Jeremiah R Brown (One Medical Center Dr, Lebanon, USA) and others report in Circulation: Cardiovascular Quality and Outcomes that a regional multicentre quality improvement intervention significantly reduced the rate of contrast-induced acute kidney injury in patients undergoing non-emergent percutaneous coronary intervention (PCI). The authors report that the intervention could prevent acute kidney injury in one in five PCI patients.
Brown et al report that contrast-induced acute kidney injury occurs in 3–14% of patients undergoing PCI and that the complication is associated with “an increased risk of cardiovascular events, prolonged hospitalisation, end-stage renal disease, all-cause mortality and increased acute care costs of US$7,500 per case.” They add that despite guidelines to reduce the incidence of acute kidney injury, preventive measures have “been applied inconsistently in US hospitals with more than five-fold variability in the adjusted rates of contrast-induced acute kidney injury”. Therefore, the authors evaluated whether a multicentre continuous quality improvement intervention could reduce the incidence of acute kidney injury in PCI patients across eight US hospitals.
Of 10 hospitals in The Northern New England Cardiovascular Disease Study Group, eight agreed to participate in the study and two did not (and subsequently acted as controls). Of the eight that agreed, two were identified as “benchmark sites” for reducing the incidence of acute kidney injury and their experience was used to inform the intervention—they did not participate in the study, leaving six hospital in the intervention group. Brown et al explain that the intervention included forming multidisciplinary team (including interventional cardiologists and nephrologists), participating in monthly conference calls facilitated by a microsystems quality improvement coach, and participating in a process of identifying best practice through formal review of the literature and structured interviews with the benchmark sites.
The authors note: “The rate of contrast-induced acute kidney injury, adjusted for case mix, was significantly reduced in the six interventional hospitals from 6.7% during the baseline period to 5.4% during the intervention period (p=0.005).” Furthermore, after adjustment for known confounders, intervention hospitals saw a significant 21% reduction in acute kidney injury for all patients (p=0.005) and saw a significant 28% reduction in patients with baseline estimated glomerular filtration rate <60mL/min per 1.73m2 (p=0.007). There were no significant differences in the rate of acute kidney injury in either the control hospitals or in the benchmark sites.
“Simple cost-effective hospital quality improvement intervention can prevent contrast-induced acute kidney injury in one in five patients undergoing non-emergent PCI and in one in four patients with baseline chronic kidney disease,” Brown et al note. They add the key attributes associated with improvement efforts reported by hospital teams included the development of multidisciplinary teams with clinical champions, standardisation of fluid protocols, decreasing nothing by mouth length from 12 to two to four hours, patient education to self-hydrate, and minimising contrast volume during the procedure.
Brown said: “Our regional success was really about hospital team talking and innovating with one another. Instead of competing with one another in similar healthcare markets, they shared their data, protocols, and ideas resulting in simple homegrown, easy to do solutions that improved patient safety across the region.”