In this QI project, our group showed that using the EMR-AKI alert with inherited ability to add diagnosis of neonatal AKI to the problem list and chronic problem list can significantly improve the documentation of neonatal AKI (driven mainly by improvement of the documentation of AKI for neonates with SCr > 1.5 mg/dL) and referral to the neonatal nephrology clinic. The increase in consultations was not significant, which is mostly attributed to the ability of the NICU team to manage newborns with AKI who did not have other laboratory abnormalities or issues with fluid overload. Embedded within the background of the system, the alert mechanism seamlessly dispatches real-time notifications to the PI for continuous real-time monitoring. Notably, the advantage of this setup is that it operates with such an efficiency that it obviates the necessity for direct intervention by the PI. However, it is crucial to emphasize that this QI endeavor was consciously rooted in the ethos of empowering the NICU team to exercise increased autonomy. This decision was in marked contrast to the more traditional approach that might have entailed consistent intervention by nephrologists. By design, our project was conceived to foster a culture of collaboration rather than unilateral direction. The emphasis on enhancing the decision-making capabilities of the NICU team had a twofold purpose. First, it enabled the team to act promptly and judiciously in response to alerts. Second, it nurtured an environment in which the accumulation of expertise and experience within the NICU was tapped into for collective benefit. This conscious decision to avoid excessive external intervention while paradoxically invoking a more collaborative spirit internally was intended to ensure the project’s viability and relevance over time.

This project configuration recognized the ongoing success of the endeavor hinged upon embedding it within the existing workflows and decision-making structures of the NICU. Imposing a top-down approach might have yielded short-term results, but long-term feasibility could have been compromised. By cultivating a sense of ownership and collective responsibility within the NICU team, we not only facilitated smoother implementation, but also paved the way for sustained progress. In essence, our QI initiative was not merely a technical solution; it was a paradigm shift toward shared responsibility and collaboration. By empowering the NICU team to act autonomously and make informed decisions, we not only enhanced patient care in the immediate context, but also set the stage for a more resilient and adaptable healthcare approach. The deliberate choice to eschew constant external involvement in favor of internal collaboration proved to be a cornerstone of the project’s evolution, ensuring its continued relevance and impact in the dynamic landscape of neonatal care.

The use of electronic alerts linked to embedded CDS tools is one of the benefits of adopting EMR, which has been demonstrated in multiple studies: notification of critical laboratory and imaging findings, mitigation of hazardous drug interactions, enhanced use of immunizations, venous thromboembolism prophylaxis, and antiplatelet therapy among hospitalized patients, among many other utilizations [5,6,7]. Goldstein et al. successfully implemented an EMR screening algorithm and decision support process (trigger) among children exposed to high nephrotoxicity, resulting in a 42% reduction in AKI intensity in a single-center study and 23.8% decrease in multicenter quality improvement initiative (NINJA) [8, 13]. Similar favorable results were reported in the baby-NINJA group among neonates [9].

Our results are consistent with the published adult data. A prospective study by Holmes et al. showed that the use of an EMR-based system for patient identification overcomes the systematic underreporting of AKI associated with previous studies [14]. The QI project by Park et al., in a tertiary hospital in Korea, showed that the introduction of the EMR-Alert significantly decreased the odds of overlooked AKI events (adjusted OR, 0.40; 95%CI, 0.30–0.52), and significantly increased the odds of an early nephrology consultation (adjusted OR, 6.13; 95% CI, 4.80–7.82). Additionally, the study showed that the odds of a severe AKI event were reduced after implementation of the alerts (adjusted OR, 0.75; 95% CI, 0.64–0.89), and the likelihood of AKI recovery was improved in the alert group (adjusted HR, 1.70; 95% CI, 1.53–1.88) [15].

In a pediatric population excluding neonates, Gubb et al. showed that using AKI alerts improved the recognition of AKI [16]. Menon et al., over a 6-month pilot period, utilized an AKI alert that was sent directly to the primary provider listed for each patient (6 months to 18 years old) and showed a significant increase in AKI documentation [17].

