RESUMO
OBJECTIVE: This study aims to use and evaluate the Nephrotoxic Injury Negated by Just-in-time Action (NINJA) program in hospitalized patients with cystic fibrosis (CF) at Children's Healthcare of Atlanta. METHODS: This was a single-center study evaluating patients with CF who were hospitalized and admitted to the pulmonary service 4 months pre- and post-NINJA implementation. Postimplementation patients with high nephrotoxic medication (NTMx) exposure were identified using an electronic reporting tool that triggered the pharmacist to alert the medical team and recommend Monday/Wednesday/Friday serum creatinine (SCr) monitoring. High NTMx exposure was defined as 3 or more NTMxs given concurrently, or at least 3 consecutive days of IV aminoglycosides or vancomycin. Outcomes assessed were rate of SCr monitoring, NTMx exposure, and days of acute kidney injury (AKI) pre- and post-NINJA implementation. RESULTS: A total of 19 patients and 25 high-NTMx exposures were identified both pre- and post-NINJA implementation. The SCr monitoring increased from 13% to 50% of NTMx exposure days in the pre- versus post-NINJA time frame. More NTMx exposure days occurred in the post-NINJA time frame, from 250 exposure days per 1000 patient days pre-NINJA to 521 post-NINJA. An increased incidence of AKI events and AKI days were noted post-implementation; however, these differences were not significantly different between the 2 groups. CONCLUSIONS: Increased SCr monitoring for patients with NTMx exposure using NINJA uncovered more episodes of AKI. Increased prevalence of NTMx use was associated with increased rates of AKI. Increased SCr monitoring as a result of NINJA implementation may allow for earlier detection of AKI.
RESUMO
BACKGROUND: Children on the ketogenic diet must limit carbohydrate intake to maintain ketosis and reduce seizure burden. Patients on ketogenic diet are vulnerable to harm in the hospital setting where carbohydrate-containing medications are commonly prescribed. We developed clinical decision support to reduce inappropriate prescription of carbohydrate-containing medications in hospitalized children on ketogenic diet. METHODS: A clinical decision support alert was developed through formative and summative usability testing. The alert warned prescribers when they entered an order for a carbohydrate-containing medication in patients on ketogenic diet. The alert was implemented using a quasi-experimental design with sequential crossover from control to intervention at two tertiary care pediatric hospitals within a single health system. The primary outcome was carbohydrate-containing medication orders per patient-day. RESULTS: During the study period, there were 280 ketogenic diet patient admissions totaling 1219 patient-days. The carbohydrate-containing medication order rate declined from 0.69 to 0.35 orders per patient-day (absolute rate reduction 0.34, 95% confidence interval 0.25-0.43), corresponding to 256 inappropriate orders prevented. The alert fired 398 times and was accepted (i.e., the order was removed) 227 times for an overall acceptance rate of 57%. CONCLUSIONS: Implementation of a clinical decision support alert at order-entry resulted in a sustained reduction in carbohydrate-containing medication orders for hospitalized patients on ketogenic diet without an increase in alert burden. Clinical decision support developed with user-centered design principles can improve patient safety for children on ketogenic diet by influencing prescriber behavior.
