{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,18]],"date-time":"2025-11-18T01:33:23Z","timestamp":1763429603931,"version":"3.37.3"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,7,31]],"date-time":"2019-07-31T00:00:00Z","timestamp":1564531200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2019,7,31]],"date-time":"2019-07-31T00:00:00Z","timestamp":1564531200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["npj Digit. Med."],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>We developed a digitally enabled care pathway for acute kidney injury (AKI) management incorporating a mobile detection application, specialist clinical response team and care protocol. Clinical outcome data were collected from adults with AKI on emergency admission before (May 2016 to January 2017) and after (May to September 2017) deployment at the intervention site and another not receiving the intervention. Changes in primary outcome (serum creatinine recovery to \u2264120% baseline at hospital discharge) and secondary outcomes (30-day survival, renal replacement therapy, renal or intensive care unit (ICU) admission, worsening AKI stage and length of stay) were measured using interrupted time-series regression. Processes of care data (time to AKI recognition, time to treatment) were extracted from casenotes, and compared over two 9-month periods before and after implementation (January to September 2016 and 2017, respectively) using pre\u2013post analysis. There was no step change in renal recovery or any of the secondary outcomes. Trends for creatinine recovery rates (estimated odds ratio (OR)\u2009=\u20091.04, 95% confidence interval (95% CI): 1.00\u20131.08, <jats:italic>p<\/jats:italic>\u2009=\u20090.038) and renal or ICU admission (OR\u2009=\u20090.95, 95% CI: 0.90\u20131.00, <jats:italic>p<\/jats:italic>\u2009=\u20090.044) improved significantly at the intervention site. However, difference-in-difference analyses between sites for creatinine recovery (estimated OR\u2009=\u20090.95, 95% CI: 0.90\u20131.00, <jats:italic>p<\/jats:italic>\u2009=\u20090.053) and renal or ICU admission (OR\u2009=\u20091.06, 95% CI: 0.98\u20131.16, <jats:italic>p<\/jats:italic>\u2009=\u20090.140) were not significant. Among process measures, time to AKI recognition and treatment of nephrotoxicity improved significantly (<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001 and 0.047 respectively).<\/jats:p>","DOI":"10.1038\/s41746-019-0100-6","type":"journal-article","created":{"date-parts":[[2019,7,31]],"date-time":"2019-07-31T18:03:40Z","timestamp":1564596220000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":36,"title":["Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions"],"prefix":"10.1038","volume":"2","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0318-1049","authenticated-orcid":false,"given":"Alistair","family":"Connell","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hugh","family":"Montgomery","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Martin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claire","family":"Nightingale","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Omid","family":"Sadeghi-Alavijeh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dominic","family":"King","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alan","family":"Karthikesalingam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cian","family":"Hughes","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Trevor","family":"Back","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kareem","family":"Ayoub","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mustafa","family":"Suleyman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gareth","family":"Jones","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer","family":"Cross","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Stanley","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary","family":"Emerson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Charles","family":"Merrick","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Geraint","family":"Rees","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chris","family":"Laing","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rosalind","family":"Raine","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2019,7,31]]},"reference":[{"key":"100_CR1","unstructured":"KDIGO Clincial Practice Guidelines Work Group. Clinical practice guidelines for acute kidney injury. Kidney Int. Suppl. 