An organizational-level program of intervention for AKI: A pragmatic stepped wedge cluster randomized trial

Nicholas M. Selby, Anna Casula, Laura Lamming, John Stoves, Yohan Samarasinghe, Andrew J. Lewington, Russell Roberts, Nikunj Shah, Melanie Johnson, Natalie Jackson, Carol Jones, Erik Lenguerrand, Eileen McDonach, Richard J. Fluck, Mohammed A. Mohammed, Fergus J. Caskey

Research output: Contribution to journalArticlepeer-review


Background Variable standards of care may contribute to poor outcomes associated with AKI. We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program) would improve delivery of care and patient outcomes at an organizational level. Methods A multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals, involving patients with AKI aged 18 years. The intervention was introduced sequentially across fixed three-month periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was 30-day mortality, with pre-specified secondary end points and anestedevaluation of careprocessdelivery. The nature of the intervention precluded blinding, but data collection and analysiswere independent of project delivery teams. Results We studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference between control and intervention periods. Hospital length of stay was reduced with the intervention (decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment of process measures in 1048 patients showed improvements in several metrics including AKI recognition, medication optimization, and fluid assessment. Conclusions A complex, hospital-wide intervention to reduce harm associated with AKI did not reduce 30-day AKImortality but did result in reductions in hospital length of stay, accompanied by improvements in in quality of care. An increase in AKI incidence likely reflected improved recognition.

Original languageEnglish
Pages (from-to)505-515
Number of pages11
JournalJournal of the American Society of Nephrology
Issue number3
Publication statusPublished - Mar 2019


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