Building specific alerts into the electronic health record (EHR) can reduce the amount of contrast used during percutaneous coronary intervention (PCI) procedures, according to new findings published in Circulation: Cardiovascular Quality and Outcomes.[1] However, researchers noted, the impact may not be significant enough to reduce the risk of contrast-associated acute kidney injury (CA-AKI).
“Approximately 4.1 million invasive cardiac procedures are performed annually in the United States,” wrote first author Neal Yuan, MD, an assist professor at the University of California, San Francisco, and colleagues. “The majority require radiocontrast, which, when used in excess, has been associated with the development CA-AKI. Of these cardiac procedures, PCI is associated with some of the highest rates of CA-AKI, with up to 14% of all PCIs resulting in this complication.”
Yuan et al. built an alert into their institution’s EHR that displayed each PCI patient’s recommended contrast limit and strategies for minimizing the risk of CA-AKI. These alerts were automatically generated using existing data, so the clinician was not required to enter any additional details or make any calculations.
Several steps were taken to promote these alerts and explain their importance to employees, the researchers explained.
“Cardiologists were educated on the contrast limit tool during multiple information sessions held at the medical center’s weekly cardiac catheterization conference,” they wrote. “Catheterization laboratory staff were also provided education on the tool during morning staff huddles. Informational emails and fliers were also used. The tool was furthermore supported as one of the cardiology department’s major annual quality initiatives.”
Overall, data from more than 1,000 PCI procedures were included in the team’s analysis. While 508 procedures were performed before the alerts were put into place, acting as the study’s control group, an additional 531 procedures were performed once the alerts were up and running. The team also evaluated patient data from 15 other facilities that did not implement the EHR alert, providing additional context for its research.
Among high-risk PCI patients, the alerts were associated with a “small, but significant” decrease in the amount of contrast being used for these procedures. Among low-risk patients, however, there was no significant change.
Also, the team found, eight of 10 clinicians studied during this analysis saw their use of contrast when treating modifiable- or high-risk patients decrease as a result of the implemented change.
Despite this evidence of improved quality, the authors found no evidence of lower CA-AKI rates for low-, modifiable- or high-risk PCI patients. There was also not a significant decrease in the odds that a clinician would exceed the recommended contrast limit during a PCI procedure.
The team also surveyed interventional cardiologists about CA-AKI after PCI, noting that 75% of respondents believed this was a “serious problem.” Despite skepticism early on, a post-intervention survey found that 80% of clinicians paid attention to the alert-generated contrast limits when making PCI-related decisions. Also, the alerts were generally appreciated as a new addition to the decision-making process.
“With regards to the alert implementation, 60% found the contrast limit clear and understandable and 70% agreed that the contrast limit alert did not significantly interfere with their clinical workflow,” the authors added. “With respect to clinician beliefs about CA-AKI, 20% were surprised by the calculated contrast limit, 40% felt that the contrast limit accurately identified a patient’s true contrast limit, and 40% felt that the contrast limit helped them reduce their patient’s rates of CA-AKI. Half of clinicians believed that the contrast limit was useful information that they would want to continue to have access to.”
The researchers concluded that it is unclear if such EHR-generated alerts can make a long-term impact on contrast using during PCI procedures. It is possible, they wrote, that the reductions in contrast use observed during this study could persist as time goes on—and even later make “an observable effect” on CA-AKI rates.
Read the full study here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.