2, 1\u2013138 (2012)."},{"key":"100_CR2","doi-asserted-by":"publisher","first-page":"1888","DOI":"10.1093\/ndt\/gfu082","volume":"29","author":"CJ Porter","year":"2014","unstructured":"Porter, C. J. et al. A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital. Nephrol. Dial. Transplant. 29, 1888\u20131893 (2014).","journal-title":"Nephrol. Dial. Transplant."},{"key":"100_CR3","doi-asserted-by":"publisher","first-page":"1362","DOI":"10.1093\/ndt\/gfu016","volume":"29","author":"M Kerr","year":"2014","unstructured":"Kerr, M., Bedford, M., Matthews, B. & O\u2019donoghue, D. The economic impact of acute kidney injury in England. Nephrol. Dial. Transplant. 29, 1362\u20131368 (2014).","journal-title":"Nephrol. Dial. Transplant."},{"key":"100_CR4","doi-asserted-by":"publisher","first-page":"174","DOI":"10.5414\/CN108153","volume":"81","author":"PJ Der Mesropian","year":"2014","unstructured":"Der Mesropian, P. J. et al. Long-term outcomes of community-acquired versus hospital-acquired acute kidney injury: a retrospective analysis. Clin. Nephrol. 81, 174\u2013184 (2014).","journal-title":"Clin. Nephrol."},{"key":"100_CR5","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000003674","volume":"95","author":"C-N Hsu","year":"2016","unstructured":"Hsu, C.-N. et al. Incidence, outcomes, and risk factors of community-acquired and hospital-acquired acute kidney injury: a retrospective cohort study. Medicine 95, e3674 (2016).","journal-title":"Medicine"},{"key":"100_CR6","doi-asserted-by":"publisher","first-page":"581","DOI":"10.7861\/clinmedicine.15-6-581","volume":"15","author":"A Connell","year":"2015","unstructured":"Connell, A. & Laing, C. Acute kidney injury. Clin. Med. 15, 581\u2013584 (2015).","journal-title":"Clin. Med."},{"key":"100_CR7","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1093\/qjmed\/hcs237","volume":"106","author":"E Aitken","year":"2013","unstructured":"Aitken, E. et al. Acute kidney injury: outcomes and quality of care. QJM 106, 323\u2013332 (2013).","journal-title":"QJM"},{"key":"100_CR8","doi-asserted-by":"publisher","first-page":"579","DOI":"10.1093\/qjmed\/95.9.579","volume":"95","author":"W Metcalfe","year":"2002","unstructured":"Metcalfe, W. et al. Acute renal failure requiring renal replacement therapy: incidence and outcome. QJM 95, 579\u2013583 (2002).","journal-title":"QJM"},{"key":"100_CR9","doi-asserted-by":"publisher","first-page":"813","DOI":"10.1001\/jama.294.7.813","volume":"294","author":"S Uchino","year":"2005","unstructured":"Uchino, S. et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294, 813\u2013818 (2005).","journal-title":"JAMA"},{"key":"100_CR10","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1159\/000337487","volume":"35","author":"HE Wang","year":"2012","unstructured":"Wang, H. E., Muntner, P., Chertow, G. M. & Warnock, D. G. Acute kidney injury and mortality in hospitalized patients. Am. J. Nephrol. 35, 349\u2013355 (2012).","journal-title":"Am. J. Nephrol."},{"key":"100_CR11","doi-asserted-by":"publisher","first-page":"1361","DOI":"10.1038\/ki.2011.42","volume":"79","author":"LS Chawla","year":"2011","unstructured":"Chawla, L. S., Amdur, R. L., Amodeo, S., Kimmel, P. L. & Palant, C. E. The severity of acute kidney injury predicts progression to chronic kidney disease. Kidney Int. 79, 1361\u20131369 (2011).","journal-title":"Kidney Int."},{"key":"100_CR12","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1093\/ckj\/sfw134","volume":"11","author":"JG Raimann","year":"2018","unstructured":"Raimann, J. G., Riella, M. C. & Levin, N. W. International Society of Nephrology\u2019s 0by25 initiative (zero preventable deaths from acute kidney injury by 2025): focus on diagnosis of acute kidney injury in low-income countries. Clin. Kidney J. 11, 12\u201319 (2018).","journal-title":"Clin. Kidney J."