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How do centres begin the process to prevent contrast-induced acute kidney injury: a report from a new regional
Jeremiah R Brown1, Peter A McCullough, Mark E Splaine
1Dartmouth-Hitchcock Medical Center, HB 7505, One Medical Center Drive, Lebanon, NH 03756, USA. jbrown@dartmouth.edu
Insights
Implementing standardized practices, such as reduced fasting and N-acetylcysteine protocols, can significantly lower contrast-induced acute kidney injury (CI-AKI) rates in cardiovascular procedures.
Area of Science:
- Cardiology
- Nephrology
- Healthcare Quality Improvement
Background:
- Contrast-induced acute kidney injury (CI-AKI) is a significant complication of invasive cardiovascular procedures.
- CI-AKI is linked to adverse cardiovascular events, extended hospital stays, end-stage renal disease, and increased mortality.
- Reducing CI-AKI is a key patient safety goal.
Purpose of the Study:
- To examine variations in CI-AKI prevention practices across different medical centers.
- To identify specific clinical strategies associated with lower CI-AKI incidence.
Main Methods:
- Prospective collection of quantitative and qualitative data from 10 centers in the Northern New England Cardiovascular Disease Study Group PCI Registry.
- Utilized clinical team meetings and focus groups to map CI-AKI care processes and understand prophylaxis attitudes.
- Employed fixed and random effects modeling to analyze inter-center variability.
Main Results:
- Significant variation in CI-AKI rates was observed across the 10 participating centers, even after adjusting for baseline factors.
- Centers with lower CI-AKI rates demonstrated distinct patterns in care processes and leadership.
- Key practices included reducing nil by mouth (NPO) time to 4 hours, standardizing hydration protocols, and administering high-dose N-acetylcysteine (1200 mg, 3-4 doses).
Conclusions:
- Clinical leadership and standardized institutional efforts are crucial for reducing CI-AKI incidence.
- Implementing evidence-based preventive measures can effectively mitigate CI-AKI risk in patients undergoing cardiovascular procedures.
Objectives:
This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI. Background CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged hospitalisation, end-stage renal disease, and all-cause mortality. Reducing the risk of CI-AKI is a patient safety objective set by the National Quality Forum.
Methods:
This study prospectively collected quantitative and qualitative data from 10 centres, which participate in the Northern New England Cardiovascular Disease Study Group PCI Registry. Quantitative data were collected from the PCI Registry. Qualitative data were obtained through clinical team meetings to map care processes related to CI-AKI and focus groups to understand attitudes towards CI-AKI prophylaxis. Fixed and random effects modelling were conducted to test the differences across centres.
Results:
Significant variation in rates of CI-AKI were found across 10 medical centres. Both fixed effects and mixed effects logistic regression demonstrated significant variability across centres, even after adjustment for baseline covariates (p<0.001 for both modelling approaches). Patterns were found in reported processes and clinical leadership that were attributable to centres with lower rates of CI-AKI. These included reducing nil by mouth (NPO) time to 4 h prior to case, and standardising volume administration protocols in combination with administering three to four high doses of N-acetylcysteine (1200 mg) for each patient.
Conclusions:
These data suggest that clinical leadership and institution-focused efforts to standardise preventive practices can help reduce the incidence of CI-AKI.
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