Adoption of a novel biomarker-guided quality improvement treatment bundle for patients with subclinical acute kidney injury after cardiac surgery: An implementation study.

BACKGROUND

Evidence-based peri-operative practices can deliver improved patient outcomes, but their benefits may be limited by obstacles to implementation into routine practice. A multicentre randomised controlled trial demonstrated a reduction in the incidence of moderate-severe acute kidney injury after cardiac surgery using a biomarker-guided renal care bundle, however these measures are not a routine part of clinical practice.

OBJECTIVE

We set out to assess the key implementation domains of acceptability, feasibility and appropriateness of this technology-intervention bundle in the cardiac intensive care unit.

DESIGN

Following introduction of the biomarker-guided renal care bundle, the implementation process was assessed using comprehensive and novel implementation science metrics: Weiner's adoption metrics and Sekhon's theoretical framework of acceptability.

SETTING

Two tertiary cardiac surgical centres in London, UK, between July 2021 and February 2022.

PARTICIPANTS

One hundred and seventy-six adult patients underwent urinary biomarker assessment 2 h after arrival on the cardiac intensive care unit and 49 respondents, including medical and surgical consultants and nursing staff, completed our implementation survey.

INTERVENTIONS: Patients with a raised biomarker level ([TIMP-2] × [IGFBP7] > 0.3 (ng ml -1 ) 2 1000 -1 ) received a renal care bundle. The clinician respondents underwent a survey designed to provide implementation metrics.

MAIN OUTCOME MEASURE: The primary outcome was the assessment of implementation using Weiner's adoption metrics and Sekhon's theoretical framework of acceptability.

RESULTS

34.7% ( n  = 61) of patients had a raised biomarker level indicating a requirement for the renal care bundle, with a mean delivery of 4.4 (out of 6) bundle items. Concerning Weiner's adoption metrics, the median scores for acceptability, appropriateness and feasibility were all 4 (out of a possible 5) indicating a high degree of positivity towards the intervention. Similarly, all domains of Sekhon's theoretical framework of acceptability scored a median of 4 (out of 5). The highest scoring domain was Perceived Effectiveness (mean 4.0), whilst the lowest were Burden (mean 3.4) and Opportunity Costs (mean 3.4).

CONCLUSIONS

This implementation science study demonstrates that this biomarker-guided renal care bundle is deliverable after cardiac surgery, outside of a research setting. Our findings show that the intervention is acceptable, feasible and appropriate, which is strongly supported by its 'perceived effectiveness'. We have also demonstrated the more negative aspects to be addressed to improve concordance in other settings.