},{"key":"100_CR13","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1159\/000439146","volume":"131","author":"NM Selby","year":"2015","unstructured":"Selby, N. M., Hill, R. Fluck, R. J. NHS England \u2018Think Kidneys' AKI Programme. Standardizing the early identification of acute kidney injury: the NHS England National Patient Safety Alert. Nephron 131, 113\u2013117 (2015).","journal-title":"Nephron"},{"key":"100_CR14","doi-asserted-by":"publisher","first-page":"1966","DOI":"10.1016\/S0140-6736(15)60266-5","volume":"385","author":"FP Wilson","year":"2015","unstructured":"Wilson, F. P. et al. Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial. Lancet 385, 1966\u20131974 (2015).","journal-title":"Lancet"},{"key":"100_CR15","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0104758","volume":"9","author":"D Manawadu","year":"2014","unstructured":"Manawadu, D., Choyi, J. & Kalra, L. The impact of early specialist management on outcomes of patients with in-hospital stroke. PLoS ONE 9, e104758 (2014).","journal-title":"PLoS ONE"},{"key":"100_CR16","doi-asserted-by":"publisher","first-page":"252","DOI":"10.1016\/j.ahj.2011.11.012","volume":"163","author":"NK Boom","year":"2012","unstructured":"Boom, N. K., Lee, D. S. & Tu, J. V. Comparison of processes of care and clinical outcomes for patients newly hospitalized for heart failure attended by different physician specialists. Am. Heart J. 163, 252\u2013259 (2012).","journal-title":"Am. Heart J."},{"key":"100_CR17","unstructured":"National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. http:\/\/guidance.nice.org.uk\/CG169 (2013)."},{"key":"100_CR18","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1038\/ki.2014.328","volume":"87","author":"ME Thomas","year":"2015","unstructured":"Thomas, M. E. et al. The definition of acute kidney injury and its use in practice. Kidney Int. 87, 62\u201373 (2015).","journal-title":"Kidney Int."},{"key":"100_CR19","unstructured":"'Think Kidneys'. Reporting the rate of Acute Kidney Injury (AKI) within England \u2013 the current state of the NHS AKI Master Patient Index and Registry. https:\/\/www.thinkkidneys.nhs.uk\/aki\/wp-content\/uploads\/sites\/2\/2018\/03\/Reporting-the-rate-of-AKI-January-2018.pdf (2018)."},{"key":"100_CR20","doi-asserted-by":"publisher","first-page":"1483","DOI":"10.1007\/s11255-018-1836-7","volume":"50","author":"Y Wu","year":"2018","unstructured":"Wu, Y. et al. Value of electronic alerts for acute kidney injury in high-risk wards: a pilot randomized controlled trial. Int. Urol. Nephrol. 50, 1483\u20131488 (2018).","journal-title":"Int. Urol. Nephrol."},{"key":"100_CR21","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1053\/j.ajkd.2017.06.008","volume":"71","author":"S Park","year":"2018","unstructured":"Park, S. et al. Impact of electronic acute kidney injury (AKI) alerts with automated nephrologist consultation on detection and severity of AKI: a quality improvement study. Am. J. Kidney Dis. 71, 9\u201319 (2018).","journal-title":"Am. J. Kidney Dis."},{"key":"100_CR22","doi-asserted-by":"publisher","first-page":"pii: u219176.w7","DOI":"10.1136\/bmjquality.u219176.w7476","volume":"6","author":"L Ebah","year":"2017","unstructured":"Ebah, L. et al. A multifaceted quality improvement programme to improve acute kidney injury care and outcomes in a large teaching hospital. BMJ Qual. Improv. Rep. 6, pii: u219176.w7476 (2017).","journal-title":"BMJ Qual. Improv. Rep."},{"key":"100_CR23","doi-asserted-by":"publisher","first-page":"657","DOI":"10.1093\/qjmed\/hcx101","volume":"110","author":"T Chandrasekar","year":"2017","unstructured":"Chandrasekar, T. et al. A whole system approach to improving mortality associated with acute kidney injury. QJM 110, 657\u2013666 (2017).","journal-title":"QJM"},{"issue":"9","key":"100_CR24","doi-asserted-by":"publisher","first-page":"e13000","DOI":"10.1111\/ijcp.13000","volume":"71","author":"Dafydd Phillips","year":"2017","unstructured":"Phillips, D. et al. Seasonal pattern of incidence and outcome of acute kidney injury: a national study of Welsh AKI electronic alerts. Int. J. Clin. Pract. 71, e13000 (2017).","journal-title":"International Journal of Clinical Practice"},{"key":"100_CR25","unstructured":"DeepMind Health. How To Use Streams. (2017). https:\/\/support.deepmindhealth.com. Accessed 18 Oct 2018."},{"key":"100_CR26","unstructured":"London AKI Network. London AKI Network Guidelines. (2011). http:\/\/www.londonaki.net\/clinical\/guidelines-pathways.html. Accessed 23 July 2018."