AKI in Hospitalized Children: Poorly Documented (and Underrecognized)

Background: Acute kidney injury (AKI) is common in hospitalized children. We hypothesized that hospital-acquired AKI would be underrecognized and under-reported, with potential implications for prevention of future AKI and CKD risk stratification.Methods: Five hundred thirty-two cases of AKI occurring over a 1 year period in a tertiary children's hospital in the United States were studied. AKI documentation was defined as any mention of AKI in the admission history and physical note, progress notes, or discharge summary. Nephrology follow-up was defined as a completed outpatient clinic visit within 1 year of discharge. Logistic regression was used to assess factors associated with documentation, consultation, and follow-up.Results: AKI developed during 584/7,640 (7.6%) of hospitalizations: 532 cases met inclusion criteria. Documentation was present in 34% (185/532) of AKI cases and 90 (16.9%) had an inpatient nephrology consult. Among 501 survivors, 89 (17.8%) had AKI in their hospital discharge summary and 54 had outpatient nephrology follow up. Stage 3 AKI, peak creatinine >1 mg/dL and longer length of stay were associated with documentation. Stage 3 AKI and higher baseline creatinine were associated with inpatient nephrology consultation. Inpatient nephrology consultation was positively associated with outpatient nephrology follow up, but documentation in the discharge summary was not.Conclusion: Most cases of AKI were not documented and the proportion of children seen by a nephrologist was low, even among those with more severe injury. Increased severity of AKI was associated with documentation and inpatient consultation. Poor rates of documentation has implications for AKI recognition and appropriate management and follow up.

Unintended discontinuation of medication following hospitalisation: a retrospective cohort study

ObjectivesWhether unintended discontinuation of common, evidence-based, long-term medication occurs after hospitalisation; what factors are associated with unintended discontinuation; and whether the presence of documentation of medication at hospital discharge is associated with continuity of medication in general practice.DesignRetrospective cohort study between 2012 and 2015.SettingElectronic records and hospital supplied discharge notifications in 44 Irish general practices.Participants20 488 patients aged 65 years or more prescribed long-term medication for chronic conditions.Primary and secondary outcomesDiscontinuity of four evidence-based medication drug classes: antithrombotic, lipid-lowering, thyroid replacement drugs and respiratory inhalers in hospitalised versus non-hospitalised patients; patient and health system factors associated with discontinuity; impact of the presence of medication in the hospital discharge summary on continuity of medication in a patient’s general practitioner (GP) prescribing record at 6 months follow-up.ResultsIn patients admitted to hospital, medication discontinuity ranged from 6%–11% in the 6 months posthospitalisation. Discontinuity of medication is significantly lower for hospitalised patients taking respiratory inhalers (adjusted OR (AOR) 0.63, 95% CI (0.49 to 0.80), p<0.001) and thyroid medications (AOR 0.62, 95% CI (0.40 to 0.96), p=0.03). There is no association between discontinuity of medication and hospitalisation for antithrombotics (AOR 0.95, 95% CI (0.81 to 1.11), p=0.49) or lipid lowering medications (AOR 0.92, 95% CI (0.78 to 1.08), p=0.29). Older patients and those who paid to see their GP were more likely to experience increased odds of discontinuity in all four medicine groups. Less than half (39% to 47.4%) of patients had medication listed on their hospital discharge summary. Presence of medication on hospital discharge summary is significantly associated with continuity of medication in the GP prescribing record for lipid lowering medications (AOR 1.64, 95% CI (1.15 to 2.36), p=0.01) and respiratory inhalers (AOR 2.97, 95% CI (1.68 to 5.25), p<0.01).ConclusionDiscontinuity of evidence-based long-term medication is common. Increasing age and private medical care are independently associated with a higher risk of medication discontinuity. Hospitalisation is not associated with discontinuity but less than half of hospitalised patients have medication recorded on their hospital discharge summary.

Data linkage to develop a mortality outcome measure for patients with sepsis

ABSTRACT BackgroundMonitoring sepsis outcomes over time is necessary to evaluate healthcare improvement interventions. However, it is a clinical diagnosis (infection with a systemic inflammatory response) that is not routinely recorded electronically. We aimed to create a proxy measure for sepsis mortality using routine data. ObjectiveICD-10 codes on hospital discharge summaries are often used to monitor disease outcome but the presence of a code for a specific infection, e.g. pneumonia, does not give any indication of severity of illness i.e. whether the patient had sepsis. There are ICD-10 codes that specifically indicate sepsis, most commonly A40 and A41. However, monitoring mortality using ICD-10 is susceptible to coding bias as practice differs between and within health boards. Using ICD-10 codes alone does not differentiate between changes in mortality and changes in coding practice. As recommended in the “Sepsis 6” care bundle, all patients with suspected sepsis should have a blood culture taken urgently. A previous study showed that having a blood culture taken was associated with a 3-fold increase in risk of mortality, over other hospital inpatients, independent of having a positive or negative result. We tested whether having a blood culture taken might be a suitable proxy marker for sepsis and compared it to data using ICD-10 sepsis codes. MethodData on all patients that had a blood culture taken in hospital in Scotland between 2011 and 2013 were obtained from hospital laboratory systems. These data were linked to hospital discharge summary records (SMR01) and death records. Monthly 30-day mortality rates from date of blood culture were calculated. Patients with an A40 or A41 ICD-10 code were extracted from hospital discharge summary records (SMR01) and linked to deaths records. Monthly 30-day mortality rates from date of admission were calculated over the same period of time. Blood culture sampling and, more strikingly, the use of A40/A41 codes increased over the study period. Blood culture data would indicate no significant change in 30-day mortality over the study period but coding data would indicate a 20% relative reduction. ConclusionA40/A41 codes lack sensitivity as the numbers of patients with these codes is many times lower than estimates of sepsis incidence, and coding practice changed dramatically over time. Blood culture data lacks specificity as many patients that had a blood culture taken will end up with an alternative diagnosis. Combining a broader group of infection codes with blood culture data may be a more useful measure.