency scale for children with medical complexity (ICC-CMC). These children have the most complex healthcare needs, complicated chronic conditions, severe functional limitations and often need a considerable amount of healthcare resources. DESIGN Cross-sectional study. SETTING The self-administered ICC-CMC questionnaire was developed based on a literature review and 12 expert interviews. PARTICIPANTS Participants were 2347 interprofessionals from the health, medical, welfare and education fields in seven prefectures in Japan. MAIN OUTCOME MEASURES We used Cronbach's alpha values to assess the internal consistency of the scale. Construct validity was confirmed with confirmatory factor analysis, and an existing scale was administered to assess criterion-related validity. RESULTS In total, 378 professionals provided valid responses. Exploratory and confirmatory factor analyses identified 12 items on three factors: 'sharing needs assessment skills', 'resource development skills' and 'creative networking skills'. The final model showed good fit on four indices (eg, goodness of fit index: 0.925). The Cronbach's alpha for the entire scale was 0.93 and was above 0.80 for each factor. The correlation coefficient between the existing scale and the ICC-CMC was 0.72 (p<0.001). CONCLUSIONS The ICC-CMC demonstrated acceptable internal consistency and validity. The scale has potential use in advancing professionals' individual practice and team performance in interprofessional collaboration. In addition, the ICC-CMC has the potential of improving satisfaction and outcomes for children with medical complexity and their families.
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Affiliation(s)
- Keiko Shimmura
- Asukayama Visiting Nursing Station, Japan Visiting Nursing Foundation, Tokyo, Japan
| | - Etsuko Tadaka
- Department of Community Health Nursing, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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20
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Silver SA, Saragosa M, Adhikari NK, Bell CM, Harel Z, Harvey A, Kitchlu A, Neyra JA, Wald R, Jeffs L. What insights do patients and caregivers have on acute kidney injury and posthospitalisation care? A single-centre qualitative study from Toronto, Canada. BMJ Open 2018; 8:e021418. [PMID: 29909373 PMCID: PMC6009618 DOI: 10.1136/bmjopen-2017-021418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Hospitalisation with acute kidney injury (AKI) is associated with short-term and long-term adverse events, but patient and caregiver experiences with AKI are not well described. We sought to better understand patient and caregiver perspectives after a hospitalisation with AKI to inform discharge strategies that may improve outcomes for this high-risk population. DESIGN Qualitative study with semistructured interviews. SETTING Tertiary care hospital in Toronto, Ontario, Canada. PARTICIPANTS Adult patients (n=15) who survived a hospitalisation with Kidney Disease Improving Global Outcomes stage 2 or 3 AKI from May to December 2016. We also interviewed five patient caregivers. We required patients to have no previous evidence of severe chronic kidney disease (ie, prior receipt of dialysis, previous kidney transplantation or pre-existing estimated glomerular filtration rate (eGFR) under 30 mL/min/1.73 m2). RESULTS We identified three over-arching themes: (1) prioritisation of conditions other than AKI, reflected by the importance placed on other comorbidities and the omission of AKI as part of the ongoing medical history; (2) variability in comprehension of the significance of AKI, represented by minimal knowledge of the causes and symptoms associated with AKI, along with misinformation on the kidneys' ability to self-repair; and (3) anxiety from discharge planning and competing health demands, illustrated by complicated discharge plans involving multiple specialist appointments. CONCLUSIONS Patients and caregivers view AKI as a short-term and reversible condition, giving it little thought during the postdischarge period. As a result, reliance on patients and caregivers to report an episode of AKI to their outpatient physicians is unlikely to be successful. Patient-centred tools and decision aids are needed to bridge the gap between a hospitalisation with AKI and the safe transition to the outpatient setting.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Marianne Saragosa
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ziv Harel
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Harvey
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Ron Wald
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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21
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Fylan B, Armitage G, Naylor D, Blenkinsopp A. A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience. BMJ Qual Saf 2017; 27:539-546. [PMID: 29146681 DOI: 10.1136/bmjqs-2017-006813] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 09/11/2017] [Accepted: 09/23/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example, when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating safer, resilient medicines management at a common transition of care. METHODS Qualitative interviews with 60 cardiology patients 6 weeks after their discharge from 2 UK hospitals explored patients' experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. RESULTS During interviews 23 patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and described their strategies to enhance their own reliability in adherence and resource management. CONCLUSION Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities-with caveats-to elicit, develop and formalise patients' capabilities which would contribute to safer patient care and more effective medicines management.
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Affiliation(s)
- Beth Fylan
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Gerry Armitage
- Faculty of Health, University of Bradford, Bradford, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Deirdre Naylor
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Alison Blenkinsopp
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
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22
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Martindale AM, Elvey R, Howard SJ, McCorkindale S, Sinha S, Blakeman T. Understanding the implementation of 'sick day guidance' to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation. BMJ Open 2017; 7:e017241. [PMID: 29122792 PMCID: PMC5695520 DOI: 10.1136/bmjopen-2017-017241] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings. DESIGN Qualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance. SETTING A single primary care health setting in the North of England. PARTICIPANTS 29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients. INTERVENTION The sick day guidance intervention was rolled out (2015-2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a 'medicine sick day guidance' card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards. RESULTS Implementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage. CONCLUSIONS Sick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.
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Affiliation(s)
- Anne-Marie Martindale
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rebecca Elvey
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
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23
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Chandrasekar T, Sharma A, Tennent L, Wong C, Chamberlain P, Abraham KA. A whole system approach to improving mortality associated with acute kidney injury. QJM 2017; 110:657-666. [PMID: 28521019 DOI: 10.1093/qjmed/hcx101] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice. AIM This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI. DESIGN AND METHODS Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet. RESULTS Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001). CONCLUSION This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.
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Affiliation(s)
- T Chandrasekar
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
| | - A Sharma
- Nephrology Directorate, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - L Tennent
- Administrative Services, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - C Wong
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
| | - P Chamberlain
- Innovation and Strategy, South Sefton CCG, Liverpool L20 3DL, UK
| | - K A Abraham
- Nephrology Directorate, Aintree University Hospital, Liverpool L9 7AL, UK
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