1. CRRT Nursing Education Program: Impact on Filter Life and Cost Theresa Mottes, RN University of Michigan C. S. Mott Children’s Hospital April 8, 2010

2. Program Redesign ► Comprehensive Program Assessment  Patient Activity ► Patient/Year; CRRT Days; Trends  Cost Metrics ► Supplies; Staff Time  Nursing Education  Nursing Roles and Responsibilities  Nursing Time Studies

3. Current State ► 25-35 Patient/year ► 300 – 350 Days/year ► $96,064 (US)/year  Supplies  Direct staff time

4. Current State ► Filter Life  Mean Filter Life 42.2 hours ( <1 to 98)  Mean filters/treatment 4.75 (1-21) ► Incident Rate for Adverse Events  Adverse Event defined as hypotension, bradycardia, de-saturation requiring medical intervention  Mean 0.85/treatment (0.28-1.84) ► 0.18/initation (0.06-0.39)

5. Current State ► Education Program  Established new user class  No infrastructure for ongoing/advanced education  Challenges with low volume/high technology ► Nursing  Overall Comfort and Specific Knowledge ► Comfort Score – 3.7 (1-5) ► CRRT Principles - 60% ► Circuit Pressures – 76%

6. Filter Life ► CRRT Filter Life – 168 Filters (Previous Year)  Filter Life > 72 hour – Only 34 (20%) ► Root Cause Analysis of Filter Life < 72 hour  31 unpreventable  113 potentially preventable (67%)  68 correlated to alarms and interventions (40%)

7. Extending Filter Life Benefits 15 % Improvement 12% Reduction 68 % Improvement 41% Reduction

8. Extending Filter Life Benefits 15% - $14,000 Saving Overall - $45,000 Saving

9. Nursing Education ► Define nursing roles and responsibilities  Initiator Role  Preceptor Role  Bedside Role ► Define behaviors and associated skills  Competent; Proficient; Expert ► Develop ongoing education for nurse to advance clinical skills and confidence  Annual – Bedside  Semiannual - Initiator ► Track nurses progression to advanced skill level

10. Nursing Education ► Education process  Simulation Technology ► Allows for integration of knowledge into practice  Scenarios based on identified targeted roles, knowledge gaps, patient safety reports and nurses suggestions ► Scenarios re-evaluated annually  4 scenarios – 10 minutes  Debriefing – Review scenarios, responses and potential future topics

11. Nursing Survey Results

12. Relative reduction of 46%

13. Average increase of >13h (32%)

15. Conclusion ► 31% (13 hr) improvement in Filter Life  Improvement in Nursing Scores in all areas  46% Reduction in Filter Loss for Unknown ► 28% Reduction in Cost  All training done budget neutral ► 22% reduction in potential adverse events Nursing education using innovative simulation techniques improves the delivery of CRRT while reducing cost.

16. Acknowledgements ► Tom Shanley and David Kershaw ► Matthew Niedner ► Tonie Owens, Alyssa Akers-Nowicki and Julie Juno ► Mike Heung