Nursing issues in renal replacement therapy: organization, manpower assessment, competency evaluation and quality improvement processes

e-Prescribing, Charting, and Documentation for Continuous Renal Replacement Therapy: A Green Intensive Care Unit and Nephrology Initiative

BACKGROUND

Patient care informatics are becoming more advanced with digital capacity and server functionality. The intensive care unit (ICU) is becoming paperless for prescribing, charting, and monitoring care. A further challenge is to include all life sustaining therapies in this digital space. Digital modules and options may be available; however, continuous renal replacement therapies (CRRTs) often require custom design for many nuances. Associated with the COVID pandemic and a surge in the paperless and "green" ICU bedside, we gathered a team to design, develop, and implement a CRRT orders, charting-documentation, and monitoring functionality into our existing Cerner (ORACLE Corp., Austin, Texas, USA) software.

KEY MESSAGES

This included new approaches to the two-dimensional paper documents used prior and a live dashboard with new metrics and data. The design linked to other relevant CRRT pages such as the master patient fluid balance, pathology results, and medication prescribing. The primary views and function are role-related for medical, nursing, and pharmacy with specific and sensitive input. Following the build and implementation, initial evaluation was positive and led to an audit trail or e-history for prescribers use and provision for concurrent therapies. Clinicians use this digital ordering differently with live data available for "handover" and case discussion. There is scope for research and further links to devices such as personal phones and via an app.

SUMMARY

This experience may assist CRRT users design and develop similar prescribing, charting, and monitoring bedside computer opportunities in the desire for digital and green nephrology in the ICU.

Management of renal replacement therapy among adults in French intensive care units: A bedside practice evaluation

Background

This study aimed to investigate renal replacement therapy (RRT) practices in a representative nationwide sample of French intensive care units (ICUs).

Methods

From July 1 to October 5 2021, 67 French ICUs provided data regarding their ICU and RRT implementation. We used an online questionnaire to record general data about each participating ICU, including the type of hospital, number of beds, staff ratios, and RRT implementation. Each center then prospectively recorded RRT parameters from 5 consecutive acute kidney injury (AKI) patients, namely the indication, type of dialysis catheter used, type of catheter lock used, type of RRT (continuous or intermittent), the RRT parameters initially prescribed (dose, blood flow, and duration), and the anticoagulant agent used for the circuit.

Results

A total of 303 patients from 67 ICUs were analyzed. Main indications for RRT were oligo-anuria (57.4%), metabolic acidosis (52.1%), and increased plasma urea levels (47.9%). The commonest insertion site was the right internal jugular (45.2%). In 71.0% of cases, the dialysis catheter was inserted by a resident. Ultrasound guidance was used in 97.0% and isovolumic connection in 90.1%. Citrate, unfractionated heparin, and saline were used as catheter locks in 46.9%, 24.1%, and 21.1% of cases, respectively.

Conclusions

Practices in French ICUs are largely compliant with current national guidelines and international literature. The findings should be interpreted in light of the limitations inherent to this type of study.

Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.

Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices

BACKGROUND

The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life.

METHODS

We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices.

RESULTS

We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in >75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (>75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200-300 mL/min and 400-600 mL/min, respectively. The dose of dialysis for continuous RRT was 25-35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine).

CONCLUSION

This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.

Organizational and financial aspects of a continuous renal replacement therapy program

Critically ill patients who develop severe acute kidney injury in the intensive care unit often require treatment with renal replacement therapies (RRTs). This complication is associated with severe morbidity and mortality and high costs, both during hospitalization and postdischarge. This article discusses the operational requirements to develop and conduct a RRT program, as well as the financial implications of this complex form of patient care. The management of these programs must occur in a context where a clear organizational and educational framework and a multidisciplinary team ensures safety, effectiveness, cost-control, and a clear quality control framework.

The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units

Background

Outpatient dialysis is standardized with several evidence-based measures of adequacy and quality that providers aim to meet while providing treatment. By contrast, in the intensive care unit (ICU) there are different types of prolonged and continuous renal replacement therapies (PIRRT and CRRT, respectively) with varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. To eventually describe appropriate quality measures for ICU-related renal replacement therapy (RRT), we first aimed to capture the variety and prevalence of basic strategies and equipment utilized in the ICUs of Veteran Affairs (VA) medical facilities with inpatient hemodialysis capabilities.

