Effect of Tiered Implementation of Clinical Decision Support System for Acute Kidney Injury and Nephrotoxin Exposure in Cardiac Surgery Patients

Background Nephrotoxin exposure may worsen kidney injury and impair kidney recovery if continued in patients with acute kidney injury (AKI). Objectives This study aimed to determine if tiered implementation of a clinical decision support system (CDSS) would reduce nephrotoxin use in cardiac surgery patients with AKI. Methods We assessed patients admitted to the cardiac surgery intensive care unit at a tertiary care center from January 2020 to December 2021, and August 2022 to September 2023. A passive electronic AKI alert was activated in July 2020, followed by an electronic nephrotoxin alert in March 2023. In this alert, active nephrotoxic medication orders resulted in a passive alert, whereas new orders were met with an interruptive alert. Primary outcome was discontinuation of nephrotoxic medications within 30 hours after AKI. Secondary outcomes included AKI-specific clinical actions, determined through modified Delphi process and patient-centered outcomes. We compared all outcomes across five separate eras, divided based on the tiered implementation of these alerts. Results A total of 503 patients met inclusion criteria. Of 114 patients who received nephrotoxins before AKI, nephrotoxins were discontinued after AKI in 6 (25%) patients in pre AKI-alert era, 8 (33%) patients in post AKI-alert era, 7 (35%) patients in AKI-alert long-term follow up era, 7 (35%) patients in pre nephrotoxin-alert era, and 14 (54%) patients in post nephrotoxin-alert era ( p = 0.047 for trend). Among AKI-specific consensus actions, we noted a decreased use of intravenous fluids, increased documentation of goal mean arterial pressure of 65 mm Hg or higher, and increased use of bedside point of care echocardiogram over time. Among exploratory clinical outcomes we found a decrease in proportion of stage III AKI, need for dialysis, and length of hospital stay over time. Conclusion Tiered implementation of CDSS for recognition of AKI and nephrotoxin exposure resulted in a progressive improvement in the discontinuation of nephrotoxins.