Plan: Hospital acquired acute kidney injury (AKI) is usually due to multiple causes (nephrotoxic medications, hypotension, etc), and renal obstruction is rarely the cause in patients without risk factors (pelvic mass, renal stone, and others). Evaluation of 100 inpatient renal US in our hospital performed for AKI revealed that 90% were negative for obstruction, and no patient had obstruction requiring an intervention. To safely reduce ordering of renal US for inpatients with AKI, we created an alert to fire when an abdominal US is ordered within 72 hours of an abdominal CT.
Do: Developed in collaboration with the nephrology department. Medicine and surgery faculty were informed by email and asked to disseminate the information to their faculty and house staff.
- Inclusion criteria: adults inpatients with abdomen CT performed within 72 hours
- Exclusion criteria for alert: pediatric, oncology and transplant patients
- Allowable acknowledgement reasons to proceed with the order
- radiologist recommended
- evaluate gallbladder
- evaluate vasculature as CT was noncontrast
- transplant patient
- paracentesis mark
- relevant intervention since CT (nephrostomy tube…)
- Other: specify in comments
Effectiveness in reducing orders: 16%
Study: Data analysis during the study phase of the initiative revealed that US added value for patients with suspected gallbladder disease, but was generally not useful for patients with normal kidneys and no existing pathology that could cause renal obstruction on CT, in the absence of an intervening procedure. For US orders that were canceled, chart review revealed that no value would have been added by performing the exam.
Lessons learned (Act): This initiative requires broad education of house staff and nephrology teams, to overcome the long-standing practice of automatically ordering or recommending renal US in patients with hospital acquired AKI. Lectures on imaging appropriateness were delivered to internal medicine house staff, and medicine chief residents were engaged in the project in January 2019.