SARS COV-2 continuous quality improvement program: Initiation of a standardized protocol for AKI prevention

ABSTRACT

Background: During the initial phase of the SARS CoV-2 pandemic our institution had high rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT). Nephrocheck (NC), a renal biomarker, indicating renal stress was the basis of a continuous quality improvement (CQI) program to identify patients at risk for AKI & RRT. Methods: Patients admitted from 4/17-5/15/2020 were all tested for SARS CoV-2. All positive patients ≥ 18 years old & with a creatinine <2.0 mg were tested with NC. Values ≥ 0.7 led to nephrology consults & utilization of a renal-protective strategy including monitoring volume status, scrutinizing nephrotoxic medications & urine studies. A 'Plan-Do-Study-Act' approach was used to increase utilization of NC and the resulting protocol for positive results. Intervention was biphasic with a follow up maintenance phase, each lasting 10 days. Phase 1 was adding NC to the SARS CoV2 admission order set & Phase 2 was educating hospitalist providers about using and interpreting NC to increase appropriate nephrology consults. Education was reinforced with protocol cards & reminders via encrypted text services. Additionally, intervention team members reviewed charts daily & reminded providers in real time. Results: In Phase 1, 58% of the SARS CoV-2 positive patients had a NC but only 48% of NC positive patients had a renal consult. In Phase 2, 79% of SARS CoV-2 positive patients had a NC with 80% of positive patients getting a renal consult. In the maintenance phase, 67% of SARS CoV-2 positive patients had NC with 59% of NC positive patients getting a renal consult. Conclusions: During our CQI project, efforts to mitigate severe AKI by using a biomarker-based alert for nephrology consultation saw the number of SARS CoV2 positive patients screened with NC & the number of positive NC patients seen by nephrologists rise significantly. Barriers to implementation included the weekly turn-over of house staff & a reliable alert system to ensure adequate screening. The multidisciplinary team reviewing charts and reminding hospitalists of the protocol also helped significantly but was difficult to sustain.