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.
Continuous renal replacement therapy (CRRT) is a modality by which critically ill and hemodynamically unstable patients in the intensive care unit (ICU) can receive hemodialysis. Documentation for CRRT includes many crucial elements and contributes significantly towards the achievement of treatment goals. One of these is ultrafiltrate (UF) removal calculation, which is imperative to addressing fluid volume overload and reducing mortality. Our large academic medical center implemented a new electronic health record (EHR) that revamped CRRT documentation and was rife with opportunities for improvement. A hospital-wide survey sent to ICU staff revealed that most nurses felt they did not receive adequate CRRT documentation education, specifically tailored towards the new EHR. Review of the literature supported the notion that improvements in documentation could be made through enhanced educational offerings. The CRRT nursing curriculum was redesigned to place more emphasis on teaching the purpose and correct implementation of documenting in our EHR. The results of the educational intervention were increased confidence in CRRT documentation as well as improved competency.
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