Australian researchers have called for improved recognition and management of AKI in hospitalised patients after finding less than half of inpatients with creatinine values consistent with an AKI received a coded diagnosis in the medical record.
Writing in the Internal Medicine Journal [link here], the researchers said under-coding was a surrogate for under-recognition and therefore represented a potential missed opportunity to intervene.
Associate Professor Craig Nelson
“Under-coding of AKI in the medical record also has important implications for ongoing care. When the AKI event is not documented in the discharge summary, the general practitioner is not informed and is therefore unaware of the increased CKD risk and requirement for ongoing CKD risk assessment and monitoring.”
The retrospective study comprised data extracted from the EMR on all adult patients admitted for more than 24 hrs to a medical or surgical unit at a tertiary hospital in Melbourne and who had a creatinine measurement during a six month period between 1 March 2023 and 31 August 2023.
In 12,543 relevant hospital admissions, the incidence of AKI was 22.9% of which 77.4% were KDIGO stage 1, 15.4% were stage 2, and 7.0% were stage 3.
Patients with AKI were typically older than the overall cohort (71 v 65 yrs) and had higher rates of cardiovascular disease (12.6% v 8.9%), diabetes (41.8% v 25.6%) and CKD (21.0% v 3.9%).
However the study found only 43.8% of the patients with creatinine levels consistent with AKI had a coded diagnosis of AKI in the medical record.
Coding of AKI was more likely in patients with more severe AKI – 36.7% in stage 1, 60.4% in stage 2 and 85.7% in stage 3.
The study found fewer than one in five (16.7%) patients referred for nephrology review had all aspects of AKI care initiated within one calendar day of meeting AKI criteria.
“Repeat serum creatinine testing was completed in most cases (93.3%), followed by AKI documentation in the medical records (83.3%), urinary studies with either a dip stick or formal urinalysis (76.7%), medication review (69.2%) and a bladder scan or renal tract imaging (65.8%),” the study said.
“Fluid balance review (48.3%) and fluid balance charting (40.0%) were the least frequently initiated aspects of care.”
Yet AKI was significantly associated with longer length of hospital stay and increased mortality.
On the positive side, the study found most patients (82.1%) had the AKI event documented in the discharge summary.
Adequate communication regarding the reinitiation of medications with cardio-metabolic-kidney benefit was evident in 39.1% of patients.
The investigators, including director of nephrology at Western Health Associate Professor Craig Nelson, said EMR alerts were a potential strategy to improve recognition and care of patients with AKI.
And there was local data [link here] demonstrating that an electronic AKI alert, supported by a management guide and medical education for junior doctors, increased recognition of and documentation of AKI and decreased LOS in patients with stage 1 AKI.
“Further quality improvement programs and research, with a focus on improving recognition, management and outcomes, are essential in improving patient outcomes and may have economic benefits associated with decreased LOS and improved longer-term patient outcomes,” A/Prof Nelson and colleagues said.
They noted their cohort had a high representation of patients from culturally and linguistically diverse backgrounds, with about half (50.7%) born outside ANZ and representing 140 countries of origin.
Reflecting “…a group known to have unique challenges and access barriers in relation to health care”, overseas born patients were slightly overrepresented in the AKI group compared to no AKI (56.2% v 49.1%).