الفهرس 
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Abstract
Acute kidney injury is a common complication that affects kidney structure and function in critically ill patients during their ICU stay. Prevention of AKI is recommended since most of causes of ICU acquired AKI is preventable. Critical care nurses can significantly improve critically ill patients outcomes through implemented such evidenced based interventions entitled in AKI care bundle, collaborating with other health care providers for better prognosis of critically ill patients, decrease length of ICU stay, costs, decrease mortality and promoting consistency in providing care to critically ill patients.
Aim of the study
A Quasi-experimental research design was used to determine the effect of implementing acute kidney injury care bundle on clinical outcomes of critically ill patients.
Materials & Method
This study was carried out in the General ICUs namely; Casualty unit (unit I), General ICU (unit II, III) at the Alexandria Main University Hospital. The general ICUs; Unit I, unit II and Unit III beds capacity is 12, 9 and16 beds respectively.
A convenience sample of 70 newly admitted adult patients aged 18-<60 years were included in this study. Patients who had preexisting AKI, chronic kidney disease and/or on renal replacement therapy were excluded from the study. The sample was equally assigned into two equal groups: group I, the control group (35 patients) and group II, the study group (35 patients).
Data collection took approximately 7 months starting from August 2021 to February 2022.
To accomplish the aim of the current study two tools were used to collect the data of this study .Tool one namely “ICU acquired AKI risk assessment”. It was used to assess critically ill patients for presence of risk factors of ICU acquired AKI. Tool II namely’’ Clinical outcomes assessment tool’’. It was developed by researcher after reviewing the related literatures to assess clinical outcomes of critically ill patients at risk for AKI.
The study design was accomplished as follow:
An informed written consent was obtained from conscious patients or witness consent for unconscious patients. It included the aim of the study, potential benefits, risks, discomforts from participation, and the right to refuse to participate in the study. Patients’ privacy, anonymity and confidentiality of the collected data were maintained during the implementation of the study.
The developed tools were tested for content validity by five experts in the field of the study. A pilot study was carried to assess the clarity and applicability of the tool and the necessary modifications were done prior to data collection. The reliability of the tool was assessed using Cronbach’s alpha test and its result was 0.712 which is acceptable.
Data were collected first from the control group and after its completion, it was collected from the study group to prevent the contamination between the control and study group that might affect the study results.
All newly admitted patients were included in this study. Patient with preexisting AKI, chronic renal failure and/or on renal replacement therapy were excluded from the study.
The bio-demographic data of the studied patients was obtained and recorded upon admission.
The patients’ risk score for AKI and injury level were assessed daily using renal angina index (RAI) and documented using part I of tool one.
Critically ill patients were assessed for presence of factors predisposing to ICU acquired AKI and recorded using part II of tool one.
Prescription of drugs such as nephrotoxic antibiotics; vancomycin, aminoglycosides, amphotericin B, and non steroidal anti-inflammatory drugs, were assessed daily and recorded using part II of tool one.
Patients in the control group were left to receive the routine hospital care which includes daily monitoring of urine output, renal function and discontinue of nephrotoxic antibiotics after rising in creatinine level. Patients in the study group were subjected to AKI care bundle intervention started from admission to ICU and for 7 consecutive days.
Outcome assessment include perfusion related outcomes including MAP, capillary refill time, urine output measurement, and cumulative fluid balance calculation were assessed and recorded using part I of tool two. Acid base and serum electrolytes related outcomes including central venous oxygen saturation, arterial blood gases, lactate level, serum Na+ and K+ were assessed and recorded using part II of tool two. Renal related outcomes including new development of AKI after ICU admission, and progression of newly developed AKI were assessed and recorded using part III of tool two.
Results
Concerning patients’ age, 42.9% of patients in the study group aged 50- ≤ 60 years compared to 57.1% of patients in the control group. The mean age was 44.31±12.41 for the study group compared to 47.71±15.57 for the control group. In relation to sex, this table showed that 51.4 % of patients in the study group were males compared to 65.7% of patients in the control group with no statistical difference between two the two groups (p=0.225).
Regarding patients’ diagnosis, 60.0% of patients in the study group diagnosed with central nervous disorder compared to 51.4% of patients in the control group. 14.3% of patients in the study group diagnosed with respiratory disorder compared to 28.6% of patients in the control group. In relation to weight, the mean weight was 76.83±6.08 for patients in the study group compared to 83.11±12.04 for patients in the control group with no statistical difference between the two groups (p=0.069).
