1. Defining Best Practice Guidelines in the
Care of Continuous Renal Replacement Therapy Patients
Kevin Lakamp1 MS, RN
Ruth Petrov1 MSN RN
Ann Popkess 2 RN PhD
Brittany Bertoni 2 SN SIUE
Ethan Brewer1 BSN RN CCRN
1SSM Healthcare St. Louis , 2Southern Illinois University of Edwardsville
Introduction
Discussion
Implications
Demographics (N=57)
Number
Percent (%)
PATIENTS BY SITE
DePaul 24
42.1
St. Mary’s 33
57.9
GENDER
Female 29
50.9
Male 27
47.4
RACE
White 23
40.4
Non-white
AGE
24-65 28
49.1
66-85
Data indicates that 50% of patients had no anticoagulation ordered with 60% of the interruptions in treatment related to clotting issues. Additionally, citrate, was never ordered.
Sepsis was a comorbid condition in more than half (56% ) of the sample.
Average time from order to initiation of therapy was nearly 5 hours ( 4.94)
Patients spent 6.3% of total time “off” therapy or a mean of 5.67 hours due to various interruptions
Nearly 60% of the sample patient group expired and 32% were discharged to an institution.
ICU RN staff delivering CRRT care was purposefully not included on any details of the study in order to collect "current state" data, and mitigate any unintended study influence on future CRRT delivery.
Treatment delivery interruptions due to clotted and clogged filter sets appear to be influenced by a high percentage of septic patients.
Citrate, an available anti-coagulant, is an option built into the CRRT order set.
Although a drop-down box for filter change reason was added in February 2014, a considerable number of nurses documented filter set changes under the free-texted comments area.
The use of the terms "clotted" and "clogged" did not appear to correlate with the clinical status of patients.
Further education on the differences between clotting and clogging, and the use of the available drop down box for indicating why a filter set was changed is worth review.
While the number of patient charts reviewed was too low to draw any significant statistical inferences, there were apparent differences between the two hospitals in terms of average time "on and off treatment".
Interdisciplinary discussions with prescribing physicians to consider the use of anticoagulation therapy to reduce the incidence of clotted filters and decrease interruption in therapy
A review of the current CRRT education plan with input by CRRT end-users would be beneficial to help clarify EHR documentation opportunities.
The outcome differences between the two hospitals in terms of time off and time on treatment suggest possible practice differences.
Purpose:
Assess continuous renal replacement therapy patient outcomes (define) for a one year period in SSM Healthcare
Describe patient characteristics of those receiving continuous renal replacement therapy
Determine number and types of interruptions to continuous replacement renal therapy
Identify implications for incorporating evidence based care into practice
Literature Review:
Acute Kidney Injury (AKI) is a well-recognized complication in critically ill patients with a substantial impact on morbidity, mortality and utilization of health resources. AKI occurs in estimates of up to 50% of ICU patients as a result of severe sepsis and septic shock.
The role of CRRT in these patients can be seen as twofold: providing renal replacement therapy during acute phases and as immunomodulatory therapy to influence systemic consequences of severe sepsis (Joannidis, 2009; Jqannidis and Forni, 2011).Advances in the technological delivery of CRRT therapy in the past 10 years has allowed for the transfer of the delivery of the CRRT from the expert dialysis nurse to the trained ICU bedside nurse.
This transition potentially decreases the delay in treatment initiation and time spent off dialysis for filter exchanges and other interruptions due to clotting (Heise et. al., 2012; Kellum & Ronco, 2010; Tolwani, 2012) and time off the unit for tests and procedures (Roeder, Ryan, Atkins, & Harms, 2013).
Thus, it is important to compare patient outcomes for patients receiving CRRT in the ICU compared to the literature and published practice guidelines to ensure best practices are implemented throughout SSM.
In 2012, at SSM Saint Louis the ICU staff at DPHC,and SMHC, began providing the CRRT after training. The purpose of this project was to systematically analyze data to determine patient outcomes for this population including interruptions in continuous therapy and lost in time in treatment. .
