Do you enjoy receiving pop-up alerts from your electronic health record? Have you instinctively memorized the fastest series of clicks to “Ignore”? “Not Clinically Significant”? “Benefit Outweighs Risk”? “Not Sepsis”?
How would you like your EHR to call you at home with more of the same?
Acute kidney injury, to be certain, is associated with poorer outcomes in the hospital – mortality, dialysis-dependence, and other morbidities. Therefore, it makes sense – if an automated monitoring system can easily detect changes and trends, why not alert clinicians to such changes, and nephrotoxic therapies could be avoided.
Interestingly – for both good and bad – the outcomes measured were patient-oriented, randomizing 2393 patients to either “usual care” or text message alerts for changes in serum creatinine. The goal, overall, was detection of reductions in death, dialysis, or progressive AKI. While patient-oriented outcomes are, after all, the most important outcomes in medicine – it’s only plausible to improve outcomes if clinicians improve care. Therefore, measuring the most direct consequence of the intervention might be a better outcome – renal-protective changes in clinician behavior.
Because, unfortunately, despite sending text messages and e-mails directly to responsible clinicians and pharmacists – the only notable change in behavior between the “alert” group and “usual care group” was increased monitoring of serum creatinine. Chart documentation of AKI, avoidance of intravenous contrast, avoidance of NSAIDs, and other renal-protective behaviors were unchanged, excepting a non-significant trend towards decreased aminoglycoside use.
No change in behavior, no change in outcomes. Text messages and e-mails alerts! Can shock collars be far behind?
“Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60266-5/fulltext