An Organisational Level Programme of Intervention for AKI: A Pragmatic Stepped-Wedge Cluster Randomised Trial

Nicholas Selby, Anna Casula, Laura Lamming, John Stoves, Yohan Samarasinghe, Lewington Andrew, Russell Roberts, Nikunj Shah, Melanie Johnson, Natalie Jackson, Carol Jones, Erik Lenguerrand, Eileen McDonach, Richard Fluck, Mohammed A Mohammed, Fergus Caskey

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Background: Variable standards of care may contribute to poor outcomes associated with acute kidney injury (AKI). We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle and an education programme) would improve delivery of care and patient outcomes.

Methods: A multi-centre, pragmatic, stepped-wedge cluster randomised trial (SWCRT) was performed in five UK hospitals. The intervention was introduced sequentially across fixed three-month periods until all hospitals were exposed. The intervention schedule was randomly determined. All patients with AKI aged ≥18 years were included. The primary outcome was 30-day mortality, with pre-specified secondary endpoints and a nested evaluation of care process delivery. The nature of the intervention precluded blinding, but data collection and analysis were independent of project delivery teams.

Findings: 24,059 AKI episodes were studied. Overall 30-day mortality was 24.5%, with no difference between control and intervention periods (OR 1.04, 95% CI 0.91-1.21). Hospital length of stay (LoS) was reduced with the intervention (-0.2days (95% CI -0.5 to 0.1), -0.7days (-1.3 to -0.2) and -1.3days (-2.5 to -0.2) at the 0.3, 0.5 and 0.7 quantiles respectively). AKI incidence increased (adjusted incidence rate ratio 1.12, 95% CI 1.03-1.22) with a parallel increase in the proportion of patients with a coded diagnosis of AKI. Process measures were assessed in 1048 patients, with improvements seen in several metrics including AKI recognition, medication optimisation and fluid assessment.

Conclusions: A complex, hospital-wide intervention to reduce harm associated with AKI did not alter 30-day AKI mortality but did result in reductions in LoS, accompanied by improvements in in quality of care. AKI incidence increased, likely reflecting improved recognition.
Original languageEnglish
Pages (from-to)505-515
Number of pages11
JournalJournal of the American Society of Nephrology
Issue number3
Early online date28 Feb 2019
Publication statusPublished - Mar 2019


  • acute renal failure
  • clinical nephrology
  • e-alert
  • care bundle
  • education
  • AKI


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