Pediatric Nurse and Pharmacist Knowledge of Acute Kidney Injury

To guide the development of a survey used to assess the attitudes and knowledge of nurses and pharmacists regarding AKI in hospitalized children, a comprehensive review of the literature was performed and revealed limited studies in pediatrics and no examples of existing surveys. The study team then met to develop the preliminary survey with the goal of creating an instrument that assessed knowledge of the definition (recognition) of AKI, common risk factors for its development, and management strategies. The Kidney Disease: Improving Global Outcomes criteria were used to define AKI.¹⁶  Existing literature about common AKI risk factors was reviewed and used to inform question development. Medications were defined as nephrotoxic on the basis of a recent review by Goswami et al.¹⁷  No free text responses were allowed in the survey. To establish content validity and establish the time needed to complete, the preliminary survey was delivered to a small group of nurses, pharmacists and pediatric nephrologists. Feedback from this group was used to establish that the survey was of appropriate length, and a few questions were rewritten for clarity. The final 16-item survey, consisting of demographic, self-assessment and attitude, and knowledge questions, was reviewed by the study team and focus group before distribution. When no revisions were suggested, approval from the institutional review board and departments of nursing and pharmacy were obtained. The survey was then sent to all inpatient nurses and pharmacists at a tertiary-care pediatric hospital by e-mail. The survey was voluntary, and nurses and pharmacists who wished not to participate were excluded. The initial survey was sent via e-mail in June 2018, with 2 reminder e-mails sent over a 3-month period. Examples of the format of knowledge questions are as follows: (1) from the following, select those that best define AKI; (2) from the following, select any medication that is associated with a high risk of AKI; (3) from the following, select any factor that puts a patient at increased risk for an AKI; and (4) which of the following actions should be taken in a patient with AKI (check all that apply). True and false (distractor) answers were provided for each question. Additionally, a few case-based questions were presented to nurses and pharmacists.

Descriptive statistics were used to analyze the data by area of practice, either nurse or pharmacist. Participant demographic data were grouped into the categories indicated in the survey. Group data from assessment questions were presented as the percentages correct and incorrect. A χ² test was used to compare responses between groups.

A survey was sent to 620 nurses and 50 pharmacists; 148 (25%) and 22 (44%), respectively, completed it. A total of 61% of nurses were <35 years of age (n = 91), and most had been in nursing practice and pediatrics for ≤10 years (n = 96; 65%). Of the nurses who responded, 20% (n = 30) worked in the PICU, and 19% (n = 28) worked in the NICU. A total of 68% of pharmacists were <35 years old (n = 15), and most had been in pharmacy practice and pediatrics for ≤10 years (n = 22; 73%). The majority (85%) of nurses held a bachelor of science degree, whereas 9% held a master’s degree. The majority of both nurse (n = 134; 91%) and pharmacist respondents (n = 20; 91%) reported they had participated in the care of a patient with an AKI.

A total of 91 (61%) pediatric nurses felt confident in their abilities to identify AKI. Most nurses were also confident in monitoring patients with an AKI and assessing volume status and felt that these activities were within their scope of practice (Fig 1). A total of 16 (73%) pharmacists felt confident in their abilities to identify AKI, and 13 (59%) were confident in estimating the glomerular filtration rate (GFR). The majority also reported confidence in monitoring patients with an AKI and adjusting medication doses (Fig 1).

When respondents were asked to identify AKI criteria from a list of creatinine and urine output criteria and brief hypothetical clinical scenarios, only 87 (59%) and 91 (61%) nurses and 16 (73%) and 20 (91%) pharmacists correctly recognized a 0.3 mg/dL or 1.5 times baseline increase in serum creatinine from the baseline represented AKI, respectively. A total of 95 (64%) nurses and 20 (91%) pharmacists correctly recognized that a decrease in urine output (UOP) to <0.5 mL/kg per hour for 6 hours represented AKI (Table 1). All serum creatinine criteria for AKI were correctly identified by 41 (28%) nurses and 15 (68%) pharmacists. However, most nurses and pharmacists classified each individual criterion correctly (Table 1). When presented with 5 hypothetical patients with changes in creatinine and/or urine output, pharmacists correctly identified patients as having AKI 59% to 86% of the time, whereas nurses correctly identified patients with AKI 48% to 76% of the time (Table 2).

