The risk factors for AKI are well estimated [14–19]. This leads to the recommendation that all admissions should undertake an AKI risk assessment so that modifiable risks factors can be identified and attenuated in a timely phase. The issue of preventability is critical, as the costs associated with AKI are high, both in the short and long term [20].
Framing AKI as a driver of substantial inequity in disease risk and mortality in developing countries, the ISN has created and launched the multifaceted human rights program “0 by 25,” which advocates that no one should die of untreated AKI, with a focus on low- and middle-income countries in Africa, Asia and Latin America [8]. In the 5-R approach proposed by “The ISN 0 by 25” project: risk assessment, recognition, response, renal support and rehabilitation, the first 3 Rs focus on the prevention area. Similarly, we must focus on simplifying every step to allow primary care providers to implement these measures regardless of their work environment. Thus, the quality of AKI risk assessment with proper measure applied is priority.
Fig. 1. Plan, Do, Study, Act (PDSA) circle model. Plan = the change to be tested or implemented. Do = carry out the test or change. Study = data before and after the change and reflect on what was learned. Act = plan the next change cycle or full implementation.
The Methodology of Quality Measure in AKI Risk Assessment
In hospitals, new ideas are often developed without sufficient testing. So the Plan, Do, Study, Act (PDSA) circle model (Fig. 1) has been widely introduced to the practitioner, for testing its feasibility and possible improvement measures that can be achieved before applying this model widely.
The PDSA circle is significant in its use to improve the quality of recognizing AKI early. It works best when it is used to test ideas on a small scale prior to full implementation. With quality improvement services, there will be multiple consecutive cycles used alongside project development. The model is based on the scientific method of encompassing a planned, systematic means to solving a problem that can be observed. Outcomes will be measured, but unlike research, the outcome measures in this model are tools for learning and demonstrating improvement, and are not to be evaluated against research criteria. This model works as a practical framework to evaluate the current service and to test and generate new ideas for the development of an AKI risk assessment. We discuss an example below.
Plan
Before AKI is diagnosed, certain risk factors shall be screened based on the patient’s manifestation and underlying complication or disease. An algorithm comprising common risk factors shall be designed for early identification. The improvement of this method is supposed to be significant.
Do
All the clinical practitioners shall regard AKI as acute myocardial infarction, which means wherever the patients visit, community hospitals or tertiary hospital setting, certain AKI symptom or manifestation may recall doctors to screen-related risk factors according to the algorithm.
Study
Comparison between before and after the implementation shall be done to identify whether or not it is beneficial.
Act
It depends on the evaluation from the last step. If the algorism is good enough, the laboratory factors shall be considered for better assessment of AKI risk.
PDSA approach can be utilized as an effective tool in the initial stages of developing an intervention to evaluate the current service delivery of the management of AKI and to generate and test ideas prior to implementation. This approach is simple and logical to use for members of the multidisciplinary team and allows for effective reporting and documentation of the development process in service improvement projects.
Existing Literature of Quality Measure in AKI Risk Assessment
National institute for health and care excellence published guidelines [21] for ensuring quality and safety in AKI. They were developed with rigorous methodology. Specific questions were raised in a population, intervention, comparison, outcome framework. These guidelines were created indicating that most of AKI is preventable, and that the risk assessment, prevention, and early recognition are key factors to decrease the incidence of AKI, prevalence of chronic kidney disease and related death.
In the recommendations for assessing the risk of AKI, suggestions are classified according to specific patients (Fig. 2).
On the other hand, Rizo-Topete et al. [22] encourage every health care provider to perform the AKI risk assessment no matter where the patient is located. This assessment is ideally situated in the electronic medical record and accessible by all team members. The proposed algorithm is based on the 4 simple steps named the “Fantastic 4” that evaluates the patient systematically and promptly referring them to nephrologists to improve outcome (Fig. 3).
Fig. 2. National institute for health and care excellence (NICE) AKI risk assessment flowchart.
The approach to the patient should be the following:
F1: refer the patient to a “clinical scenario” where the patient’s signs and symptoms and the surrounding circumstances and risks are reviewed and considered;
F2: interview the patient or his/her relatives and review the “past history” with a goal of identifying the level of susceptibility and intensity of exposures;
F3: conduct a “physical examination” on the patient aiming at characterizing hemodynamic instability, volume depletion or fluid overload and signs/source of infection, if any;
F4: analyze “laboratory results” including possible AKI biomarkers to complete the patient risk stratification.
This AKI F4 model is considered collaborated with the electronic medical record to alert caregivers to the risk assessment results.
Fig. 3. The composition of the acute kidney injury risk assessment (ARA) is based on the analysis of 4 following items: actual clinical scenario, past history, physical examination and laboratory analysis.
There are several AKI risk assessment scores in specific fields, like cardiac surgery. AKI is one of the common complications after cardiac surgery with high incidence and mortality. Therefore, early identification is crucial in preventing CSA-AKI. In the last decades, several risk scores were generated to improve the outcome of patients [23–25]. However,