Impact of a Quality Improvement Initiative to Reduce Medication-induced Kidney Injury

Acute kidney injury (AKI) is a common complication of nephrotoxic medication use in hospitalized children. Prior studies have shown that the use of electronic health record alerts to identify patients exposed to nephrotoxic medications reduced exposure and the incidence of AKI. This initiative aimed to reduce the incidence of AKI by implementing a process to identify nephrotoxic exposures and standardize care for patients receiving nephrotoxic medications.

We used quality improvement methodology to identify and reduce nephrotoxic medication exposure and to standardize hydration and monitoring for patients receiving them. We tested the process on a single hospital service before expanding to other services, with ongoing optimization via monthly Plan-Do-Study-Act cycles.

During the 48-month study period, we observed a significant decrease in the mean number of patients exposed to nephrotoxic medications, from a baseline of 11.3 patients per 1,000 patient-days per month to 6.6 patients per 1,000 patient-days per month, a 42% decrease. For patients exposed to nephrotoxic medications, there was an increase in AKI monitoring (via increased creatinine testing) and an increase in the percentage who developed AKI.

We adapted and implemented a screening process for exposure to nephrotoxic medications, along with a novel hydration and monitoring pathway. Consistent with previous studies, we observed a dramatic decrease in exposure. An increase in the detection of AKI and a reduction in the proportion of lower risk patients may explain the unexpected increase in the percentage who developed AKI. Our study suggests that implementing standardized identification and monitoring processes can reduce exposure, and that automation and adherence monitoring are important for demonstrating reductions in AKI.