Randomized trial of AKI alerts in hospitalized patients

Objective: To determine whether electronic health record (EHR) alerts for
Acute Kidney Injury (AKI) would improve patient outcomes of mortality,
dialysis and progression of AKI.  Design: Double-blinded,
multicenter, parallel, randomized, controlled trial of an electronic AKI
alert versus usual care (no alert). Participants were electronically
identified and randomized via a best practice alert build using simple
randomization with allocation concealment. Setting: Six diverse hospitals
(four teaching and two non-teaching) ranging from small community
hospitals to large tertiary care centers. Participants: 6,030 adult
inpatients with AKI, as defined by the Kidney Disease: Improving Global
Outcomes (KDIGO) creatinine criteria. Interventions: An
 EHR-based “pop-up” alert for AKI with an associated AKI order
set upon provider opening of the patient’s medical record. Main Outcome
Measures: A composite of AKI progression, receipt of dialysis, or death
within 14 days of randomization. Pre-specified secondary outcomes included
per-hospital outcome rates and rates of various AKI care
practices.  Results: 6,030 patients were randomized over 22
months. The primary outcome occurred in 653 (21.4%) patients in the alert
group and 622 (20.9%) in the usual care group (relative risk 1.02, 95%
confidence interval [CI] 0.93 to 1.13, p=0.67). Per-hospital analysis
revealed worse outcomes in the two non-teaching hospitals (N=765, 13%),
where alerts were associated with a relative risk of the primary outcome
of 1.49 (95% CI, 1.12 to 1.98, p=0.006). More deaths (15.6% in the alert
group vs. 8.6% in the usual care group) occurred at these centers
(p=0.003). Certain AKI care practices were increased in the alert group
but did not appear to mediate these outcomes. Conclusions: Alerts did not
reduce rates of our primary outcome among hospitalized patients with
AKI.  The overall lack of clinical benefit and signals of harm in
non-teaching hospitals should lead to a re-evaluation of existing AKI
alerting systems. Trial Registration:  ClinicalTrials.gov
NCT02753751.