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.

Factors other than patient care dictate imaging acquisition in almost half of those surveyed. Misperception of expectations, misunderstanding of legal imperatives, and liability concerns all delay transport of the injured. ATLS-certified individuals use imaging more appropriately, thus, promoting more timely transfer. State-wide protocols, education, and liability reform may reduce transport delays.

Simulation-based team training improved teamwork attitudes, perceptions, and performance. Team communication demonstrated significant improvement in 2 of the 3 instruments. Most participants agreed or strongly agreed that they were satisfied with simulation and had gained self-confidence.

Alcohol withdrawal syndrome (AWS) manifests after alcohol-dependent individuals suddenly cease alcohol consumption. Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) is a widely used tool to assess and guide treatment of AWS. CIWA-Ar was developed in voluntarily detoxification centers, and the reliability and validity of CIWA-Ar have been minimally evaluated in hospitalized patients. We performed a retrospective chart review of 479 cases of screening and treatment of AWS using CIWA-Ar, of which 118 were admitted to a trauma/orthopedic (T/O) service and 361 to an internal medicine (IM) service. Exploratory factor analyses with varimax rotation were applied for each population, and reliability testing was performed on the determined subscales. Exploratory factor analyses yielded 2 unique structures, each explaining 56% of the variance of CIWA-Ar. The IM group had a 3-factor structure with the Physical Disturbances (23%), Anxiety (19%), and Confusion (14%) subscales. The T/O group had a 2-factor structure with the Neurological Disturbances (36%) and Physical Disturbances (20%) subscales. Overall, Cronbach's alphas were acceptable (0.74 and 0.82 for IM and T/O, respectively); however, Cronbach's alphas for the IM subscales were 0.66 and 0.69 for physical disturbances and anxiety, respectively. Cronbach's alpha for the Confusion subscale was not calculated because only 1 scale item loaded. The subscales of the T/O factor structure yielded Cronbach's alphas of 0.81 for neurological disturbances and 0.62 for physical disturbances. Our analyses did not support the reliability or validity of CIWA-Ar in acutely ill or injured patients, warranting further investigation and tool development for AWS management in the hospital setting.