Table 4 Barriers to implementing recommendations for prevention, recognition, and management of Acute Kidney Injury (AKI) following major surgery, according to the clinical practice guidelines framework for improvement

Lack of awareness:

Interpretation of evidence:

Lack of compatibility with current practices:

● Care providers may not know current definition of AKI based on small change in serum creatinine. Providers may not be aware that a patient has Stage 1 AKI when serum creatinine remains within reference range

● The common research definitions of AKI differ from those often used in clinical care; too many different definitions across research studies

● It is common to give NSAIDs to patients to control pain and increase mobilization, although they may contribute to AKI.

● Providers may not be aware of the mortality and expense associated with AKI; some may not be aware that it is preventative and modifiable

● Uncertainty about whether AKI guideline recommendations apply to post-surgical care

● Many current patients undergoing surgery have comorbidities and use anti-hypertensive medications like ACEI/ARB that may contribute to AKI

● Providers are not always aware of a patient’s risk of AKI after surgery, and if made aware may be more careful to implement monitoring and preventative measures

● Uncertainty about use of medications such as ACE/ARB, diuretics, and NSAIDs and risk of AKI in the perioperative period

● Liver surgery patients are kept “dry” to decrease blood loss and increase transfusion, but the lack of fluids may contribute to AKI.

Lack of familiarity:

Lack of applicability due to patient characteristics:

● Colorectal surgery patients are also kept “dry” because of a perception that the anastomotic failure rate goes down, but the lack of fluids may contribute to AKI.

● Providers may prescribe ACE inhibitors or ARB following surgery, in particularly restarting these medications when they do not recognize a patient is at risk of AKI

● Belief that AKI guideline recommendations are not generalizable to post-surgical care

Surgeons often withhold IV fluids in the 24–48 hours following surgery because the third space volume will be redistributed and patients retain fluids post-operatively; this practice may contribute to AKI

● It is common to prescribe NSAIDs following surgery to reduce pain; providers prescribing these medications may not be aware of the patient’s risk or history of AKI

● Cardiac surgery patients already received intensive post-operative care in intensive care units, so it less likely that interventions targeting AKI prevention and recognition can improve the quality of care or outcomes in this setting

Complexity:

● Providers receive many calls about fluid balance and output, but may lack skills in determining volume status

● Patients undergoing colorectal, hepatic, and some other open abdominal surgeries are often intentionally kept “dry” to aid bowel anastomosis, decrease bleeding, and to avoid volume overload after fluid shifts into third spaces

● AKI is not a discrete entity

● Recognition of AKI will be inadequate if one doesn’t know how to respond

Concern about cost impacts:

● Fluid balance (which affects AKI) is extremely complex

Forgetting:

● Serum creatinine and physiologically monitoring will increase costs if done repeatedly

● Physicians do not want to put a Foley catheter in every patient that has surgery because there are side effects from this practice, even when it may improve recognition of AKI based on low urine output

● Care providers on surgical services experience many competing demands and are often primarily concerned about surgical performance; providing guidance and recommendations may facilitate better care

● Treating patients that are unlikely to improve can be expensive

● Low urine output has been described in varying ways (eg. with or without standardization by weight and over varying periods of time), but there is uncertainty about the way in which urine output should be measured and recorded, including which is most valid and should be acted upon.

● Forgetting may be particularly common when on-call and during night shifts when tired; residents may be less likely to remember to ask the important questions to guide care decisions when called upon

Lack of agreement in general:

Lack of observability:

● Physicians from other specialties may express competing priorities (i.e., cardiologists may not agree with withholding ACEI inhibitors and ARB because they can improve cardiac output post-operatively)

● Physicians do not always see direct links between their practices and prevention/reversal of AKI.

● While some medication types should generally be withheld, there is a lot of room for judgment and exceptions for a minority of patients

● AKI does not have symptoms like many other diseases to help with identification and prompt treatment.

Too “cookbook”/rigid to be applicable:

Communication:

● Educational initiatives often lack context and are too far removed from the realities of the workplace to be relatable

● There is a lack of mechanisms to facilitate appropriate consultation and communication between care providers

Challenge to autonomy:

● Communication often does not occur promptly and so recommendations are not put in place in a timely manner.

● There needs to be room for clinical judgment because there are always exceptions

● Nurses routinely notify physicians about low urine output but changes in serum creatinine are rarely communicated

Not practical:

● Nurses may not give feedback to physicians following a therapy or intervention that did not have desired effect.

● Current guidelines for AKI are not practical because they lack specificity about which patients are “at risk”

Time pressure:

Lack of expectation involving feelings:

● Physicians on call receive may calls and thorough evaluation or recognition of AKI risk may not occur prior to ordering medications

● Some physicians may not perceive AKI as a true threat, but rather, as “just” AKI; interventions may need to take into account these preconceptions

● High volume of patients and busy operating rooms may lower attention to serum creatinine levels

Lack of self-efficacy:

Lack of Resources:

● Some physicians may feel that factors leading to AKI, particularly in elderly patients with complications and/or comorbidities, are not modifiable and therefore, they cannot prevent AKI

● There is a lot of work done by few people; so intensive physiological and laboratory monitoring may not be possible for all patients.

Lack of motivation:

● Physicians must often respond to some problems over the phone rather than at the bedside

● Physicians may not feel motivated to treat patients that they feel will not improve (due to age or comorbidities)

Organizational constraints:

● Some physicians may lack motivation to prevent AKI because they are not aware of its impact

● In some centers the usual practice may be to consult internal medicine while in others it will be to consult nephrology for AKI, depending on the availability of consult services in the hospital.

Lack of access to services:

● Some centers may not have electronic health records for reporting and accessing lab results and for computerized clinical decision support for medication prescribing in the setting of reduced kidney function

● Important information may not be immediately accessible/available when decisions are being made (ie. lab results for the day not yet back, urine output not charted for high risk patients)

Shared responsibility with patient:

● The risks of developing AKI and its potential consequences may not always been properly conveyed or framed for a patient prior to surgery