},{"key":"100_CR27","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-11-83","volume":"11","author":"SK Thygesen","year":"2011","unstructured":"Thygesen, S. K., Christiansen, C. F., Christensen, S., Lash, T. L. & S\u00f8rensen, H. T. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med. Res. Methodol. 11, 83 (2011).","journal-title":"BMC Med. Res. Methodol."},{"key":"100_CR28","unstructured":"Ministry of Housing, Communities & Local Government. English Indices of Deprivation. (2015). http:\/\/imd-by-postcode.opendatacommunities.org\/. Accessed 23 July 2018."},{"key":"100_CR29","doi-asserted-by":"publisher","first-page":"1033","DOI":"10.12688\/f1000research.11637.1","volume":"6","author":"A Connell","year":"2017","unstructured":"Connell, A. et al. Service evaluation of the implementation of a digitally-enabled care pathway for the recognition and management of acute kidney injury. F1000Res. 6, 1033 (2017).","journal-title":"F1000Res."},{"key":"100_CR30","doi-asserted-by":"publisher","first-page":"1853","DOI":"10.1093\/ndt\/gfv094","volume":"30","author":"S Sawhney","year":"2015","unstructured":"Sawhney, S. et al. Acute kidney injury\u2014how does automated detection perform? Nephrol. Dial. Transplant. 30, 1853\u20131861 (2015).","journal-title":"Nephrol. Dial. Transplant."},{"key":"100_CR31","unstructured":"R. Core Team. R: A Language and Environment for Statistical Computing (R Foundation for Statistical Computing, Vienna, 2017)."},{"key":"100_CR32","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-11-144","volume":"11","author":"GN Brock","year":"2011","unstructured":"Brock, G. N., Barnes, C., Ramirez, J. A. & Myers, J. How to handle mortality when investigating length of hospital stay and time to clinical stability. BMC Med. Res. Methodol. 11, 144 (2011).","journal-title":"BMC Med. Res. Methodol."},{"key":"100_CR33","unstructured":"NHS Health Research Authority. Is my study research? (2014). http:\/\/www.hra-decisiontools.org.uk\/research\/redirect.html. Accessed 23 Mar 2018."},{"key":"100_CR34","unstructured":"Royal Free London NHS Foundation Trust. Royal Free London publishes audit into Streams app. (2018). https:\/\/www.royalfree.nhs.uk\/news-media\/news\/royal-free-london-publishes-audit-into-streams-app\/. Accessed 18 Oct 2018."},{"key":"100_CR35","unstructured":"DeepMind. Scaling Streams with Google. (2018). https:\/\/deepmind.com\/blog\/scaling-streams-google\/. Accessed 21 Nov."},{"key":"100_CR36","unstructured":"NHS Digital. NHS Data Model and Dictionary Service. (2010). https:\/\/www.datadictionary.nhs.uk\/data_dictionary\/attributes\/attributes.asp. Accessed 14 Aug 2018."}],"container-title":["npj Digital Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41746-019-0100-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-019-0100-6","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-019-0100-6.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,17]],"date-time":"2022-12-17T18:30:28Z","timestamp":1671301828000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41746-019-0100-6"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,7,31]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2019,12]]}},"alternative-id":["100"],"URL":"https:\/\/doi.org\/10.1038\/s41746-019-0100-6","relation":{},"ISSN":["2398-6352"],"issn-type":[{"type":"electronic","value":"2398-6352"}],"subject":[],"published":{"date-parts":[[2019,7,31]]},"assertion":[{"value":"23 August 2018","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 February 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"31 July 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"C.L., H.M., G.R. and R.R. are paid clinical advisors to DeepMind. The clinical research fellowship of A.C. was part-funded by DeepMind, where he has been a full-time employee since May 2018. DeepMind remained independent from the collection and analysis of all data. C.L. was a member of the NICE clinical guideline 169 development group referenced in the article. H.M. co-holds a patent on a fluid delivery device which might ultimately help in preventing some (dehydration-related) cases of AKI occurring.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"67"}}