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An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial

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

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Anna Casula

Laura Lamming

John Stoves

Yohan Samarasinghe

Andrew J. Lewington

Russell Roberts

Nikunj Shah

Melanie Johnson

Natalie Jackson

Carol Jones

Erik Lenguerrand

Eileen McDonach

Richard J. Fluck

Mohammed A. Mohammed

Fergus J. Caskey


Background Variable standards of care may contribute to poor outcomes associated with AKI. We evaluated
whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program)
would improve delivery of care and patient outcomes at an organizational level.
Methods A multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals,
involving patients with AKI aged$18 years. The intervention was introduced sequentially across fixed three-month
periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was
30-day mortality,withpre-specifiedsecondaryendpointsandanestedevaluationof careprocessdelivery.Thenature
of the intervention precluded blinding, but data collection and analysiswere independent of project delivery teams.
Results We studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference
between control and intervention periods. Hospital length of stay was reduced with the intervention
(decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased
and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment
of process measures in 1048 patients showed improvements in several metrics including AKI recognition,
medication optimization, and fluid assessment.
Conclusions A complex, hospital-wide intervention to reduce harm associated with AKI did not reduce
30-day AKImortality but did result in reductions in hospital length of stay, accompanied by improvements
in in quality of care. An increase in AKI incidence likely reflected improved recognition


Selby, N. M., Casula, A., Lamming, L., Stoves, J., Samarasinghe, Y., Lewington, A. J., …Caskey, F. J. (2019). An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial. Journal of the American Society of Nephrology, 30(3), 505-515.

Journal Article Type Article
Acceptance Date Jan 11, 2019
Online Publication Date Feb 21, 2019
Publication Date 2019-03
Deposit Date Apr 8, 2019
Publicly Available Date Apr 9, 2019
Journal Journal of the American Society of Nephrology
Print ISSN 1046-6673
Electronic ISSN 1533-3450
Publisher American Society of Nephrology
Peer Reviewed Peer Reviewed
Volume 30
Issue 3
Pages 505-515
Keywords Nephrology; General Medicine
Public URL
Publisher URL


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