Determining the Incidence of Drug-Associated Acute Kidney Injury in Nursing Home Residents

doi:10.1016/j.jamda.2014.03.014

Journal of the American Medical Directors Association

Volume 15, Issue 10, October 2014, Pages 719-724

https://doi.org/10.1016/j.jamda.2014.03.014 Get rights and content

Abstract

Objective

Although acute kidney injury (AKI) is well studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, or End-Stage kidney disease) criteria in NH residents.

Design/Setting/Participants/Measurements

We conducted a retrospective study between February 9, 2012, and February 8, 2013, for all residents at 4 UPMC NHs located in southwest Pennsylvania. The TheraDoc™ Clinical Surveillance Software System, which monitors laboratory and medication data and fires alerts when patients have a sufficient increase in serum creatinine, was used for automated case detection. An increase in serum creatinine in the presence of an active medication order identified to potentially cause AKI triggered an alert, and drug-associated AKI was staged according to the RIFLE criteria. Data were analyzed by frequency and distribution of alert type by risk, injury, and failure.

Results

Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, and the mean age was 74.2 years. Using the total number of alerts (n = 668), the rate of drug-associated AKI was 0.41 events per 100 resident-days. Based on the RIFLE criteria, there were 191, 70, and 44 residents who were classified as AKI risk, injury, and failure, respectively. The most common medication classes included in the AKI alerts were diuretics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs), and antibiotics.

Conclusion

Drug-associated AKI was a common cause of potential adverse drug events. The vast majority of cases were related to the use of diuretics, ACEIs/ARBs, and antibiotics. Future studies are needed to better understand patient, provider, and facility risk factors, as well as strategies to enhance the detection and management of drug-associated AKI in the NH.

Section snippets

Study Design

We conducted our study within UPMC Senior Communities, which is the largest long-term care organization in southwestern Pennsylvania, as well as the largest nationally that is part of an integrated health care delivery system. UPMC Senior Communities has approximately 2500 beds, of which 752 are located in the NH setting. There are 6 UPMC NHs, all of which are nonprofit, academically affiliated, and not part of a national chain. Four of the 6 NHs (2 urban and 2 suburban) have the same health

Results

Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, and the mean ± SD age was 74.2 ± 14.0 years. The baseline SCr was 0.90 ± 0.64 mg/dL. During the study period, there were a total of 1475 admissions, providing 188,426 resident-days with an average length of stay of 75 days. The average length of stay for each of the 4 individual NHs was 69, 90, 92, and 120 days.

Using the total number of alerts (n = 668), the rate of drug-associated AKI among these residents

Discussion

To the best of our knowledge, this is the first study to determine the incidence of drug-associated AKI by using a validated set of diagnostic and staging criteria in the NH. We found a total of 668 drug-associated AKI alerts associated with 249 unique residents for an incidence rate of 0.41 cases per 100 resident-days. In other words, among those residents with a length of stay of 100 days, 34% would be expected to have had at least one drug-associated AKI event during their stay. Comparing

Conclusion

This is the first study that assessed the incidence of drug-associated AKI in NHs. Based on our analysis, drug-associated AKI was a common cause of potential ADEs. The vast majority of the cases were related to the use of diuretics, ACEI/ARBs, and antibiotics. Future studies are needed to better understand patient, provider, and facility risk factors, as well as strategies to enhance the detection and management of drug-associated AKI in the NH.

Funding Sources

The project described was supported by the National Institutes of Health through Grant Numbers UL1 RR024153 and UL1TR000005.