Methods

Via email to the dialysis directors of all VA facilities that provided inpatient hemodialysis during 2018, we requested survey participation regarding aspects of RRT in VA ICUs. Questions centered around the mode of therapy, equipment, solutions, prescription authority, nursing, anticoagulation, antimicrobial dosing, and access.

Results

Seventy-six centers completed the questionnaire, achieving a response rate of 87.4%. Fifty-five centers reported using PIRRT or CRRT in addition to intermittent hemodialysis. Of these centers, 42 reported being specifically CRRT-capable. Over half of respondents had the capabilities to perform PIRRT. Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was largely prescribed by nephrologists (94.4% of centers).

Conclusions

Within the VA system, ICU-related RRT practice is quite varied. Variation in processes of care, prescription authority, nursing care coordination, medication management, and safety practices present opportunities for developing cross-cutting measures of quality of intensive care RRT that are agnostic of modality choice.

Acute kidney injury and continuous renal replacement therapy: A nursing perspective for my shift today in the intensive care unit

Handover, clinical discussion, and care for patients in the Intensive Care Unit (ICU) require visual cues to a verbal "story" in an attempt to quickly understand the patient status. Continuous renal replacement therapy (CRRT) is often associated with sepsis or a toxic cause and "kidney attack" not apparent to the patient; "silent" with no pain, discomfort, or vital sign changes initially. Language, terminology, and definitions for this acute kidney injury (AKI) are a graded classification with guidelines. CRRT and dialysis techniques use the physiological principles of diffusion and or convection for solute removal providing a replacement for the basic kidney functions to sustain life until function returns. When to stop CRRT is based on clinical assessment of the patient overall status and urine production re-starting. The medical treatment is focused on the key interventions of resuscitation, remove the cause, support with CRRT or dialysis and monitor for recovery of function. CRRT requires a multidisciplinary team and quality process, local policies, education, and competency pathways to promote best outcomes and efficacy.

Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit

Critically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.

Optimizing continuous renal replacement therapy in the ICU: a team strategy

PURPOSE OF REVIEW

The consideration of acute kidney injury, its incidence and its impact on the outcome of patients has grown continuously in recent years, leading to an increase in the use of renal replacement therapy (RRT) techniques. However, the successful conduct of RRT depends on the effectiveness of the entire team, doctors and nurses. It is therefore important to know the essential elements to be implemented in the ICU to ensure optimal RRT.

RECENT FINDINGS

Recent studies show that the successful conduct of a RRT session requires a good knowledge of the principles of the technique, regular basic training, identification of experts, drafting clear and well followed protocols and good communication between the various stakeholders. In addition, the use of the latest advances, such as regional citrate anticoagulation, allows further optimization of therapy, only if, again, both physicians and nurses are properly trained and highly involved.

SUMMARY

We now have a better understanding of the measures to be deployed to optimize RRT. Organization, training, evaluation and protocols are the key points of the team's efficiency for a safe and effective implementation of RRT.

Training and Maintaining: Developing a Successful and Dynamic Continuous Renal Replacement Therapy Program

Continuous renal replacement therapy (CRRT) is commonly used to support critically ill patients with acute kidney injury or chronic renal disease whose condition is too unstable for them to tolerate intermittent hemodialysis. Current publications related to CRRT programs in the United States and Canada note key themes related to the development and maintenance of CRRT training programs. A successful CRRT training program should consider and incorporate adult learning principles whenever possible. A variety of teaching methods to deliver information to nurses, including online learning modules, didactic lecture, return demonstration, and high-fidelity patient simulation are key to training programs for this high-risk complex therapy. This article outlines the approach to training nurses to care for patients receiving CRRT at a health care system in Arizona.

Optimal Role of the Nephrologist in the Intensive Care Unit

As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.

Quality measures for acute kidney injury and continuous renal replacement therapy

PURPOSE OF REVIEW

Quality and safety are important priorities in the care of critically ill patients. For patients with acute kidney injury (AKI) or for those receiving continuous renal replacement therapy (CRRT), measures and outcomes associated with quality of care have been suboptimally developed and evaluated. The review is timely as it summarizes current quality practices in AKI and CRRT, and presents ongoing and future developments.

