Hospital-acquired acute kidney injury: a proposed patient safety indicator

ABSTRACT

Patient safety, which includes adverse event reporting and routine collection of outcome measures, has become an increasingly important aspect of inpatient care worldwide. In the United States, the National Quality Forum leads the effort in developing such measures for use in payment and public reporting programs. However, choosing and prioritizing events to serve as patient safety indicators is difficult in a dynamically changing and complex healthcare environment. In this perspective, we propose that hospital-acquired acute kidney injury (HA-AKI), for example, contrast-induced and postoperative AKI, should be added to existing, more traditional measures, such as surgical site infections and patient falls. The article highlights the significance of HA-AKI as a common complication resulting from a multitude of diagnostic and therapeutic procedures, how it lends itself well to measuring patient safety, and how reporting of this complication can contribute to further improvement of patient safety and overall quality of care.

KEYWORDS:

• Acute kidney injury
• patient safety
• hospital-acquired conditions
• quality of care
• hospital medicine

Maximizing patient safety is a priority for healthcare providers and government regulatory agencies. In the United States (U.S.), the Agency for Healthcare and Research Quality (AHRQ) launched in 2015 the Patient Safety Network [1], which serves as an information resource for practitioners and healthcare organizations. In addition, the Organization of Economic Cooperation and Development, has identified the importance of advancing patient safety internationally [2]. Despite these initiatives, uniform reporting of patient safety indicators (PSI) does not currently exist, greatly impeding a comparative evaluation of healthcare delivery. According to the AHRQ, a PSI is defined as a set of measures that screen for adverse events experienced by patients as a result of exposure to the healthcare system.

In the U.S., the National Quality Forum (NQF), a non-governmental organization comprised of independent experts and key stakeholders, has created and endorsed quality measures and set standards to enhance healthcare value, safety, and improve outcomes. These are widely accepted by the federal government and private sector payers. This highlights the complexity in choosing and prioritizing PSIs that can be reliably measured and are deemed representative of overall quality of care and safety standards, while remaining relevant in different national health systems. Indeed, hospital-based diagnostic and therapeutic procedures have been steadily increasing over the past years, with a concomitant focus on reduction of hospital length of stay and improved efficiency of hospital care, often accompanied by a reduction in staff-to-patient ratios, increased density of the workload, and high speed of care delivery. These trends have the potential to compromise quality of care and patient safety, and increase the likelihood of errors. Hospital-acquired acute kidney injury (HA-AKI) is a common complication following diagnostic and therapeutic procedures and is associated with increased morbidity and mortality. Since this complication of care can be prevented using stringent process improvement measures, HA-AKI could be considered a PSI candidate [3–5].

To prevent patient harm, it is paramount to reliably standardize, quantify and analyze PSI through accurate identification and measurement, as well as accuracy and reliability of reporting. Post-procedural complications naturally lend themselves to gauge patient safety, such as surgical site infections, central venous catheter-associated bloodstream infections, catheter-associated urinary tract infections, and patient falls. Such events can be easily measured and provide a clear cause-and-effect relationship between patient care and complication. Another important issue is the accuracy and reliability of reporting these hospital-acquired conditions. The establishment of patient safety departments in acute-care hospitals has proven efficient to enhance the frequency and quality of reporting hospital-acquired conditions. Within this framework, the complication of HA-AKI, including post-operative (e.g. post-cardiac or abdominal surgery) and contrast-induced AKI (CI-AKI) following diagnostic (e.g. CT-scan imaging) or therapeutic procedures (e.g. angiography), might qualify as an underrecognized and important PSI. The National Cardiovascular Data Registry collects data on outcomes associated with percutaneous coronary interventions (PCIs) from hospitals across the U.S., and reports CI-AKI rates across institutions averaging at approximately 7% [6].

