Personalised recommendations for hospitalised patients with Acute Kidney Injury using a Kidney Action Team (KAT-AKI): protocol and early data of a randomised controlled trial.

INTRODUCTION: Although studies have examined the utility of clinical decision support tools in improving acute kidney injury (AKI) outcomes, no study has evaluated the effect of real-time, personalised AKI recommendations. This study aims to assess the impact of individualised AKI-specific recommendations delivered by trained clinicians and pharmacists immediately after AKI detection in hospitalised patients. METHODS AND ANALYSIS: KAT-AKI is a multicentre randomised investigator-blinded trial being conducted across eight hospitals at two major US hospital systems planning to enrol 4000 patients over 3 years (between 1 November 2021 and 1 November 2024). A real-time electronic AKI alert system informs a dedicated team composed of a physician and pharmacist who independently review the chart in real time, screen for eligibility and provide combined recommendations across the following domains: diagnostics, volume, potassium, acid-base and medications. Recommendations are delivered to the primary team in the alert arm or logged for future analysis in the usual care arm. The planned primary outcome is a composite of AKI progression, dialysis and mortality within 14 days from randomisation. A key secondary outcome is the percentage of recommendations implemented by the primary team within 24 hours from randomisation. The study has enrolled 500 individuals over 8.5 months. Two-thirds were on a medical floor at the time of the alert and 17.8% were in an intensive care unit. Virtually all participants were recommended for at least one diagnostic intervention. More than half (51.6%) had recommendations to discontinue or dose-adjust a medication. The median time from AKI alert to randomisation was 28 (IQR 15.8-51.5) min. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of each study site (Yale University and Johns Hopkins institutional review board (IRB) and a central IRB (BRANY, Biomedical Research Alliance of New York). We are committed to open dissemination of the data through clinicaltrials.gov and sharing of data on an open repository as well as publication in a peer-reviewed journal on completion. TRIAL REGISTRATION NUMBER: NCT04040296.

Did the gold standards framework (GSF) support NIV withdrawal during the COVID-19 pandemic?

IntroductionDespite this year’s challenges with Covid-19, the data collected by Dudley Group Foundation Team has offered assurance that GSF has continued to be embedded across the hospital with improved identification of patients in the last year of life, enabling an individual plan of care and continued use of data to drive improvements. There has been local variation with the level of Specialist Palliative Care (SPC) support for COVID-19 patients and withdrawal of NIV. Local guidelines vary and these can be compared with the Association for Palliative Medicine guidance developed. This review was carried out to look at practice in Dudley Group NHS Foundation Trust.MethodRetrospective review of 20 randomly selected COVID deaths whereby NIV had been used outside of the ITU setting between November 2020 and February 2021.ResultsOver a third of patients were on NIV for 1 day only. A decision to withdraw NIV was made in 65% (13/20) of cases reviewed and the remaining 35% (7/20) died with NIV in place. Good discussions were documented around NIV withdrawal with the patients where they had capacity (7/13) and 100% with family. For those that died with NIV in place there were discussions with family regarding an individual plan of care.Seventy five percent of cases reviewed had anticipatory medication prescribed, however, none required a syringe driver. None of the cases reviewed were referred to the specialist palliative care team and 100% had a DNACPR in place.ConclusionThe results illustrate that none of the cases resulted in referral to the SPC team, however, there was evidence of good discussions and provision of anticipatory medication via the sub-cutaneous route. This suggests that the GSF has supported the respiratory team in providing individualised, good end of life care without the need for Specialist Palliative care input for all cases of NIV withdrawal.