Patient Outcomes
Mean
Range
Percent (%)
Total time on CRRT (hours per patient)
89.36
1-412
Total time off CRRT (hours)
5.67
1-25
Total number of interruptions
2.71
1-13
Time from order to initiation (hours)
4.94
1-29
Percent time off/total treatment
6.3
*Percentages do not add up to 100 due to missing data
Therapy Type (N=57)
Number of Patients
Percent
Continuous Veno-Venous Hemodiafiltration (CVVHDF) 49
86.0
Continuous Veno-Venous Hemofiltration (CVVH) 7
12.3
Slow Continuous Ultrafiltration (SCUF) 1
1.8
Continuous Veno-Venous Hemofiltration/ Dialysis(CVVH/D)
Use of Anti-coagulation therapy
Labs at initiation of therapy
Number
Percent (%)
None 28
49.1
Systemic Heparin 16
28.1
Heparin 13
22.8
Citrate
Mean
Range
Normal Range
BUN
56.21
15-166
5-25
Creatinine
3.73
Comorbidities (N=57)
Reason for Treatment Interruption
Number of Patients with the Comorbidity
Percent (%)
Vasopressors 51
89.5
Hypertension 46
80.7
Cardiovascular disease 38
66.7
Sepsis 32
56.1
Diabetes 29
50.9
Chronic respiratory disease 19
33.3
Chronic Kidney Disease 18
31.6
Hematologic disease 6
10.5
Liver disease 4
7.0
Number
Percent (%)
Clotting Dialyzer 23
40.4
Clotting and machine 10
17.5
Clogging 9
15.8
Treatment not stopped 7
12.3
Routine Filter change 4
Filter Pressure 2
3.5
References
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group (2012). KDIGO Clinical Practice Guidelines For Acute Kidney Injury. Kidney International Suppl. 2:1-138
Bellomo, R., Ronco, C., Kellum, J. A., et. al. (2004). Acute Renal Failure-definition, outcomes measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care, 8, R
Clark, W. R., Letteri, J. J.,Uchino, S., Bellomo, R., & Ronco, C. (2006). Recent Clinical Advances in the Management of Critically Ill Patients with Acute Renal Failure. Blood Purification, 24,
Heise, D., Gries, D., Moerer, O., Bleckmann, A., & Quintel, M. (2012). Predicting restoration of kidney function during CRRT-free intervals. Journal of Cardiothoracic Surgery, 7(6).
Hussain, S., Piering, W., Mohyuddin, T., Saleh, M., Zhu, Y. R., Hanan, M., & Cohen, E. (2009). Outcome among patients with acute renal failure needing continuous renal replacement therapy: A single center study. Hemodialysis International, 13,
Kellum, J. A., & Ronco, C. (2010). Dialysis: results of renal-What is the optimal CRRT target dose? Nature Reviews Nephrology, 6(4),
Roeder, V. R., Atkins, H. N., Ryan, M. A., & Harms, H. J. (2013). Putting the “C” back into continuous renal replacement therapy. Nephrology Nursing Journal, 40(6),
Seabra, V. F., Balk, E. M., Liangos, O., Sosa, M. A., Cendoroglo, M., & Jaber, B. L. (2008). Timing of renal replacement therapy initiation in acute renal failure: A meta-analysis. American Journal of Kidney Diseases, 52(2),
Tolwani, A. (2012). Continuous renal-replacement therapy for acute kidney injury. New England Journal of Medicine, 367(26),
Procedures
Implications
Retrospective audits of 57 patients who received CRRT therapy from March March Purposive sampling was used to obtain at least 25 patients from each site ( DPHC or SMHC). Chart reviews were completed by two nurse leaders and one staff RN.
Data collected included: demographics, therapy type, lab results, comorbidities, anticoagulation therapy, number and reason for interruptions, time on/off therapy, discharge disposition. Permission was obtained to adapt the Patient Data Collection Tool for CRRT (Roeder, et al., 2013).
SSM StL IRB approval was obtained in June 2014
Identify learning opportunities to understand the differences among the various CRRT treatment modalities, anti-coagulation options, and expected delays in treatment due to filter set changes for some clinical conditions, for example, sepsis.
Collaborative, RN-to-RN communication between ICU unit end-users and unit leadership could build an inter-hospital team to improve practice in the future.
The high mortality rate associated with the use of CRRT underlines the high acuity and co-morbidities of the population for which this therapy is prescribed.
Discharge Disposition
Number
Percent (%)
Expired 34
59.6
SNF/Institution 18
31.6
Home 3
5.3
Other 2
3.5