In relation to co-morbidities, 54.3% of patients in the study group had hypertension compared to 42.9% of patients in the control group. In relation to DM, this table shows that 11.4% of patients in the study group had DM compared to 31.4% of patients in the control group with no statistical difference between the two groups (p=0.126). Regarding previous episodes of AKI, 94.3% of patients in the study group didn’t have previous episodes of AKI compared to 85.7% of patients in the control group with no statistical difference between the two groups (p=0.232).
As regard EWS score, the mean score was 3.74±1.54 for patients in the study group compared to 5.0±1.59 for patients in the control group. In relation to APACHE II score, it can be noted that the mean score was 24.37±4.52 for patients in the study group compared to 23.89±4.56 for patients in the control group with no statistical difference between the two groups (p=0.656).
Regarding the occurrence of ICU acquired AKI over the seven consecutive days after implementation of AKI care bundle interventions. It can be noted that neither patients in the study group nor the control group had AKI on 1st day (baseline), however during 2nd to 7th day 0.0%, 14.3%, 8.6%, 0.0%, 0.0% and 0.0% of patients in the study group developed AKI compared to 14.3%, 42.9%, 45.7%, 20.0%, 28.6% and 22.9% of patients in the control group. The differences between the study and control group regarding incidence of AKI on the days 2nd ,3rd , 4th 5th and 6th were found to be a statistical significance where (p=0.020, p=0.008, p=0.008, p= 0.008 and p=<0.001 and) respectively.
In relation to progression of AKI stage over the seven consecutive days. Regarding the study group, it can be noted that during 3rd day 14.3% of patients developed AKI stage I and then decreased to 8.6% on the 4th day. Patients who developed stage I AKI were recovered and returned to normal on 5th day and none of patients had AKI. Concerning the control group, it can be noted that 14.3% developed stage I AKI on 2nd day and then the number increased to 42.9% on the 3rd day. On the 4th day 42.85% were in stage I AKI while 2.85% were in stage II AKI. The number of patients in stage I AKI then decreased to 14.28% while 5.71% were in stage II AKI on the 5th day. The number of patients in stage I AKI then increased to 22.85% while 5.71% were still in stage II AKI on the 6th day. The number of patients in stage I AKI finally decreased to 20.0% and none of patients had stage II AKI while 2.85% developed stage III AKI on the 7th day.
Regarding mean duration of ICU acquired AKI over the seven consecutive days. The mean duration of AKI was ≤ 2 days in 22.85% of patients in the study group compared to 54.28% in the control group while the mean duration of AKI was 3-5 days in 14.28% of patients in the control group.
Conclusion
• Implementation of AKI care bundle interventions significantly decreased the occurrence of ICU acquired AKI.
• Implementation of AKI care bundle interventions significantly decreased the progression of AKI stage.
• Implementation of AKI care bundle interventions significantly decreased the duration of ICU acquired AKI
• Implementation of AKI care bundle interventions significantly maintained normal hemodynamic status of critically ill patients.
Recommendations
Based on the findings of this study, it can be recommended that:
Recommendation regarding clinical practice:
- Critical care nurses should conduct a baseline assessment on admission to identify high risk patients for development of ICU acquired AKI.
- Critical care nurses should correct hemodynamics and securing hydration in high risk critically ill patients in collaboration with health care provider.
- Critical care nurses should monitor serum creatinine and hourly urine output.
- Critical care nurses should comply with all interventions of AKI care bundle.
Recommendations regarding education and training:
- Undergraduate critical care nursing courses should handle the concept of AKI care bundle focusing on its positive outcomes.
- The content of lecture must emphasize the importance of prevention, early identification and early response that nurses can provide for critically ill patients.
- Implementing an educational program for health care providers as regard AKI care bundle emphasizing that AKI care bundle interventions are feasible, cost effective and applicable by critically care nurses.
- In-service training for critical care nurses to minimize the gap between their limited skills/experience and expected performance
Recommendations regarding administration:
- Policies and protocols should be established according to standardized interventions for AKI care bundle.
- Develop nurse-led AKI protocols to detect and manage critically ill patients in ICUs.
- Standardized guidelines and interventions must be available in the form of educational handouts provided to critical care nurses.
- Develop policies to simplify the charting and documentation system as regard early identification using renal angina index, prevention and supportive care of AKI.
- Outreach Systems should emphasize on monitoring of renal function before and after hospital discharge as expanded role of critically care nurses.
Recommendations regarding future research:
- Replication of this study on a larger sample is needed to allow generalization of the finding.
- Evaluation the effect of AKI care bundle interventions on long term outcomes such as CKD and post discharge mortality.