1. Quality Metrics In CRRT Dr Prabh Nayak Lead Consultant for CRRT, Liver, Kidney & Small Bowel Transplant Birmingham Children’s Hospital, UK

2. Where are we?

3. BCH 31 bedded PICU with approx 1500 admissions annually Children’s hospital with all major subspecialities represented (renal, liver, cardiac surgery, ECLS, haem-onc, neurosurgery, trauma, burns, metabolic, transplant) CRRT service model: PIC driven and PIC delivered 50-60 patients receive CVVH/CVVHDF per year

4. Critically ill pts on CRRT have high mortality Death in CRRT pts CRRT pts Mortality % 2009154335 2010124030 2011153148 2012146023 2013246338 2014133735 2015 (Q1)71547 Grand Total10028935

5. Quality in CRRT To be able to deliver a consistent service with minimal deviation from the standard & minimise variation in practice with minimal complications. Standards & guidelines To the right patient At the right time In the right setting Using the right equipment By the right people Knowledge sharing & improvement

6. Quality Improvement Metrics Outcomes - Circuit life - Circuit downtime - Time to initiate in time-critical conditions (hyperammonaemia) - Ability to provide intra-operative CRRT cover Safety - Any human factors issues? Cost Improvement Process (Vascath, CVVH solutions) Morbidity and mortality case reviews; Audit against standards Service improvements Educational preparedness: Wet labs, simulation sessions

7. ‘Standardisation’ of timing of CRRT initiation possible?

8. Fluid Overload and outcomes Gillespie et al, Pediatr Nephrol (2004) 19:1394-1999 Kaplan-Meier survival estimates, by percentage fluid overload category

10. Randomised Evaluation of Normal vs Augmented Level (RENAL) therapy 1500 critically ill adults CVVHDF 25 ml/kg/hour 40 ml/kg/hour

11. Where speed of initiation is of the essence Change of provision of service Many of these patients retrieved from referring hospitals Pre-primed circuit Senior ready for Vascath insertion Small numbers but ticking time-bombs! Need to decrease the time delay between admission & filtration Hyperammonaemia Year Numbers 2010 5 20115 20125 20137 20143 20152 Grand Total27

13. Build a good ‘CRRT team’

16. Bridging The Gap: Improving Patient Safety Through Targeted In-Situ Simulation Training Nayak PP, Kidd N, Osborne-Ricketts B, Martin J, Heward Y Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 (=proof of high quality care and excellent outcomes)

17. Bridging The Gap: Improving Patient Safety Through Targeted In-Situ Simulation Training Nayak PP, Kidd N, Osborne-Ricketts B, Martin J, Heward Y Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 (=proof of high quality care and excellent outcomes)

20. Collect data, analyse and modify practice

22. CRRT Database @ BCH

27. PICANET (Paediatric Intensive Care Audit Network, UK) dataset collection from 2015

30. CRRT durations Median CRRT duration 90 hrs ( IQR 32 – 186 hrs) Mean 166:52:03 Minimum duration 1hr 40min Maximum duration 1975 hrs!

31. Anticoagulation in our program Heparin alone Year Numbers 2009 23 2010 26 2011 21 2012 48 2013 41 2014 26 2015 7 Grand Total 192 Prostacyclin alone4 Heparin + Prostacyclin Year Numbers 2009 3 2012 1 2013 7 2014 3 2015 1 Grand Total15

32. Prognostication & treatment decision Herpes Survivors (n=5) Non-Survivors (n=6) Initial presentation Non-specific illness (8) Clinical septicaemia (2) Clinical coagulopathy (3) 5/8(62%) 0/2 0/3 3/8 (38%) 2/2 (100%) 3/3 (100%) HSV 1 HSV 2 2 (40%) 3 (60%) 4 (66%) 2 (33%) Aciclovir (time commenced at referring hospital) ≤ 2days (5) > 2days (4) 3/5 (60%) 2/4 (50%) 2/5 (40%) 2/4 (50%) Inotropes (8)2/8 (25%)6/8 (75%) CVVH (7)1/7 (15%)6/7 (85%)

34. What does the future hold? Timing of initiation of CRRT & role of biomarkers? Drug PK studies on extracorporeal circuit Technological innovations in circuit sizes Subspecialised CRRT teams Shared learning from pooled data; multi-centre research

35. Thank you