Interventions, Barriers, and Proposed Solutions Associated With the Implementation of a Protocol That Uses Clinical Decision Support and a Stress Biomarker Test to Identify ICU Patients at High-Risk for Drug Associated Acute Kidney Injury. Issue 4 (April 2023)

• Record Type: Journal Article
• Authors: Williams, Victoria L.; Smithburger, Pamela L.; Imhoff, Allison N.; Groetzinger, Lara M.; Culley, Colleen M.; Burke, Clayton X.; Murugan, Raghavan; Lamberty, Phillip E.; Mahmud, Mujtaba; Benedict, Neal J.; Kellum, John A.; Kane-Gill, Sandra L.
• Is Part Of: Annals of pharmacotherapy. Volume 57:Issue 4(2023)
• Page Start: 408
• Page End: 415
• Publication Date: 2023-04
• Subjects: acute kidney injury -- biomarkers -- tissue inhibitor of metalloproteinase-2-insulin-like growth factor-binding protein 7 -- clinical decision support systems -- implementation -- medication safety; Chemotherapy -- Periodicals; Pharmacology -- Periodicals; 615.5805
• DOI: 10.1177/10600280221117993
• Languages: English
• ISSNs: 1060-0280

Abstract

Background: Damage biomarkers are helpful in early identification of patients who are at risk of developing acute kidney injury (AKI). Investigations are ongoing to identify the optimal role of stress/damage biomarkers in clinical practice regarding AKI risk prediction, surveillance, diagnosis, and prognosis. Objective: To determine the impact of utilizing a clinical decision support system (CDSS) to guide stress biomarker testing in intensive care unit (ICU) patients at risk for drug-induced acute kidney injury (D-AKI). Methods: A protocol was designed utilizing a clinical decision support system (CDSS) alert to identify patients that were ordered 3 or more potentially nephrotoxic medications, suggesting risk for progressing to AKI from nephrotoxic burden. Once alerted to these high-risk patients, the pharmacist determined if action was needed by ordering a stress biomarker test, tissue inhibitor of metalloproteinase-2-insulin-like growth factor-binding protein 7 (TIMP-2IGFBP7). If the biomarker test result was elevated, the pharmacist provided nephrotoxin stewardship recommendations to the team. Pharmacists recorded the response to the clinical decision support alert, ordering, and interpreting the TIMP-2IGFBP7, and information regarding clinical interventions. An alert in conjunction with TIMP-2IGFBP7 as a strategy for AKI risk prediction and stimulant for patient care management was assessed. In addition, barriers and solutions to protocol implementation were evaluated. Results: There were 394 total activities recorded by pharmacists for 345 unique patients. Ninety-three (93/394; 23.6%) actionable alerts resulted in a TIMP-2IGFBP7 test being ordered. Thirty-one TIMP-2IGFBP7 results were >0.3 (31/81; 38.3%), suggesting a high-risk of progression to AKI, which prompted 191 pharmacist/team interventions. On average, there were 1.64 interventions per patient in the low-risk patients, 3.43 in high-risk patients, and 3.75 in the highest-risk patients. Conclusion and Relevance: Stress biomarkers can be used in conjunction with CDSS alerts to affect therapeutic decisions in ICU patients at high-risk for D-AKI.