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Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention
Jeremiah R Brown1, Richard J Solomon2, Mark J Sarnak2
1From The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH (J.R.B., M.E.S., C.S.R.); Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (J.R.B., J.L.S., S.M.C., J.F.R., D.J.M.); Department of Community and Family Medicine, Lebanon, NH (J.R.B., T.A.M.); Fletcher Allen Health Care, Burlington, VT (R.J.S., H.L.D.); Tufts Medical Center, Boston, MA (M.J.S.); Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX (P.A.M.); The Heart Hospital, Plano, TX (P.A.M.); Department of Veterans Affairs Medical Center, White River Junction, VT (L.D.); Concord Hospital, Concord, NH (K.C.); Catholic Medical Center, Manchester, NH (P.L., D.J.G.); Portsmouth Regional Hospital, Portsmouth, NH (D.L., F.A.F.); Maine Medical Center, Portland, ME (M.A.K.); Central Maine Medical Center, Lewiston, ME (S.H., W.J.P.); and Eastern Maine Medical Center, Bangor, ME (C.D., A.W.). jbrown@dartmouth.edu.
Background:
Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions.
Methods And Results:
We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67-0.93; P=0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate <60 mL/min per 1.73 m(2) (risk ratio, 0.72; 95% confidence interval: 0.56-0.91; P=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration.
Conclusions:
Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.
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