Findings from a new study published in The Clinical Journal of the American Society of Nephrology, involving a collaborative effort between researchers from Dartmouth Geisel School of Medicine, Vanderbilt, and Veterans Affairs (VA) medical centers, show that an implementation science approach using team-based training and automated surveillance reporting improves significantly the risk of acquiring acute kidney disease after the procedure. (LRA) compared to other interventions.
Up to 14 percent of the more than two million people in the US who undergo cardiac catheterization procedures each year experience acute kidney injury (AKI), making it one of the most frequent adverse events. Acute kidney injury is associated with increased risk of cardiovascular events, prolonged hospitalization, end-stage renal disease, all-cause mortality, and increased acute care costs.
A growing body of research conducted in recent years has shown that there are some basic steps cardiovascular intervention teams can take to help prevent AKI from occurring in their patients. These include making sure patients are well hydrated before procedures and receiving an IV bolus of fluid, allowing them to eat and drink up to two hours before procedures and limiting the amount of contrast dye used. in procedures.
The problem is that only about 25 percent of medical centers or cardiovascular intervention teams at those sites are applying the evidence base or official guidelines from leading consortia like KDIGO (Kidney Disease: Improving Global Outcomes).”
Jeremiah Brown, PhD, professor of epidemiology at Geisel and lead author of the study
Rather than conduct another individual randomized trial to test how well certain components of the prevention guidelines worked, the study team’s goal was to increase acceptance of those guidelines through a hybrid randomized design of implementation and effectiveness. “We use a team-oriented approach based on implementation science, an emerging area of multidisciplinary research that focuses on translating scientific evidence into routine practice,” explains Brown.
Using what is known as a “2 x 2 factorial cluster randomized trial,” researchers measured the effectiveness and implementation of three different monthly interventions to prevent AKI at 20 VA medical centers across the country over a period of 18 months. Half of the centers received team coaching sessions in virtual collaborative learning (Collaborative) and half received personalized technical assistance (Assistance) from a nephrologist expert in prevention from the FRA. The two main groups were further randomized to receive either a surveillance panel report (Surveillance) that provided automated feedback on key performance metrics or no report (No Surveillance).
A total of 4,517 patients participated in the study, of whom 510 suffered acute kidney injury. The study team found that the Collaborative Surveillance intervention significantly outperformed the other groups, reducing the odds of AKI by 46 percent; to date, the best find in the field. Comparatively, the Unguarded Collaborative group and the Surveillance Assist group saw a 28 percent and 24 percent reduction in the odds of AKI, respectively.
The study is the first US national randomized trial to use an implementation science approach to advance the field, providing a unique opportunity for researchers, Brown says.
“This gives us the recipe for the combination of interventions that work best,” he says. “We hope to take what we’ve learned and scale it up so it can be shared with other cath lab teams across the country and internationally to help them more effectively address the problem of AKIs.”
The Geisel School of Medicine in Dartmouth
Brown, J.R., et al. (2023) Team-based training intervention to improve contrast-associated AKI. The Clinical Journal of the American Society of Nephrology. doi.org/10.2215/CJN.0000000000000067.
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