The Landscape of Renal Replacement Therapy in Veterans Affairs Medical Center Intensive Care Units

Abstract

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 continuous and prolonged renal replacement therapies with numerous and varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. In order to eventually understand what quality measures are appropriate 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 87 VA facilities that provided inpatient hemodialysis during 2018, we requested participation in a survey regarding aspects of RRT in VA ICUs. Questions centered around 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 or 72.4%, reported using some form of prolonged or continuous renal replacement therapy (CRRT) in addition to intermittent hemodialysis. Of these 55 centers, 42 reported being specifically CRRT-capable. Over half of the respondents had the capabilities to perform prolonged intermittent renal replacement therapy (PIRRT). Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was overwhelmingly 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, RRT 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.