Since it began, the NINJA initiative has prevented hundreds of AKI episodes at Children’s. (Stock photo)
Acute kidney injury (AKI) is a common but under-recognized complication in hospitalized children. In non-ICU patients, the most common cause is due to nephrotoxic medications such as aminoglycosides, NSAIDs and vancomycin. It’s hardly a benign condition; even a single episode of AKI can set a child on a trajectory toward hypertension and chronic kidney disease later in life.
Traditional care often detects AKI only after it occurs—when creatinine rises. That’s reactive, not preventive. The NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) initiative flips the script by identifying children exposed to high nephrotoxic medication—defined as three or more in one day or prolonged aminoglycoside/vancomycin use—and then screening daily for signs of kidney harm to prevent AKI.
Children’s of Alabama has been one of more than 20 children’s hospitals that are part of the NINJA project. “NINJA is designed to help prevent AKI by educating providers that AKI is not a benign condition, helping them identify high-risk patients, and providing them with the knowledge they need to prevent and mitigate medication-associated AKI,” Children’s pediatric nephrologist David Askenazi, M.D., MSPH, said.
Multi-center studies on NINJA show that collectively, institutions can reduce the rate of AKI by as much as 62%. Those reductions are attributed to the core tenets of NINJA: screening and stewardship; early detection through daily creatine monitoring; and a cultural shift toward preventive renal care.
“What we do is simple. We systematically identify patients at high risk of AKI and put them on the NINJA list,” Askenazi said. “Then, the pharmacist lead from each team ensures the team monitors the child’s creatinine levels daily and discusses possible alternative drugs with them.”
“Our pharmacists are the real ninjas of this program, and they deserve the credit,” he added.
After 10 years participating in the NINJA program, Children’s continues to see the number of AKI events drop. “It’s a testament to the dedication from the top down at Children’s to provide the best quality care to our children,” Askenazi said. He and his team are currently parsing the data to determine how many AKI episodes have been prevented. The number appears to be close to 1,000.
Now, the department is working with the hospital’s IT experts to integrate the NINJA system into the EPIC electronic medical record (EMR). This will enhance the clinician’s ability to see what’s happening in real time since patients on the NINJA list will be flagged immediately and a dashboard with all their medications and labs listed, Askenazi said. “We’re building data sets and clinical decision support tools for providers so they can navigate through NINJA and care for their patients with up-to-date data and suggestions.”
Until now, because pharmacists are not there on nights and weekends, at-risk patients could have been missed. With an EMR-based system, clinicians have access to the data 24 hours a day, 365 days a year. The EMR integration should also significantly increase efficiency for pharmacists and quality improvement specialists who previously had to manage the data on Excel spreadsheets and create reports manually.
In addition, a new urine test that can detect AKI without the need to prick the child for blood is being implemented. “We’ll incorporate that within our NINJA initiative,” Askenazi said, “as we continue to optimize patient comfort and safety throughout the hospital.”
Overall, he said, “NINJA has been successful because we’ve been able to convince everyone that preventing harm from nephrotoxic drugs is important.”
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