Clinical Audit of In-Hospital Recognition, Management, Discharge Planning, and Post-Discharge Follow-Up of Acute Kidney Injury in Adult Medical Patients

Abstract

Background: Acute kidney injury (AKI) is a frequent and clinically important complication of acute illness and hospitalization. Delayed recognition, inadequate assessment of reversible causes, inappropriate medication management, incomplete discharge documentation, and poor continuity of care after discharge may contribute to adverse outcomes. Clinical audit provides a practical approach to measuring practice against explicit standards and implementing targeted quality-improvement measures. Aim: To assess the quality of in-hospital recognition and management, discharge planning, and post-discharge follow-up of AKI among adult medical inpatients in the Department of Medicine, Lady Reading Hospital, Peshawar, and to evaluate the effect of a structured AKI care bundle, staff education, medication-review prompts, and standardized discharge and follow-up processes on compliance with predefined audit standards. Methods: A two-cycle clinical audit and quality-improvement project was conducted among 200 adult medical inpatients with KDIGO-defined AKI. The baseline cycle included 100 eligible patients, followed by a separate re-audit sample of 100 patients. Patients with established end-stage kidney disease on maintenance dialysis and those managed exclusively in intensive care were excluded. Baseline performance was assessed across AKI recognition and staging, clinical assessment, inpatient management, medication safety, specialist referral, discharge documentation, and post-discharge follow-up. A targeted intervention comprising an AKI care bundle, staff education, medication-review prompts, and a structured discharge and follow-up checklist was implemented before re-audit. The same predefined standards were reassessed. Results: At baseline, AKI recognition was documented in 68% of patients and AKI staging in 54%. Volume or fluid status assessment was documented in 61%, serial serum creatinine monitoring in 74%, and nephrotoxin review in 63%. AKI was documented in the discharge summary in 52%, while a post-discharge follow-up plan was documented in 43% of patients discharged alive. Following implementation, corresponding compliance increased to 92%, 88%, 91%, 94%, 94%, and 90%, respectively. Among patients with available 30-day follow-up data, repeat serum creatinine assessment increased from 49% to 82%, medication review from 43% to 80%, and assessment for recurrent AKI or readmission from 54% to 86%. Conclusion: The baseline audit identified important gaps across the AKI care pathway, particularly in staging, medication safety, discharge documentation, and continuity of care. Implementation of a structured AKI care bundle with staff education and standardized discharge and follow-up processes was associated with substantial improvement in compliance with predefined standards. Continued periodic re-audit is required to determine whether these improvements are sustained