In this context, it is important to distinguish between community-acquired and hospital-acquired-AKI. The former is typically not the result of exposure to the healthcare system and therefore it is by definition not a hospital-acquired condition and will not be discussed here. Hospital-acquired AKI by contrast, and CI-AKI for instance, fulfills many of the preconditions required to qualify as a PSI. First, HA-AKI generally, and CI-AKI specifically, greatly increases short- and long-term morbidity/mortality, resource utilization, and healthcare costs. Second, there is a clear cause-and-effect relationship and this hospital-acquired condition is clinically well-defined. Third, its occurrence can be reduced through preventive measures, including the administration of intravenous saline and minimization of contrast volume. The effectiveness of systematic quality improvement initiatives to prevent CI-AKI is supported by evidence. In one report, the implementation of a continuous quality improvement program for PCI across five hospitals significantly reduced CI-AKI from 7.1% to 4.5%. The interventions included nursing protocols for assessment of pre-PCI medications, volume expansion, biplane coronary angiography, and avoidance of unnecessary angiographic views, among other measures [5]. A similar multifaceted regional quality improvement intervention across six hospitals reduced CI-AKI by 21% [3]. Multidisciplinary cooperation is required to enable successful implementation of such a program. Table 1 illustrates such an approach for prevention, management and care coordination of CI-AKI.

Table 1. Conceptual framework of strategies for prevention and management of contrast-induced AKI, a common type of hospital-acquired AKI

Clinical context	Proposed interventions
Recognition and identification of vulnerable subpopulations	Identify high-risk patients with advanced age, preexisting chronic kidney disease, heart failure, and diabetes
Careful decision-making process to set indication for contrast agent administration	Avoid contrast agent exposure if alternative imaging modalities are available or if conservative approach is feasible
Inclusion of a quantitative risk-benefit evaluation for the planned procedure	Use of quantitative scoring systems, e.g. the Mehran score for predicting post-PCI CI-AKI
Implementation of a bundle of evidence-based preventive interventions	Implementation of an ‘AKI prevention bundle’, e.g. avoidance of nephrotoxic medications, intravenous fluid administration*, minimization of contrast volume, use of biplane imaging, avoidance of ventriculography
Increased vigilance in the detection of post-procedure development of contrast-induced AKI	Routine pre- and post-procedure serum creatinine measurements, and urine output monitoring
Implementation of an evidence-based management bundle for patients who develop contrast-induced AKI	Implementation of an ‘AKI management bundle’, e.g. delay of hospital discharge, daily monitoring of kidney function, optimization of fluid balance, judicious use of diuretics, medication dosing adjustment, and avoidance of nephrotoxic medications
Effective planning of appropriate post-acute discharge care and follow-up	Implementation of high-quality transitions of care for all patients with AKI following hospital discharge

*For example, normal saline 3 mL/kg/h administered over 1 hour before contrast agent exposure, followed by 1 mL/kg/h during a period of 6 hours following contrast agent exposure.

Hospital-acquired AKI might qualify as a PSI, as it frequently represents a preventable adverse event that patients might experience as a result of exposure to the healthcare system. The Hospital-Acquired Condition (HAC) Reduction Program of the Centers for Medicare and Medicaid Services (CMS) links payments to healthcare quality and may set economic incentives for future implementation of HA-AKI reduction programs. In 2009, the NQF defined CI-AKI as a patient safety measure, and issued a safe practice guideline [7]. In 2012, CMS proposed the addition of CI-AKI under its HAC Reduction Program, which would be subject to reduced payment provisions to hospitals under the inpatient prospective payment system, but it was never released or formally adopted [8]. More recently, however, CMS implemented in its pay-for-performance program the use of Patient Safety Indicators 90 (PSI-90), which comprises 10 safety measures, including postoperative dialysis-requiring AKI [9]. While these regulatory changes may advance the implementation of quality improvement programs for prevention of HA-AKI, they should not hamper the delivery of high-risk procedures to vulnerable populations, for example, the provision of contrast enhanced diagnostic imaging or cardiac procedures to patients with chronic kidney disease, who are at a higher risk for CI-AKI.

In conclusion, HA-AKI deserves to be recognized as a PSI. In doing so, this may increase awareness, and improve quality and consistency of its management, including post-hospital discharge care coordination. Further research is needed to strengthen the evidence-base for prevention, detection and management of HA-AKI through the implementation of care bundles to improve patient outcomes. Use of electronic alert systems for early detection of HA-AKI [10] and use of structured interventions to prevent progression to higher stages of severity [4] are promising areas of research.

Declaration of financial/other relationships

The authors received no financial support for the research, authorship, and/or publication of this article.Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Disclosure statement

The authors declare no conflict of interest pertaining to this work.