Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention

Abstract

Background: Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions.

Methods and results: We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67-0.93; P=0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate <60 mL/min per 1.73 m(2) (risk ratio, 0.72; 95% confidence interval: 0.56-0.91; P=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration.

Conclusions: Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.

Keywords: acute kidney injury; contrast media; percutaneous coronary intervention; quality improvement.

Conflict of interest statement

Disclosure Statement

All other authors have no conflicts of interest or financial information to disclose in relation to this research.

© 2014 American Heart Association, Inc.

Figures

Figure 1. Adjusted Rates of CI-AKI

Adjusted rates of contrast-induced acute kidney injury (CI-AKI) are plotted for baseline (blue) and the intervention (red) phases for intervention and benchmark hospitals. The graph is divided by all patients (left) and high-risk patients with eGFR2 to the right).

Figure 2. Adjusted Rates of CI-AKI Over Time

Adjusted rates of contrast-induced acute kidney injury (CI-AKI) is plotted by month stratified by intervention hospitals (red), benchmark hospitals (blue), and control hospitals (green) using interrupted time series analysis. The vertical dashed line represents the start of the quality improvement intervention.

Figure 3. Adjusted Rates of CI-AKI Over Time for patients with eGFR2)

Adjusted rates of contrast-induced acute kidney injury (CI-AKI) is plotted by month stratified by intervention hospitals (red), benchmark hospitals (blue), and control hospitals (green) using interrupted time series analysis. The vertical dashed line represents the start of the quality improvement intervention.