Electronic health record identification of nephrotoxin exposure and associated acute kidney injury.
OBJECTIVE
Nephrotoxic medication exposure represents a common cause of acute kidney injury (nephrotoxin-AKI) in hospitalized children. Systematic serum creatinine (SCr) screening has not been routinely performed in children receiving nephrotoxins, potentially leading to underestimating nephrotoxin-AKI rates. We aimed to accurately determine nephrotoxin exposure and nephrotoxin-AKI rates to drive appropriate interventions in non-critically ill hospitalized children.


METHODS
We conducted a prospective quality improvement project implementing a systematic electronic health record (EHR) screening and decision support process (trigger) at a single quaternary pediatric hospital. Patients were all noncritically ill hospitalized children receiving an intravenous aminoglycoside for ≥3 days or ≥3 nephrotoxins simultaneously (exposure). Pharmacists recommended daily SCr monitoring in exposed patients. AKI was defined by the modified pediatric Risk, Injury, Failure, Loss and End-stage Renal Disease criteria (≥25% decrease in estimated creatinine clearance). We developed 4 novel metrics: exposure rate per 1000 patient-days, AKI rate per 1000 patient-days, AKI rate (%) per high nephrotoxin admission, and AKI days per 100 exposure days (AKI intensity).


RESULTS
This study included 21 807 patients accounting for 27 711 admissions. A total of 726 (3.3%) unique exposed patients accounted for 945 hospital admissions (6713 patient-days). AKI occurred in 25% of unique exposed patients and 31% of exposure admissions (1974 patient-days). Our EHR-driven SCr nephrotoxin-AKI surveillance process was associated with a 42% reduction in AKI intensity.


CONCLUSIONS
Nephrotoxin-AKI rates are high in noncritically ill children; systematic screening for nephrotoxic medication exposure and AKI detection was accomplished reliably through an EHR based trigger tool.
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. stuart.goldstein@cchmc.org
Stuart L
SL
Goldstein
Eric
E
Kirkendall
Hovi
H
Nguyen
Joshua K
JK
Schaffzin
John
J
Bucuvalas
Tracey
T
Bracke
Michael
M
Seid
Marshall
M
Ashby
Natalie
N
Foertmeyer
Lori
L
Brunner
Anne
A
Lesko
Cynthia
C
Barclay
Carole
C
Lannon
Stephen
S
Muething
D000046:Academic Medical Centers; D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control; D000465:Algorithms; D000617:Aminoglycosides / Q000008:administration & dosage / Q000633:toxicity; D003404:Creatinine / Q000097:blood; D003430:Cross-Sectional Studies; D057286:Electronic Health Records; D006776:Hospitals, Pediatric; D006801:Humans; D007049:Iatrogenic Disease; D007262:Infusions, Intravenous; D007677:Kidney Function Tests; D008403:Mass Screening; D009820:Ohio; D010607:Pharmacy Service, Hospital; D055553:Prescription Drugs / Q000008:administration & dosage / Q000633:toxicity*; D011446:Prospective Studies; D012307:Risk Factors
D000617:Aminoglycosides; D055553:Prescription Drugs; D003404:Creatinine
acute kidney injury; children; electronic health record; nephrotoxic medications