Acute kidney injury electronic alerts: mixed methods evaluation of their implementation into secondary care, utilising normalisation process theory

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.Setting and participantsThree secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).AnalysisQualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation.ResultsParticipants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).ConclusionsClinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

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SP246ACUTE KIDNEY INJURY ELECTRONIC ALERTS: MIXED METHODS NORMALIZATION PROCESS THEORY EVALUATION OF THEIR IMPLEMENTATION INTO SECONDARY CARE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfy104.sp246 ◽

2018 ◽

Vol 33 (suppl_1) ◽

pp. i426-i426

Author(s):

Jason Scott ◽

Nigel Kanagasundaram ◽

Tracy Finch ◽

Mark Bevan ◽

Gregory Maniatopoulos

Keyword(s):

Mixed Methods ◽

Secondary Care ◽

Kidney Injury ◽

Normalization Process Theory ◽

Process Theory ◽

Theory Evaluation ◽

Electronic Alerts ◽

Normalization Process

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Mixed methods evaluation of a computerised audit and feedback dashboard to improve patient safety through targeting acute kidney injury (AKI) in primary care

International Journal of Medical Informatics ◽

10.1016/j.ijmedinf.2020.104299 ◽

2021 ◽

Vol 145 ◽

pp. 104299

Author(s):

Jung Yin Tsang ◽

Benjamin Brown ◽

Niels Peek ◽

Stephen Campbell ◽

Thomas Blakeman

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Patient Safety ◽

Mixed Methods ◽

Improve Patient Safety ◽

Kidney Injury ◽

Audit And Feedback ◽

Mixed Methods Evaluation ◽

Improve Patient

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OP86 Using normalisation process theory to explore the impact of general practitioners working in or alongside emergency departments in England: qualitative findings from a national mixed methods evaluation

10.1136/jech-2021-ssmabstracts.86 ◽

2021 ◽

Author(s):

Arabella Scantlebury ◽

Joy Adamson ◽

Helen Anderson ◽

Heather Leggett ◽

Sarah Voss ◽

...

Keyword(s):

Mixed Methods ◽

General Practitioners ◽

Emergency Departments ◽

Process Theory ◽

Normalisation Process Theory ◽

Mixed Methods Evaluation ◽

The Impact

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Electronic alerts for acute kidney injury across primary and secondary care

BMJ Open Quality ◽

10.1136/bmjoq-2020-000956 ◽

2021 ◽

Vol 10 (2) ◽

pp. e000956

Author(s):

Joseph Barker ◽

Karl Smith-Byrne ◽

Oliver Sayers ◽

Krishan Joseph ◽

Mark Sleeman ◽

...

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Secondary Care ◽

Kidney Injury ◽

Renal Recovery ◽

Standards Of Care ◽

Care Bundle ◽

Quality Improvement Initiative ◽

Electronic Alerts

ProblemIn 2009 the National Confidential Enquiry into Patient Outcome and Death suggested only 50% of patients with acute kidney injury (AKI) receive good standards of care. In response National Health Service (NHS) England mandated the use of electronic AKI alerts within secondary care. However, we recognised AKI is not just a secondary care problem, where primary care has a crucial role to play in prevention, early detection and management as well as post-AKI care.MethodsAKI alerts were implemented in primary and secondary care services for a population of 480 000. Comparisons were made in AKI incidence, peak creatinine following AKI and renal recovery in the years before and after using Byar’s approximation (95% CI).InterventionA complex quality improvement initiative was implemented based on the design and integration of an AKI alerting system within laboratory information management systems for primary and secondary care, with an affixed URL for clinicians to access a care bundle of AKI guidelines on safe prescribing, patient advice and early contact with nephrology.ResultsThe intervention was associated with an 8% increase in creatinine testing (n=32 563). Hospital acquired AKI detection increased by 6%, while community acquired AKI detection increased by 3% and AKI stage 3 detected in primary care fell by 14%. The intervention overall had no effect on AKI severity but did improve follow-up testing and renal recovery. Importantly hospital AKI 3 recoveries improved by 22%. In a small number of AKI cases, the algorithm did not produce an alert resulting in a reduction in follow-up testing compared with preintervention levels.ConclusionThe introduction of AKI alerts in primary and secondary care, in conjunction with access to an AKI care bundle, was associated with higher rates of repeat blood sampling, AKI detection and renal recovery. Validating accuracy of alerts is required to avoid patient harm.

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