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Utilizing electronic medical records alert to improve documentation of neonatal acute kidney injury
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Journal Article
Utilizing electronic medical records alert to improve documentation of neonatal acute kidney injury
2024
Overview
Background
Neonatal acute kidney injury (AKI) is a common yet underdiagnosed condition in neonates with significant implications for long-term kidney health. Lack of timely recognition and documentation of AKI contributes to missed opportunities for nephrology consultation and follow-up, potentially leading to adverse outcomes.
Methods
We conducted a quality improvement (QI) project to address this by incorporating an automated real-time electronic medical record (EMR)-AKI alert system in the Neonatal Intensive Care Unit (NICU) at Le Bonheur Children’s Hospital. Our primary objective was to improve documentation of neonatal AKI (defined as serum creatinine (SCr) > 1.5 mg/dL) by 25% compared to baseline levels. The secondary goal was to increase nephrology consultations and referrals to the neonatal nephrology clinic. We designed an EMR-AKI alert system to trigger for neonates with SCr > 1.5 mg/dL, automatically adding AKI diagnosis to the problem list. This prompted physicians to consult nephrology, refer neonates to the nephrology clinic, and consider medication adjustments.
Results
Our results demonstrated a significant improvement in AKI documentation after implementing the EMR-AKI alert, reaching 100% compared with 7% at baseline (
p
< 0.001) for neonates with SCr > 1.5 mg/dL. Although the increase in nephrology consultations was not statistically significant (
p
= 0.5), there was a significant increase in referrals to neonatal nephrology clinics (
p
= 0.005).
Conclusions
Integration of an EMR alert system with automated documentation offers an efficient and economical solution for improving neonatal AKI diagnosis and documentation. This approach enhances healthcare provider engagement, streamlines workflows, and supports QI. Widespread adoption of similar approaches can lead to improved patient outcomes and documentation accuracy in neonatal AKI care.
Graphical Abstract
A higher resolution version of the Graphical abstract is available as
Supplementary information
Publisher
Springer Berlin Heidelberg,Springer,Springer Nature B.V
Subject
Acute Kidney Injury - diagnosis
/ Acute Kidney Injury - therapy
/ Diseases
/ Documentation - statistics & numerical data
/ Electronic Health Records - statistics & numerical data
/ Female
/ Humans
/ Intensive Care Units, Neonatal - standards
/ Intensive Care Units, Neonatal - statistics & numerical data
/ Kidneys
/ Male
/ Medicine
/ Neonates
/ Original
/ Referral and Consultation - standards
/ Referral and Consultation - statistics & numerical data
/ Urology
