Regional Quality-Improvement Effort Reduces Contrast-Induced AKI After PCI

Employing a quality-improvement initiative involving multidisciplinary teams, conference calls, and regular reporting of outcomes can successfully reduce contrast-induced acute kidney injury (AKI) after percutaneous coronary intervention (PCI), according to a study published online July 29, 2014, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Researchers led by Jeremiah Brown, PhD, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), conducted a prospective study of 21,067 patients undergoing nonemergent PCI at 10 hospitals in New England between 2007 and 2012. While 2 hospitals with low baseline rates of contrast-induced AKI (defined as ≥ 0.3 mg/dL within 48 hours of the procedure or ≥ 50% increase in serum creatinine from baseline at any point during hospitalization) served as benchmark centers and 2 served as controls, 6 hospitals adopted the following quality improvement initiatives beginning in 2008:
  • Multidisciplinary teams
  • Monthly conference calls
  • Identifying best practices through literature review and interviews with benchmark sites
  • Annual focus groups
  • Biannual reporting of AKI rates
  • Microsystems coaching for 1 member from each hospital’s team 
Compared with patients who had PCI during the baseline phase (n = 6,983), those in the quality-improvement phase (n = 14,084) were older, more likely to have diabetes, hypertension, prior MI or PCI, congestive heart failure, and multivessel CAD. Radial access was more common than femoral during the intervention period. Also, total contrast volume decreased from 290.8 mL/case to 237.5 mL/case from baseline to the intervention period (P < .001). 

Initiative Spares Kidneys

The incidence of contrast-induced AKI decreased from baseline to follow-up in the 6 intervention hospitals (coefficient -0.011; P = .036), but it did not change in either the benchmark (coefficient 0.008; P = .120) or control (coefficient 0.014; P = .342) hospitals. 

After adjustment for confounders, AKI rates were reduced by 21% in hospitals that participated in the quality-improvement program, with no changes observed in the benchmark or control centers (table 1). 

Table 1. Adjusted AKI Rates in All Patients: Before vs After Program



95% CI

P Value

Quality-Improvement Hospitals




Benchmark Hospitals




Control Hospitals




A similar pattern was observed in a propensity-matched analysis; AKI was reduced only in intervention hospitals, where rates declined from 6.6% to 4.5% (RR 0.68; 95% CI 0.56-0.82). 

Among 4,131 patients considered high risk (baseline eGFR < 60 mL/min per 1.73 m2), AKI decreased in intervention hospitals from 14.0% to 10.0% (P = .007). No significant changes were seen in the other hospital settings. Adjustment for potential confounders confirmed these results (table 2). 

Table 2. Adjusted AKI Rates in High-Risk Patients: Before vs After Program



95% CI

P Value

Quality-Improvement Hospitals




Benchmark Hospitals




Control Hospitals





In-hospital mortality declined by 0.4% (RR 0.44; 95% CI 0.24-0.82) and bleeding complications were reduced by 0.7% (RR 0.59; 95% CI 0.43-0.83) among patients treated at hospitals adopting quality-improvement initiatives, but there was no change in rates of emergency CABG. Benchmark hospitals saw improved bleeding, but no difference in in-hospital mortality or emergency CABG, and control hospitals reported no changes in any of the 3 outcomes. 

Change for the Better, Even if ‘Painful’

In an email with TCTMD, Dr. Brown said, “Our success was really about hospital teams talking and innovating with one another instead of competing in the healthcare market, which resulted in simple, homegrown, easy to do solutions that improved patient safety.”

The simplest changes in protocol had the most impact, he observed. These included:

  • Recommending patients self-hydrate before and after the procedure
  • Allowing patients to drink water up to 2 hours preprocedure
  • Training doctors to use less contrast
  • Creating checkpoints in the system to delay procedures if patients are not adequately hydrated

“One of the most influential factors we observed was not only having one clinical champion driving the improvement, but a team of champions all leading improvements to the processes and protocols they were working [under] every day,” Dr. Brown added. “So it's not just your cath-lab director… saying let’s do this. It’s the cath lab manager, the nurse managers, the nurses, and staff on the numerous units feeding patients into the cath-lab.” 

The largest barrier to change, he commented, is teaching the team to unlearn habits. “However, it really comes down to finding what in your process doesn't work, fixing it, and… going through the growing pains of learning how to do the process in a new better way, even if it's painful,” Dr. Brown noted. 

Although more work is needed, he said the approach outlined in the study is “generalizable to all cath labs.” 

The field should focus less on large-scale randomized trials of particular treatments and spend more “time and resources on improving the delivery of effective care,” according to Dr. Brown. “We need to focus on disseminating these findings to cath labs around the world and start protecting patients undergoing other radio contrast procedures at our hospitals.”


Source: Brown JR, Solomon RJ, Sarnak MJ, et al. Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention. Circ Cardiovasc Qual Outcomes. 2014;Epub ahead of print.

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  • The study was funded by the Agency for Healthcare Research and Quality, the National Institute of Diabetes and Digestive Kidney Diseases, and the Northern New England Cardiovascular Disease Study Group.
  • Dr. Brown reports receiving funding from the Agency for Healthcare Research and Quality.