Electronic health record identification of nephrotoxin exposure and associated acute kidney injury

• Published in: Pediatrics (Evanston) 2013-09, Vol.132 (3), p.e756-e767
• Main Authors: Goldstein, Stuart L, Kirkendall, Eric, Nguyen, Hovi, Schaffzin, Joshua K, Bucuvalas, John, Bracke, Tracey, Seid, Michael, Ashby, Marshall, Foertmeyer, Natalie, Brunner, Lori, Lesko, Anne, Barclay, Cynthia, Lannon, Carole, Muething, Stephen
• Format: Article
• Language: English
• Subjects: Academic Medical Centers; Acute kidney failure; Acute Kidney Injury - chemically induced; Acute Kidney Injury - diagnosis; Acute Kidney Injury - epidemiology; Acute Kidney Injury - prevention & control; Acute renal failure; Adverse and side effects; Adverse drug reactions; Algorithms; Aminoglycosides - administration & dosage; Aminoglycosides - toxicity; Children; Children & youth; Creatinine - blood; Cross-Sectional Studies; Demographic aspects; Diagnosis; Drugs; Electronic Health Records; Electronic records; Hospitals, Pediatric; Humans; Iatrogenic Disease; Infusions, Intravenous; Intervention; Kidney diseases; Kidney Function Tests; Mass Screening; Medical screening; Ohio; Pediatrics; Pharmacy Service, Hospital; Prescription Drugs - administration & dosage; Prescription Drugs - toxicity; Prospective Studies; Risk Factors
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.2013-0794

Nephrotoxic medication exposure represents a common cause of acute kidney injury (nephrotoxin-AKI) in hospitalized children. Systematic serum creatinine (SCr) screening has not been routinely performed in children receiving nephrotoxins, potentially leading to underestimating nephrotoxin-AKI rates. We aimed to accurately determine nephrotoxin exposure and nephrotoxin-AKI rates to drive appropriate interventions in non-critically ill hospitalized children. We conducted a prospective quality improvement project implementing a systematic electronic health record (EHR) screening and decision support process (trigger) at a single quaternary pediatric hospital. Patients were all noncritically ill hospitalized children receiving an intravenous aminoglycoside for ≥3 days or ≥3 nephrotoxins simultaneously (exposure). Pharmacists recommended daily SCr monitoring in exposed patients. AKI was defined by the modified pediatric Risk, Injury, Failure, Loss and End-stage Renal Disease criteria (≥25% decrease in estimated creatinine clearance). We developed 4 novel metrics: exposure rate per 1000 patient-days, AKI rate per 1000 patient-days, AKI rate (%) per high nephrotoxin admission, and AKI days per 100 exposure days (AKI intensity). This study included 21 807 patients accounting for 27 711 admissions. A total of 726 (3.3%) unique exposed patients accounted for 945 hospital admissions (6713 patient-days). AKI occurred in 25% of unique exposed patients and 31% of exposure admissions (1974 patient-days). Our EHR-driven SCr nephrotoxin-AKI surveillance process was associated with a 42% reduction in AKI intensity. Nephrotoxin-AKI rates are high in noncritically ill children; systematic screening for nephrotoxic medication exposure and AKI detection was accomplished reliably through an EHR based trigger tool.