ABSTRACT
BACKGROUND AND 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.
Subject(s)
Acute Kidney Injury/chemically induced , Acute Kidney Injury/diagnosis , Electronic Health Records , Prescription Drugs/toxicity , Academic Medical Centers , Acute Kidney Injury/epidemiology , Acute Kidney Injury/prevention & control , Algorithms , Aminoglycosides/administration & dosage , Aminoglycosides/toxicity , Creatinine/blood , Cross-Sectional Studies , Hospitals, Pediatric , Humans , Iatrogenic Disease , Infusions, Intravenous , Kidney Function Tests , Mass Screening , Ohio , Pharmacy Service, Hospital , Prescription Drugs/administration & dosage , Prospective Studies , Risk FactorsABSTRACT
BACKGROUND: Narcotics are responsible for many adverse drug events in children and there has been an increase in opioid oversedation events in hospitalised patients. OBJECTIVES: To use improvement methods to prevent perioperative opioid oversedation adverse events while continuing to provide appropriate pain control. METHODS: Interventions included revising the post-anaesthesia order form so that prescribers could choose only one narcotic and one dose for moderate pain and one narcotic and one dose for severe pain, modifying a nursing tool to provide more objective criteria for assessing patient sedation level, and restructuring the pain service. Clinicians on the Acute Pain Service saw all postoperative patients receiving intravenous patient-controlled analgesia or neuraxial narcotics in the mornings and afternoons and a nurse saw them on weekday evenings. RESULTS: The rate of opioid-related oversedation events decreased from 0.15 per 1000 patient days at baseline to 0.111 during the intervention period to 0.074 in the post-intervention period. The days between events increased from 21.0 to 27.5 to 48.8 during the same periods. The number of opioid-related oversedation events decreased from 22 to 17 to 5 during these periods, respectively. CONCLUSIONS: Opioid-related oversedation events decreased over the course of the study. Because the perioperative period is an especially likely time for opioid oversedation events, strict opioid prescribing practices, while maintaining adequate pain control and improved sedation assessment during the perioperative period, were emphasised. The restructured pain service and increased visits by pain team experts were also associated with the reduction in oversedation events.
Subject(s)
Analgesics, Opioid/administration & dosage , Analgesics, Opioid/adverse effects , Perioperative Period , Quality Improvement/organization & administration , Adolescent , Adult , Analgesia, Patient-Controlled/adverse effects , Analgesics, Opioid/therapeutic use , Child , Child, Preschool , Drug Overdose/prevention & control , Female , Hospitals, Pediatric , Humans , Infant , Infant, Newborn , Male , Socioeconomic FactorsABSTRACT
OBJECTIVE: To apply the principles of statistical process control (SPC) to manage calcineurin inhibitor (CNI) blood levels. We hypothesized that the use of SPC would increase the proportion of CNI blood levels in the target range. STUDY DESIGN: The study population consisted of 217 patients more than 3 months after liver transplantation. After demonstration of proof of concept using the rapid cycle improvement process, SPC was applied to the entire population. The change package included definition of target ranges for CNI, implementation of a web-based tool that displayed CNI blood levels on a control chart, and implementation of a protocol and a checklist for management of CNI blood levels. The principal outcome measure was the proportion of CNI blood levels in the target range. RESULTS: In the pilot study, the proportion of CNI blood levels in the target range increased from 50% to 85%. When the protocol was spread to the entire population, the proportion of drug levels in the target range increased to 77% from 50% (P < .001), whereas the range of CNI levels decreased. The rate of allograft rejection did not change. CONCLUSIONS: Utilization of SPC increased the proportion of CNI blood levels in target range. These observations may be applicable to the care of other chronic healthcare problems.
