Your trust's AKI e-alerts show that only 48% of stage 2 and 3 alerts receive a documented senior review within 24 hours. You have been asked to lead the improvement work. Outline your approach.

Question

You are the renal registrar. The trust mortality review group has flagged AKI as a theme in several deaths. You have been asked to lead a project with the acute medicine and pharmacy teams.

Accepted Answer

I would start by finding out what actually happens to an alert, because the framing of the question assumes clinicians are not responding, and in my experience that is rarely the whole story. I would trace the pathway end to end: where the alert is generated, who receives it, on what device, at what time, whether it appears in a task list or an inbox, and what action it prompts. Then I would segment the 48% by ward, by specialty, by time of day and by day of week. Alerts firing overnight or at weekends into an unmonitored inbox are a common and entirely fixable cause, and that segmentation usually localises the problem within a week. I would talk to the foundation doctors and ward nurses who receive them, and to pharmacy, who often see the nephrotoxin problem before anyone else. My aim would be SMART: to increase documented senior review within 24 hours of a stage 2 or 3 alert from 48% to 80% within six months. My outcome measure would be that percentage on a run chart, process measures would include the proportion of alerts with a completed AKI care bundle and with a documented medication review, and my balancing measures would be alert fatigue — measured through response to other alerts — and the rate of inappropriate nephrology referrals, because making the alert louder can degrade everything else. My interventions would be designed to make the right thing the easy thing: an AKI care bundle embedded in the electronic record that opens from the alert, a pharmacy-led nephrotoxin review triggered automatically, routing alerts to a monitored role rather than an individual, and an AKI nurse or outreach model if the business case supports it. I would test these in small PDSA cycles, engage a consultant sponsor and the mortality review group, and before rotating embed it in the SOP and induction with a named owner.

Improving AKI Recognition and Response

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