Given a list of medications, only 1 (0.7%) nurse and 3 (14%) pharmacists correctly classified all medications according to risk of AKI (Table 3). Nurses with ≤5 years of experience were more likely to incorrectly identify clindamycin as a nephrotoxin (24% vs 9%; P = .011), compared with more experienced nurses, whereas nurses with >5 years of experience correctly identified intravenous vancomycin as a nephrotoxin less often (79% vs 93%; P = .02). When presented with a list of potential nonmedication risk factors for AKI, 15 nurses (10%) and 6 pharmacists (27%) correctly classified the factors that put patients at risk for AKI (Table 3). Nurses with >5 years’ experience were more likely to incorrectly identify total parenteral nutrition as a risk factor for AKI, compared with nurses with less experience (50% vs 33%; P = .039). When presented with a list of potential actions that should be taken in patients with AKI, most pharmacists and nurses correctly identified interventions that could mitigate AKI; individual interventions were correctly identified by 77% to 98% of nurses and 50% to 100% of pharmacists (Table 4). “Ensuring adequate blood pressure” was identified by 117 (79%) nurses and 11 (50%) pharmacists and was the intervention most frequently missed. The proportion of correct answers did not differ between nurses working in an ICU or non-ICU area.

Two additional patient cases specific to the scope of practice of pharmacists were included in the survey (Table 2). In a case-based question that included serum creatinine level in an extremely oliguric patient, only 9 pharmacists (41%) correctly identified an appropriate estimated GFR. Those who answered incorrectly overestimated the GFR because of sole reliance on serum creatinine, a lagging biomarker for AKI, particularly in early stages. However, most pharmacists (n = 17; 77%) chose to dose vancomycin by level after the first dose was delivered, when given a case in which a patient had near-normal serum creatinine and oliguria. Most nurses (n = 137; 93%) and pharmacists (n = 20; 91%) indicated interest in targeted education regarding normal kidney function and AKI.

A multidisciplinary approach to the recognition and mitigation of AKI in hospitalized patients is critical to providing optimal health care and, specifically, reducing the morbidity, mortality and increased costs associated with this prevalent disease. In recognition of this priority, the 22nd Acute Disease Quality Initiative meeting was convened to review the current evidence and provide guidance for future directions of AKI-related quality measures and care processes.⁴  Preventive strategies for high-risk populations, such as hospitalized patients, included raising awareness of the definitions, signs, symptoms, and acute exposures associated with AKI among clinicians and enhanced coordination among all stakeholders to identify variations in care. In this study, 72% of pediatric nurses felt that identification of AKI was within their scope of practice, and ∼60% felt confident in their ability to do so. Greater than 80% of pediatric pharmacists felt confident in abilities to adjust medication doses in pediatric patients with AKI, but <60% felt confident in their ability to estimate the GFR in these patients. Nurses and pharmacists were able to correctly identify specific AKI criteria 60% to 70% and 70% to 90% of the time, respectively. This study reveals that, although pediatric nurses and pharmacists have knowledge of AKI prevention and mitigation, gaps exist, and there is a desire for education in recognition of their key roles in the clinical team.

