Impact of Compliance with a Care Bundle on Acute Kidney Injury Outcomes: A Prospective Observational Study

Background A recent report has highlighted suboptimal standards of care for acute kidney injury (AKI) patients in England. The objective of this study was to ascertain if improvement in basic standard of care by implementing a care bundle (CB) with interruptive alert improved outcomes in patients with AKI. Methods An AKI CB linked to electronic recognition of AKI, coupled with an interruptive alert, was introduced to improve basic care delivered to patients with AKI. Outcomes were compared in patients who had the CB completed within 24 hours (early CB group) versus those who didn’t have the CB completed or had it completed after 24 hours. Results In the 11-month period, 2297 patients had 2500 AKI episodes, with 1209 and 1291 episodes occurring before and after implementation of the AKI CB with interruptive alert, respectively. The CB was completed within 24 hours in 306 (12.2%) of AKI episodes. In-hospital case-fatality was significantly lower in the early CB group (18% versus 23.1%, p 0.046). Progression to higher AKI stages was lower in the early CB group (3.9% vs. 8.1%, p 0.01). In multivariate analysis, patients in the early CB group had lower odds of death at discharge (0.641; 95% CI 0.46, 0.891), 30 days (0.707; 95% CI 0.527, 0.950), 60 days (0.704; 95% CI 0.526, 0.941) and after a median of 134 days (0.771; 95% CI 0.62, 0.958). Conclusions Compliance with AKI CB was associated with a decrease in case-fatality and reduced progression to higher AKI stage. Further interventions are required to improve utilization of the CB.研究背景 近期一项报告指出，英格兰地区急性肾损伤（AKI, acute kidney injury）患者的临床护理标准未达最优水平。本研究旨在探究：通过引入搭载中断式警报（interruptive alert）的护理包（CB, care bundle）优化基础护理标准，是否能够改善AKI患者的临床结局。 研究方法 本研究引入了与AKI电子识别系统联动且搭载中断式警报的AKI护理包，以优化AKI患者的基础护理。将AKI发作后24小时内完成护理包干预的患者（早期护理包组）与未完成护理包干预或干预时间晚于24小时的患者进行结局对比。 研究结果 本次研究为期11个月，共纳入2297名患者，总计发生2500例AKI发作；其中1209例发作于中断式警报联动AKI护理包实施前，1291例发作于实施后。共有306例（12.2%）AKI发作实现了24小时内完成护理包干预。早期护理包组的住院病死率显著更低（18.0% vs. 23.1%，p=0.046）；该组患者进展至更高AKI分期的比例也更低（3.9% vs. 8.1%，p=0.01）。多因素分析结果显示，早期护理包组患者在出院时、出院后30天、60天以及中位随访134天后的死亡比值比均显著降低，分别为0.641（95%置信区间CI：0.46~0.891）、0.707（95%CI：0.527~0.950）、0.704（95%CI：0.526~0.941）以及0.771（95%CI：0.62~0.958）。 研究结论 遵循AKI护理包流程与降低病死率、减少AKI进展至高分期均存在显著关联。未来仍需进一步干预以提升护理包的临床应用率。