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Acute kidney injury electronic alerts: mixed methods Normalization Process Theory evaluation of their implementation into secondary care in England

Lookup NU author(s): Dr Tracy Finch, Dr Gregory Maniatopoulos, Dr Chris Gibbins, Professor Neil SheerinORCiD, Dr Suren Kanagasundaram



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


ABSTRACTObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalization Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care. DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods. Setting and participantsThree secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, Vascular or General Surgery, or Care of the Elderly. Qualitative data were supplemented by NoMAD surveys (n=101). AnalysisQualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using Chi Square and Wilcoxon Signed Ranks Test for differences in current and future normalization. ResultsParticipants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalized in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying sub-constructs identified several mechanisms indicative of successful normalization (internalization, legitimation) or unsuccessful normalization (initiation, differentiation, skill set workability, systematization). ConclusionsClinicians recognised the value and importance of AKI e-alerts in their practice, though this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalize the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

Publication metadata

Author(s): Scott J, Finch T, Bevan M, Maniatopoulos G, Gibbins C, Yates B, Kilimangalam N, Sheerin NS, Kanagasundaram NS

Publication type: Article

Publication status: Published

Journal: BMJ Open

Year: 2019

Volume: 9

Issue: 12

Print publication date: 11/12/2019

Online publication date: 11/12/2019

Acceptance date: 11/11/2019

Date deposited: 11/11/2019

ISSN (electronic): 2044-6055

Publisher: BMJ Publishing Group


DOI: 10.1136/bmjopen-2019-032925


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