In few studies have researchers examined knowledge of AKI risk factors and definitions among nurses and pharmacists, particularly in pediatrics. Among 134 pharmacists who cared for children in Japan, 37% reported awareness of AKI, and approximately two-thirds reported they did not know the normal creatinine reference values for children aged 4 and 8 years.⁶  A survey of 135 pharmacists who care for adults in Saudi Arabia revealed that 78% reported encountering AKI and 45% performed a daily risk assessment of AKI in their patients. Patient risk factors for AKI were correctly identified 22% to 75% of the time, and AKI-causing drugs were correctly identified 54% to 80% of the time.⁷  With a questionnaire related to AKI prevention, diagnosis, and treatment answered by 216 nurses caring for hospitalized adult patients in Brazil in 2010, researchers found that 57% were unable to identify clinical signs or symptoms that could result from AKI and 67% thought that a slight increase in creatinine had no major impact on mortality. The authors concluded that the nurses participating in this study did not have enough knowledge to identify early-stage AKI and further education was needed.¹³  A similar questionnaire was distributed to nurses caring for adults in government hospitals in Nigeria in 2016.¹¹  Among 156 nurse respondents, 68% reported having received formal lectures on AKI in the past, and 8% and 63% of nurses were assessed to have good and fair knowledge of AKI, respectively, with the rest characterized as having poor knowledge. Discrete patient characteristics and nephrotoxic medications associated with AKI were correctly identified by 18% to 81% of nurses. The results of studies of AKI recognition among members of the multidisciplinary team who care for adult patients may not be easily extrapolated to pediatrics, given the unique challenges of AKI recognition in children. Creatinine must be interpreted in the context of muscle mass, which is highly variable in children, and baseline levels, which may not be readily available because of the decreased frequency of laboratory monitoring in many children. Quantifying changes in urine output may be more challenging in those who are not continent. Thus, changes in creatinine and urine output representing AKI are likely to be more easily missed in children.

Quality improvement (QI) and education interventions have revealed success in improving AKI knowledge and recognition among clinicians. At a general hospital in the United Kingdom, a QI project including short teaching sessions and a brief checklist to aid in AKI management was targeted to nurses, nursing assistants, pharmacists, and physicians.⁸  AKI recognition improved from 31% to 100%, and implementation of a goal threshold of steps on the AKI checklist improved from 20% to 67%; these results were replicated across multiple hospital units. In a university hospital setting in the United Kingdom, an electronic alert was initiated in the pathology reporting system, and an AKI specialist nurse informed the treating nurse, pharmacist, and doctor on the ward of new AKI cases. Simultaneously, an AKI checklist of best practices in the management of AKI was distributed, along with an education campaign. Compared with the preintervention period, hospital-acquired AKI cases decreased by 28%, and the length of stay for patients with AKI decreased by 23%.¹⁸  This intervention was replicated with similar results in other UK hospitals, and the importance of nurse and pharmacist champions as part of a QI intervention to reduce and mitigate hospital-acquired AKI was underscored.^19,20  The Nephrotoxic Injury Negated by Just-in Time Action program, implemented by 9 centers in the United States, screens hospitalized children daily for high exposure to nephrotoxic medication(s) and AKI. The risk and/or injury is then communicated to the clinical care teams by an outreach team that includes a nurse, pharmacist and/or physician, and daily screening of serum creatinine is recommended while the exposure exists, as well as substitution of equally efficacious but less nephrotoxic medications when possible. The Nephrotoxic Injury Negated by Just-in Time Action program resulted in a 24% decrease in an AKI associated with nephrotoxic medication administration across the 9 centers, sustained over the 24-month observation period.²¹ 

This study of the knowledge and attitudes of nurses and pharmacists caring for hospitalized pediatric patients at risk for AKI is unique. The response rate was <50%; however, the 170 respondents represented a wide variety of experience and training. The nurses and pharmacists responding to this survey worked at a tertiary-care pediatric hospital associated with a university, potentially limiting the generalizability of the findings. Although this survey was developed by and piloted in a multidisciplinary group including nurses, pharmacists, and physicians, it is possible that the survey may contain unknown biases, inherent to the development of a new survey.

AKI, a common and significant morbidity among hospitalized children and adults, requires a multidisciplinary team to decrease its incidence and severity. With this study, we affirm that pediatric nurses and pharmacists view AKI prevention and mitigation as part of their scope of practice and desire continuing education to position them to best care for hospitalized children at risk for an AKI. Evidence regarding the effectiveness of QI interventions surrounding AKI knowledge and management skills of the clinical care team exists, and future study should be focused on establishing best practices and how to propagate these interventions broadly.