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Data tracking program reduces AKI by 62% at Phoenix Children’s Hospital
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In a collaborative effort between clinicians and information technology experts, Phoenix Children’s Hospital has pioneered a program of tracking nephrotoxic drugs that has led to a 62% decrease in acute kidney injuries per 1,000 patient days.
“One of our most common consults in the hospital is for children who have developed acute kidney injury, up to the point of actual kidney failure, due to nephrotoxic drugs that they were exposed to, sometimes as an outpatient, but more often as an inpatient,” Martin A. Turman, MD, division chief of nephrology at Phoenix Children’s Hospital, told Nephrology News & Issues. “We were hoping to decrease the rate of kids getting acute kidney injury due to dangerous combinations of nephrotoxic drugs.”
The program, which was established in November 2016, uses a visual display of information gleaned from electronic medical records to identify children whose risk of developing AKI may make nephrotoxic drugs an unsafe choice. This information is sent to the hospital’s clinicians and pharmacists, who may then modify the treatment regimen.
“The electronic solution goes and looks at every chart continuously, whenever something is updated, as opposed to a physician, who goes to the electronic medical record as needed,” Vinay Vaidya, PhD, vice president and chief medical informatics officer at Phoenix Children’s Hospital, said. “This electronic surveillance is 25/7, 365 days a year. It is constantly monitoring these drugs. It doesn’t sleep.”
An unavoidable situation
Oftentimes, the nephrotoxic drugs that are used in children are the most effective drugs for their particular indication. Turman cited aminoglycosides, a class of antibiotics that are generally the only effective drugs for children with cystic fibrosis, complicated urinary tract infections and other infections.
“These antibiotics are stellar at tissue penetration and sometimes the best medication by far, but we don’t know for sure what organisms are growing, so we might need to add gram-positive bacteria coverage, which would be with a medicine like vancomycin,” he said. “That class of drugs, in combination with aminoglycosides, makes the toxicity to the kidney go up. The combination increases the nephrotoxicity more than either drug alone.”
In addition to children with infections, those being treated for hematological/oncological conditions are at risk of developing AKI due to nephrotoxic medication. Turman said for these children, the risk is twofold: Not only are many chemotherapy drugs nephrotoxic, but chemotherapy may also cause infection.
“Then, you have to add more nephrotoxic antibiotics on top of their other drugs, so sometimes these kids are on five or six nephrotoxins at the same time,” he said. “With so many complex interactions of drugs, it’s difficult for the provider to always keep track of how the kidney is doing during this whole process when they’re focused on trying to save the child’s life.”
It became apparent there was a need to better surveil and coordinate the use of these drugs to minimize the risk of AKI.
“We have about 1,000 to 1,200 drugs in our hospital inpatient formulary and of those, about 5% to 7% have a side effect in the kidneys,” Vaidya said. “These are essential medications, but they do have a side effect. A relatively simple intervention, such as asking every day, ‘Are all the medications necessary or can we cut down on some?’ could decrease AKI risk in these children.”
Alerts and adjustments
Building on the basic idea of reviewing each patient’s regimen for nephrotoxic drugs, the team at Phoenix Children’s Hospital began to develop its data dashboard and alerting system.
“We needed an automatic, automated way to alert providers and our pharmacists who work with us on this, to help us identify kids who are getting up to three or more nephrotoxins, even if they’re vancomycin or gentamicin and bring up a nephrotoxin alert,” Turman said. “Then we have a chance to have the pharmacologist review the chart and see if there’s any way we can switch the medicines around and still get the same clinical efficacy.”
If the medications are considered to be necessary, clinicians will need to monitor the patient’s kidney function daily. Measures of creatinine should be compared to baseline measurements to determine the possible effects of the drug. While these data elements are available in the EMRs, these are not merged into an easily accessible visual representation.
“We brought all these things together in one simple, consolidated, comprehensive visual dashboard which has flags and colors,” Vaidya said. “It’s a nice visual pattern and then our nephrology group, as well as our pharmacists, can operate it, track it, measure the results and go through iterative cycles of improvement.”
Due to this program, the hospital has seen a 20% to 21% reduction in the use of nephrotoxin medications during the past 2 years, Vaidya said.
“Of course, if we have to use them, we use them, but every time we use them, we ask ourselves, ‘Can I reduce the spectrum? Can I stop the medication?’” he said. “It’s never going to go down to zero, because these are essential life-saving medications, but we cut down wherever we could cut down and we achieved a reduction.”
Vaidya added this decrease did not take 2 years to occur.
“In the first couple of months, it dropped and then it is continuing to drop in a downward trajectory,” he said. “We saw early results, which were encouraging.”
Model for other centers
The reduction in nephrotoxic drug use and the decrease in AKI at the hospital, has made Phoenix Children’s Hospital a model for tracking and adjusting such medications. Vaidya said the team has participated in numerous national consultations with interested hospitals.
“Most pediatric hospitals are now part of a group where they are monitoring this, and they have initiatives and various stages. We definitely do serve as an example of early adopters, early innovators so they don’t have to reinvent the wheel,” he said. “Any improvement process that is new involves a shift from existing practice and is always a challenge.”
Vaidya said the hospitals might be in the initial process of making sure the dashboard data are accurate or making sure that nephrologists and pharmacists are accessing the dashboard tool, making necessary calls to the primary caregivers on the floor or ensuring that lab value checks are ordered for these patients. Vaidya emphasized the importance of monitoring nephrotoxic drugs, as AKI can have an ongoing effect on pediatric patients.
“Even transient acute kidney injury can have long-lasting effects,” he said. “So, not only does the hospital stay increase, the cost increases and the complications and the morbidity increase.”
Turman said that because there is no cure for kidney disease, hospitals should focus on prevention, not cure.
“Even sometimes when it looks like it’s almost completely reversed, you might find 10 years later that the child now has chronic kidney disease or high blood pressure,” he said.
Minimizing avoidable risk factors like nephrotoxic drugs was the motivation for Phoenix Children’s Hospital to improve its technology and streamline its treatment regimens.
“All these elements are critical, and everybody plays their crucial role to come together,” he said. “So, the collaboration in working together for the common good of our patients is what drives improvements like these.” – by Jennifer Byrne
Disclosures: Turman and Vaidya report no relevant financial disclosures.