St. Luke’s University Health Network Reduces Acute Kidney Injury and Hypotension

As the frequency of total joint replacement procedures continues to increase, St. Luke’s University Health Network realized that there were growing challenges associated with these surgeries that were negatively impacting their patients’ health outcomes. There was a significant increase in cases of patients experiencing post-operative acute kidney injury (AKI) and hypotension while receiving elective total hip and total knee arthroplasty. These issues are also associated with increased length of stay, readmissions, need for transfer to nursing homes for long or short-term care, cardiovascular complications and overall mortality.

The organization recognized that there were opportunities to address prevention of these post-operative complications in every phase of the surgical experience. To make this possible, quickly implementing new protocols to prevent and reduce these instances was critical.

Tackling the Challenges

St. Luke’s University Health Network started by creating a more holistic approach in every stage of the patient journey for those presenting for a total joint replacement—before, during and after surgery. Initiatives were organized around leveraging technology for each phase of care throughout the surgical experience.

Within their Surgical Optimization Center (SOC) and orthopedic care facility, best practice advisories and preoperative order sets were modified in the EHR. Health records were optimized accordingly for patients who were identified as high-risk for complications. Eventually the order set would become a one-stop shop for the entire preoperative process. Once the surgeon entered the request for optimization and tasks to be completed by the SOC, the SOC would review and enter those tasks in advance of the surgery.

The process for determining surgical optimization risk was also reimagined with new best practice interventions. The detailed workflows included information that would apply based on the scenario and state of the patient. Important reminders for patients that could be easily missed in the past—such as holding NSAIDs for at least 10 days before the procedure—were also built directly into workflows. Potentially nephrotoxic medications, such as ACE inhibitors and diuretics, were held for up to 48 hours prior to surgery based on patient risk factor stratification. Those patients identified as high-risk based on the optimization evaluation would have modified tasks, such as an additional nephrology consult for their upcoming admission to the hospital for surgery.

To address hypotension going into the surgery, best practices for blood pressure management during the intraoperative care phase were also implemented—including an advisory that would notify the provider intraoperatively if the patient’s blood pressure was within a certain range so the anesthesiologist could manage as needed.

The organization recognized another potential contributor to complications: Only 30% to 40% of post-operative patients were receiving a basic metabolic panel (BMP) after their surgery. Upon realizing this, the organization added other BMP tasks into the order set so that BMP was evaluated before and after surgery. This allowed the team to determine a better sense of how prevalent the development of AKI is after surgery.

A nurse-driven hypotension protocol was also designed to minimize the time between developing hypotension and receiving intravenous fluids. The new protocol significantly engaged acute care nurses in the process by allowing them to initiate fluid boluses based on blood pressure readings post-operatively. To track the effectiveness of the protocol, reports were created to monitor the action associated with each notification, with follow-up tasks occurring as needed.

Thanks to these efforts, St. Luke’s University Health Network achieved the following:

• AKI complication rates decreased from a peak of 9% to top decile rates of 0.2% or less
• Hypotension rates decreased from approximately 15% to 6%
• Quality measure outcomes such as length of stay improved and contributed to an estimated $585,000 saved over three years
• Health outcomes improved organization-wide as the initiative expanded to other surgical specialties

HIMSS Davies Award of Excellence

The HIMSS Davies Award of Excellence recognizes the thoughtful application of health information and technology to substantially improve clinical care delivery, patient outcomes and population health around the world. The Davies Awards program promotes HIMSS’s vision and mission by recognizing and sharing use cases, model practices and lessons learned on how to improve health and wellness through the power of information and technology.

“St. Luke’s thoughtfully leverages a variety of information and technology tools to change the standard of care for joint replacement surgeries,” said Jonathan French, CPHIMS, SHIMSS, senior director of thought advisory at HIMSS. “As result, St. Luke’s has sustained some of the lowest post-surgical complication and acute kidney injury rates in the country. HIMSS is proud to recognize St. Luke’s Health Network as a 2019 Davies Award recipient.”

“Our physicians and nurses used EMR technology to identify, analyze and reduce the risk for acute kidney injury in patients undergoing elective joint replacement surgery,” said James Balshi, MD, chief medical information officer, St. Luke’s University Health Network. “Combining operational process change, best practice alerts, dedicated order sets and nursing protocols, our team approach to care dramatically reduced the incidence of perioperative AKI in these patients.”

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Updated March 6, 2020