title: Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm.
abstract: BACKGROUND
  Nephrotoxic medication-associated acute kidney injury (NTMx-AKI) is a costly clinical phenomenon and more common than previously recognized. Prior efforts to use technology to identify AKI have focused on detection after renal injury has occurred.
  
  
  OBJECTIVE
  Describe an approach and provide a technical framework for the creation of risk-stratifying AKI triggers and the development of an application to manage the AKI trigger data. Report the performance characteristics of those triggers and the refinement process and on the challenges of implementation.
  
  
  METHODS
  Initial manual trigger screening guided design of an automated electronic trigger report. A web-based application was designed to alleviate inefficiency and serve as a user interface and central workspace for the project. Performance of the NTMx exposure trigger reports from September 2011 to September 2013 were evaluated using sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV).
  
  
  RESULTS
  Automated reports were created to replace manual screening for NTMx-AKI. The initial performance of the NTMx exposure triggers for SN, SP, PPV, and NPV all were ≥0.78, and increased over the study, with all four measures reaching ≥0.95 consistently. A web-based application was implemented that simplifies data entry and couriering from the reports, expedites results viewing, and interfaces with an automated data visualization tool. Sociotechnical challenges were logged and reported.
  
  
  CONCLUSIONS
  We have built a risk-stratifying system based on electronic triggers that detects patients at-risk for NTMx-AKI before injury occurs. The performance of the NTMx-exposed reports has neared 100% through iterative optimization. The complexity of the trigger logic and clinical workflows surrounding NTMx-AKI led to a challenging implementation, but one that has been successful from technical, clinical, and quality improvement standpoints. This report summarizes the construction of a trigger-based application, the performance of the triggers, and the challenges uncovered during the design, build, and implementation of the system.
authors.affiliation: Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio ; Department of Information Services, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio ; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio ; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: E S
authors.initials: ES
authors.lastname: Kirkendall
authors.affiliation: Department of Information Services, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: W L
authors.initials: WL
authors.lastname: Spires
authors.affiliation: Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: T A
authors.initials: TA
authors.lastname: Mottes
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: J K
authors.initials: JK
authors.lastname: Schaffzin
authors.affiliation: Division of Pharmacy, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: C
authors.initials: C
authors.lastname: Barclay
authors.affiliation: Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: S L
authors.initials: SL
authors.lastname: Goldstein
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced*; D000465:Algorithms; D002648:Child; D064420:Drug-Related Side Effects and Adverse Reactions; D057286:Electronic Health Records; D006801:Humans; D020407:Internet; D008490:Medical Informatics / Q000379:methods*; D058028:Research Report; D018570:Risk Assessment
keywords: Electronic health record; acute kidney injury; clinical decision support systems; electronic medical record; patient safety