RECENT FINDINGS

The review begins with the history of quality and safety in healthcare. We then discuss the current quality of care offered in AKI and CRRT. Quality measure development methodology, such as plan-do-study-act and the focus-analyze-describe-execute models and lean thinking are then presented and discussed. Finally, recent evidence for quality in AKI and CRRT care, including proposed quality measures, are discussed.

SUMMARY

Few studies have examined the quality of care provided to patients with AKI and CRRT. Evidence suggests opportunities to improve the quality of care received by patients at risk of or who have developed AKI. Priorities for improving quality of care exist across several important themes including risk identification, diagnosis, monitoring, investigation, and strategies for management. Similarly, evidence-informed quality measures of CRRT care have not been rigorously evaluated. These are important knowledge-to-care gaps that require further investigation.

Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD)

Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

[The impact of continuous renal replacement therapy training on nursing competence]

Specific training adapted to the needs of caregivers in intensive care enables professional competence and quality of care to be developed in continuous renal replacement therapy. In addition, it contributes to reducing the stress felt by caregivers and the costs of this technique.

Comparison of circuit patency and exchange rates between 2 different continuous renal replacement therapy machines

BACKGROUND

Continuous renal replacement therapy (CRRT) is an important tool in the care of critically ill patients. However, the impact of a specific CRRT machine type on the successful delivery of CRRT is unclear. The purpose of this study was to evaluate the effectiveness of CRRT delivery with an intensive care unit (ICU) bedside nurse delivery model for CRRT while comparing circuit patency and circuit exchange rates in 2 Food and Drug Administration-approved CRRT devices. This article presents the data comparing circuit exchange rates for 2 different CRRT machines.

MATERIALS AND METHODS

A group of ICU nurses were selected to undergo expanded training in CRRT operation and empowered to deliver all aspects of CRRT. The ICU nurses then provided all aspects of CRRT on 2 Food and Drug Administration-approved CRRT devices for 6 months. Each device was used exclusively in the designated ICU for a 2-week run-in period followed by 3-month data collection period. The primary end point for the study was the differences in average number of filter exchanges per day during each CRRT event.

RESULTS

A total of 45 unique patients who underwent 64 separate CRRT treatment periods were included. Four CRRT events were excluded (see text for details). Twenty-eight CRRT events occurred in the NxStage System One arm (NxStage Medical, Lawrence, Mass) and 32 events in the Gambro Prismaflex arm (Gambro Renal Products, Boulder, Colo). Average (SD) filter exchanges per day was 0.443 (0.60) for the NxStage System One machine and 0.553 (0.65) for Gambro Prismaflex machine (P = .09).

CONCLUSIONS

There was no demonstrable difference in circuit patency as defined by the rate of filter exchanges per day of CRRT therapy.

Improving delivery of continuous renal replacement therapy: impact of a simulation-based educational intervention

PURPOSE

To describe our experience with transitions in both nursing model and educational training program for delivery of continuous renal replacement therapy. There have been very few comparisons between different care and educational models, and the optimal approach remains uncertain. In particular, we evaluated our experience with introducing a simulation-based educational model.

DESIGN

Prospective quality control observational study.

SETTING

The ICU of a tertiary care pediatric referral center.

PATIENTS

All patients undergoing CRRT between July 2007 through July 2010 were included.

MEASUREMENTS AND MAIN RESULTS

We monitored CRRT filter life during a transition from a collaborative to critical care nursing model, and subsequently during a transition from a didactic education program to simulation-based training. During the study period, 80 patients underwent continuous renal replacement therapy with use of 343 filters. Process control charts demonstrated a significant increase in filter life and a decrease in unplanned filter changes. Both of these signals emerged at the same time and corresponded with the introduction of the simulation-based education program. Further statistical analysis showed that filter life improved from 42.5 hours (18.2-66.4 hr) during the didactic education program to 59.4 hours (22.2-76.4 hr) during the simulation-based education program (p = 0.008). This relationship persisted when excluding nonpreventable premature filter discontinuations and in a multivariate model that accounted for other potential influences on filter life.

CONCLUSIONS

We report on the impact of transitioning between different educational programs for continuous renal replacement therapy, specifically with the introduction of a simulation-based approach. We observed a significant and sustained improvement in the delivery of continuous renal replacement therapy as demonstrated by a marked increase in filter lifespan.