Severe hymenoptera stings can lead to systemic toxicity and end-organ complications, including acute kidney injury (AKI). This study investigated whether implementing a nurse-led dynamic urine monitoring protocol was associated with lower AKI risk and improved clinical outcomes in patients with severe hymenoptera envenoming. The protocol was launched on January 1, 2022, and a historically controlled retrospective design was used to compare outcomes before and after implementation.
Design and groups
A historically controlled retrospective study design used January 1, 2022 as the cutoff for protocol implementation. Patients presenting with severe hymenoptera stings from 2019–2021 formed the historical control group, while patients from 2022–2024 comprised the dynamic monitoring group.
Intervention: nurse-led dynamic urine monitoring protocol
The implemented protocol included three core elements: objective urine color grading, high-frequency dynamic urine recording, and a standardized situation-background-assessment-recommendation escalation pathway led by nursing staff. The protocol emphasized early urine-based recognition of renal risk and timely escalation of interventions by a structured nursing assessment process.
Statistical approach
To reduce baseline differences between groups, propensity score matching was applied before comparing outcomes. AKI incidence and measures of intervention timeliness were compared between matched groups. A multivariate logistic regression model assessed whether the nurse-led dynamic urine monitoring protocol was independently associated with AKI risk.
Population after matching
After propensity score matching, 260 patients were included in the analysis. The matched cohorts were used to compare AKI incidence, progression to more severe AKI, timeliness of interventions, and length of stay in the emergency intensive care unit (ICU).
AKI incidence and severity
The dynamic monitoring group had a significantly lower overall incidence of AKI compared with the historical control group: 33.8% versus 52.3% (P = .003). Progression to more severe AKI (Kidney Disease Improving Global Outcomes [KDIGO] stages 2–3) was also reduced in the dynamic monitoring group: 27.7% versus 42.3% (P = .013).
Timeliness of interventions and resource use
Patients managed under the nurse-led protocol had shorter times to initiation of urine alkalinization and reached target fluid resuscitation volumes more quickly than those in the historical control group. The dynamic monitoring group also had a shorter length of stay in the emergency ICU. All reported timeliness and length-of-stay differences reached statistical significance (all P < .001).
Independent association with AKI risk
In multivariate logistic regression, implementation of the nurse-led dynamic urine monitoring protocol was independently associated with a lower risk of AKI (odds ratio [OR] = 0.409, 95% confidence interval [CI]: 0.232–0.720, P = .002), indicating that the association persisted after adjustment for other variables included in the model.
This historically controlled retrospective analysis found that a structured, nurse-led dynamic urine monitoring approach was associated with a substantial reduction in AKI incidence and with fewer patients progressing to KDIGO stage 2–3 AKI after severe hymenoptera stings. The protocol also correlated with faster initiation of urine alkalinization, quicker achievement of target fluid resuscitation, and shorter emergency ICU length of stay.
The authors suggest that enabling nurses to perform objective urine assessment and to follow a standardized escalation pathway may permit earlier recognition of renal risk and a more timely, standardized clinical response. As reported, the nurse-led protocol was independently associated with lower AKI risk on multivariate analysis (OR 0.409, 95% CI 0.232–0.720, P = .002), supporting its potential role as an effective nursing strategy in this high-risk population.
Limitations
Specific limitations of the study design and potential sources of bias beyond the use of historical controls and propensity score matching were not detailed in the abstract. The full article would need to be consulted for additional information on residual confounding, selection criteria, exact matching variables, and other methodological considerations.
The authors declared no conflict of interest.
The study reported funding from the Zhejiang Provincial Traditional Chinese Medicine Science and Technology Program (grant 2024ZL677).