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Medication Holds in CKD During Acute Volume-Depleting Illnesses: A Randomized Controlled Trial of a “Sick-Day” Protocol
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Citation Excerpt :
Although there are reports examining the epidemiology of hospitalized-acquired AKI,4,9 determining the incidence of AKI among community dwellers has been challenging and ranges from 100-500 cases of nondialysis-requiring AKI per million community dwellers, with dialysis-requiring AKI about 10-fold less common.8,10 Drugs are implicated in ≥20% incidents of AKI, especially among the elderly, with NSAIDs and RAAS blockers the most prominent potential causative agents.2-4 Hypotension with RAAS blockers is more common than expected among elderly individuals submitting to 24-hour blood pressure monitoring,11 and AKI is not infrequent among nursing home patients treated with RAAS blockers.2
Some drugs prescribed for chronic kidney disease (CKD) may become hazardous on sick days with volume depletion by increasing the risk of acute kidney injury (AKI) and kidney function loss; however, the risks and benefits of their use during intercurrent illness is unknown.
6-month pragmatic trial examining a sick-day protocol to determine if withholding prespecified drugs during a volume-depleting illness reduces the incidence AKI or kidney function loss in CKD.
315 veterans with stage 3-5 CKD, treated with a renin-angiotensin-aldosterone inhibitor blocker, diuretic, nonsteroidal anti-inflammatory drug, or metformin were randomized into the study with n = 159 and n = 156 in sick-day protocol and usual care groups, respectively.
Sick-day protocol administered via interactive voice response system (IVRS) or usual care with 6-month follow-up.
The outcomes of the study are as follows: (1) Change in kidney function, (2) incidence of AKI based on International Classification of Diseases, Tenth Revision codes and ambulatory laboratory testing, (3) urgent service utilizations, and (4) sick days.
The mean age was 70.1 ± 7.4 and 69.2 ± 8.1 years, with a mean baseline glomerular filtration rate (GFR) of 43.1 ± 13.1 and 43.8 ± 13.0 mL/min/1.73 m², and 112 (70%) and 100 (64%) of participants with diabetes in the sick-day protocol and usual care groups, respectively. The mean change in GFR in the sick-day protocol and usual care groups from baseline to 6-month follow-up, adjusting for baseline GFR, was −0.71 (95% CI, −2.11 to 0.69) and −0.72 (95% CI, −2.12 to 0.68), respectively, with no significant difference, P = 0.99. Hospitalizations in the sick-day protocol and usual care groups were 11.5/100 and 8.4/100 events per person-months, respectively, with the adjusted rate ratio not significantly increased (prevalence ratio, 1.30; 95% CI, 0.96-1.76). Participants interacted with the IVRS in 81% of expected weeks and 19 had one or more qualifying events. In 33 true sick days, participants correctly followed the protocol in only 14.
Low incidence of sick days over the 6-month period of the study.
The sick-day protocol was not associated with a significant reduction in AKI episodes or kidney function loss in a high-risk CKD population. Engagement with the IVRS was high, but successful implementation of the sick-day protocol was not optimal.
ClinicalTrials.gov; NCT03141905.
APRN-Conducted Medication Reviews for Long-Stay Nursing Home Residents
2018, Journal of the American Medical Directors Association
As part of the Missouri Quality Initiative (MOQI) to reduce hospitalizations for long-stay nursing home residents, this article describes reasons MOQI advanced practice registered nurses (APRNs) recommended medication order changes as part of their medication review process as well as the outcomes of their recommendations.
Cross-sectional descriptive study of MOQI APRN-conducted medication reviews.
Long-stay nursing homes participating in the MOQI project.
Seventeen MOQI APRNs recorded medication reviews for 3314 long-stay residents residing in 16 Midwestern nursing homes over a 2-year period.
APRNs conducted medication reviews and made recommendations for medication order changes to residents' medical providers.
The MOQI medication review database was used to abstract data.
There were 19,629 medication reviews recorded for 3314 residents during the 2-year period. Of the 19,629 reviews, 50% (n = 9841) resulted in recommended order changes of which 82% (n = 8037) of order changes occurred. More than two-thirds of recommendations were because of changes in the residents' plans of care. Other recommendations included adjusting and/or discontinuing medications that had the potential for harm.
Resident care needs are dynamic, resulting in the need for frequent medication order changes. MOQI APRNs, because of their advanced pharmacological education and daily presence in the nursing home, are uniquely positioned to ensure residents' medications aligned with their overall goals of care while minimizing risk of harm.
Comprehensive Literature Review of Factors Influencing Medication Safety in Nursing Homes: Using a Systems Model
2017, Journal of the American Medical Directors Association
Citation Excerpt :
Acute kidney injury (AKI) and falls are also frequent ADEs in NHs. A study examining data available for 4 NHs found the medications associated with AKI alerts were diuretics, ACEIs/angiotensin II receptor blockers, and antibiotics.70 An Italian study found a fall incidence of 1.38 per 100 resident-months, and 48.1% of these falls resulted in injuries.
The objectives of this review were to identify the work system factors influencing medication safety measures [adverse drug events (ADEs), adverse drug reactions, or medication errors (MEs)], to determine the incidence of ADEs, and describe the most common ADEs in nursing homes (NHs).
A comprehensive literature review was conducted using PubMed and CINAHL to identify studies investigating factors that influence ADEs, adverse drug reactions, and MEs in NHs and skilled nursing facilities. An initial search identified related studies over 3 decades (1985-2016). Studies were classified according to Systems Engineering Initiative for Patient Safety model factors.
Sixty studies were included in this review, which identifies 5 categories of work system factors affecting medication safety in NHs: persons (resident and staff), organization, tools and technology, tasks, and environment. The personal characteristics of NH residents included age, number and types of scheduled medications, and number and types of comorbidities. In addition, inadequate nursing staff medication knowledge and training are usually associated with administration MEs. Organizational factors include interprofessional collaboration, physician and pharmacist accessibility, and staff/resident ratio. A high staff number plays an essential role in preventing MEs and fracture incidents. The technology (barcode medication system) and tools (ME-reporting systems, ADE trigger tool, and potentially inappropriate medication criteria) can enhance the detection of MEs and ADEs. Workload and time pressure negatively impact NH staff task performance. Use of an ADE trigger tool by healthcare providers enhanced the ability to identify ADEs more than 50-fold over 6 months. Several environmental characteristics such as staff distraction and interruption negatively influence medication safety in NHs. The incidence rates of ADEs in NHs ranged from 1.89 to 10.8 per 100 resident-months. The most common ADEs were bleeding, thromboembolic events, hypoglycemia, falls, and constipation.
The Systems Engineering Initiative for Patient Safety model is a useful framework for investigating the factors contributing to ADEs. Multiple work-system factors affect the medication safety of NH residents. A comprehensive study is needed to quantify the influence of various work-system factors on ADEs in NHs.
Ensuring Patient Safety During the Transition to ESRD
2017, Seminars in Nephrology
Citation Excerpt :
Common conditions under which the kidney is dependent on autoregulation to maintain renal plasma flow and GFR include congestive heart failure (CHF), active diuresis, and systemic illness with attendant volume depletion, and, at times, hypotension.52 Periods of hypotension with RAAS blocker treatment are more common than expected among the elderly subjects submitted to 24-hour blood pressure monitoring,53 and AKI of all stages of severity are not infrequent among nursing-home patients treated with RAAS blockers.54 AKI is more common among patients treated with RAAS blockers when exposed to high summer temperatures and subject to volume depletion.55
Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission
2016, Journal of the American Medical Directors Association
Citation Excerpt :
First, more intensive monitoring of these patients during the first 48 hours to 7 days after SNF admission may help identify changes in condition early enough to intervene before hospital transfer is necessary. This might include more frequent routine vital signs (including weight in patients with CHF and pulse oximetry in patients at risk for hypoxia), having direct care staff and families complete the INTERACT Stop and Watch Early Warning Tool (or a similar tool) every shift (as opposed to reactively), and specific monitoring for common high-risk adverse events in this patient population, including volume depletion (for patients on diuretics and/or with poor oral intake), bleeding (for those on warfarin and other anticoagulants), and hypo- or hyperglycemia in diabetics.26 In addition to these monitoring strategies, more frequent on-site clinician visits may be warranted during this time period.
Close to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF.
To describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs.
Trained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.
SNFs from across the United States.
64 of 88 SNFs randomized to the intervention group submitted RCAs.
SNFs were implementing the INTERACT quality improvement program.
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Among 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital.
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View all citing articles on Scopus

