Comprehensive Clinical Quality Initiative for Reducing Acute Kidney Injury in at-risk Patients Undergoing Diagnostic Coronary Angiogram and/or Percutaneous Coronary Interventions

Background
Our program focused on developing, implementing, monitoring, and refining policies and procedures that aligned with 2011 PCI Guidelines for complication prevention. In January 2018, we implemented standardized pre-procedure patient risk assessment practices. In April 2018, we implemented pre-procedure hydration practices consisting of a sodium chloride 0.9% infusion at 1ml/kg/hr as a continuous infusion for 12 hours prior to the procedure in non-CHF patients and at 0.5ml/kg/hr for CHF patients (Poseidon, 2012). Beginning in April 2018, MMH implemented utilization of the DyeVert Contrast Reduction Systems. DyeVert Systems provide fluid pathway resistance modulation such that excess contrast media (CM) is minimized in the patient’s vasculature and total contrast media volume (CMV) reduction occurs, while maintaining adequate image quality. Excess CM is not needed for diagnostic or therapeutic purposes. In October 2018, we developed the AKI Reduction Protocol mandating the use of DyeVert Plus in all inpatient procedures and for outpatients with eGFR <60. We also implemented the DyeTect Contrast Monitoring System for contrast accounting and monitoring in all outpatients with eGFR ≥60.

Methods
Patient charts will be abstracted for compliance with intravenous hydration protocols utilizing the electronic medical record.

Results
Based on the data fields referenced in our methods MMH will prove appropriate intravenous fluid hydration along with reducing intravascular injection of contrast media will decrease AKI in Cath PCI procedures (Gurm,2018). Evidence shows we will achieve a relative reduction of 13-18% in the observed AKI rate.

Conclusions
At MMH, a targeted, ongoing quality improvement effort will result in a clinically meaningful reduction in AKI events by an expected 20%. Implementation of procedures and new technologies aimed at assessing risk, hydration, contrast monitoring, and contrast minimization will be the foundation of our program.