Comprehensive documentation of neonatal AKI diagnoses serves as a pivotal link in the healthcare chain, profoundly impacting multiple facets of patient care. First, it significantly heightens the awareness of the primary care team, enabling them to swiftly identify high-risk neonates. This heightened vigilance empowers primary care physicians to take proactive measures, including essential follow-up consultations with nephrologists. These follow-up appointments are pivotal in screening for the potential development of long-term complications such as hypertension, proteinuria, and CKD.

Beyond the medical realm, meticulous documentation is vital. It acts as a conduit of information, ensuring that families are well informed about their child’s condition. This newfound awareness equips families with valuable knowledge about the nature of their children’s health challenges and the importance of continued medical surveillance. Consequently, it can significantly enhance adherence to follow-up appointments and treatment regimens, thereby promoting the overall well-being of neonates. In essence, documentation in the context of neonatal AKI is not merely a record-keeping exercise; it is a linchpin that unites healthcare providers, families, and the patient in a collaborative effort toward comprehensive care. It empowers healthcare teams to intervene proactively, shields against potential long-term complications, and ensures that families actively participate in their child’s healthcare journey. This multifaceted role of documentation underscores its indispensable significance in optimizing the health outcomes and quality of life of neonates with a history of AKI. Finally, accurate documentation of AKI diagnosis holds substantial significance, particularly within the realm of multicenter studies and databases reliant on the International Classification of Diseases (ICD) codes. This meticulous documentation not only enhances the reliability of data extracted from diverse medical settings, but also amplifies the robustness of cross-institutional analyses. In this interconnected age of healthcare research, where collaborative investigations span various healthcare facilities, the precision of AKI diagnosis documentation contributes profoundly to the integrity and comprehensiveness of the datasets underpinning critical research initiatives. By establishing a consistent and reliable foundation of diagnostic information, healthcare practitioners, researchers, and policymakers can gain more accurate insights, draw meaningful comparisons, and derive well-informed conclusions, ultimately advancing our understanding of AKI and its management on a larger scale.

To the best of our knowledge, this is the first neonatal EMR-AKI alert that is linked with automatic documentation of AKI, prompting consultations, and referral to neonatal nephrology clinics to mitigate the problem of under-documentation and loss of follow-up. To the best of our knowledge, our initiative represents a pioneering effort in the neonatal realm, an EMR alert system intricately integrated with automated documentation of AKI occurrences. This novel approach extends beyond conventional methods by seamlessly incorporating not only timely alerts, but also comprehensive mechanisms for documenting AKI diagnoses, orchestrating consults, and facilitating referrals to specialized neonatal nephrology clinics. This multifaceted innovation is meticulously designed to address a critical challenge that has long plagued the field: the issue of under-documented AKI cases and the subsequent loss of follow-up. By forging this innovative linkage between EMR-based alerts and automatic documentation, we transcend the traditional boundaries in neonatal care. This integrated system is poised to usher in a new era of streamlined and coordinated responses to AKI incidents, elevating the standard of care and bolstering the potential for positive patient outcomes. No longer will the intricacies of AKI diagnosis and the complexities of referral slip through the cracks. Instead, our comprehensive approach ensures that each step in the diagnostic and management process is seamlessly captured, ensuring a meticulous record of patient care that is invaluable for clinicians, researchers, and administrators.

This endeavor marks a significant leap forward in harnessing technology to address critical gaps in healthcare management, thereby fostering a more thorough understanding of AKI in the neonatal context and fostering improved outcomes across the spectrum of neonatal care. Through this pioneering fusion of EMR alerts and automated documentation, we set the stage for a transformative shift in neonatal AKI management, one that champions efficiency, precision, and comprehensive care delivery, ultimately forging a path toward enhanced patient well-being and future advancements in neonatal medicine. Moreover, the alert helped us identify areas of improvement, such as collaboration with neonatologists to increase early consults and the gap in diagnosing AKI using the modified KDIGO criteria.