: This study was funded by the Agency for Healthcare Research and Quality (R01HS018721), the National Institute on Aging (R01AG027017, P30AG024827, K07AG033174), the National Institute of Diabetes, Digestive, and Kidney Diseases (R01DK083961), and a Centers for Medicare and Medicaid Services Cooperative Agreement/Health Care Innovation Award (1E1CMS331081-01-00). The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality or any of the other funding sources.

: The authors declare no conflicts of interest.

View full text

Original StudyDetermining the Incidence of Drug-Associated Acute Kidney Injury in Nursing Home Residents

Abstract

Objective

Design/Setting/Participants/Measurements

Results

Conclusion

Section snippets

Study Design

Results

Discussion

Conclusion

Funding Sources

Clin Geriatr Med

Lancet

Kidney Int

Am J Kidney Dis

Kidney Int

J Am Med Dir Assoc

Clin Geriatr Med

Am J Kidney Dis

Acute renal failure: Definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group

Crit Care

An assessment of the RIFLE criteria for acute renal failure in hospitalized patients

Crit Care Med

RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: A cohort analysis

Crit Care

North East Italian prospective hospital renal outcome survey on acute kidney injury (NEiPHROS-AKI). Targeting the problem with the RIFLE criteria

Clin J Am Soc Nephrol

Incidence and outcomes in acute kidney injury: A comprehensive population-based study

J Am Soc Nephrol

Costs and outcomes of acute kidney injury (AKI) following cardiac surgery

Nephrol Dial Transplant

Five-year outcomes of severe acute kidney injury requiring renal replacement therapy

Nephrol Dial Transplant

Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery

Circulation

Baseline creatinine to define acute kidney injury: Is there any consensus?

Nephrol Dial Transplant

Challenges of defining acute kidney injury

QJM

Consensus guidelines for oral dosing of primarily renally cleared medictions in older adults

J Am Geriatr Soc

Utility of an adverse drug event trigger tool in Veterans Affairs nursing facilities

Consult Pharm

Effect of computer-based alerts on the treatment and outcomes of hospitalized patients

Arch Intern Med

Original Study
Determining the Incidence of Drug-Associated Acute Kidney Injury in Nursing Home Residents