Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative

Benjamin R Griffin, Amanda Thomson, Mark Yoder, Isaiah Francis, Sophia Ambruso, Adam Bregman, Michelle Feller, Shannon Johnson-Bortolotto, Christine King, Deborah Bonnes, Lisa Dufficy, Chaorong Wu, Anip Bansal, Darlene Tad-Y, Sarah Faubel, Diana Jalal, Benjamin R Griffin, Amanda Thomson, Mark Yoder, Isaiah Francis, Sophia Ambruso, Adam Bregman, Michelle Feller, Shannon Johnson-Bortolotto, Christine King, Deborah Bonnes, Lisa Dufficy, Chaorong Wu, Anip Bansal, Darlene Tad-Y, Sarah Faubel, Diana Jalal

Abstract

Rationale & objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25mL/kg/h. However, practice patterns nationwide are highly variable; this inconsistent prescribing may lead to errors in medication dosing and increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability.

Study design: Quality improvement study.

Setting & participants: Adult patients treated with CRRT at the University of Colorado Hospital between January 2016 and October 2017.

Quality improvement activities: An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented during the course of 1 year: (1) modification of the electronic medical record (EMR) to include calculated average 24-hour dose in real time, (2) modification of the CRRT procedure note to include comments on dosing, (3) modification of the CRRT order set to display calculations, and (4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets.

Outcomes: The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 to 25mL/kg/h. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction.

Analytical approach: Rates of weekly CRRT dosing in compliance with national guidelines were determined and used to create run charts showing compliance rates before and after the quality improvement interventions.

Results: Among 837 treatments before the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20 to 25mL/kg/h. Following implementation of interventions, 631 of 952 (66%) treatments achieved this goal. Week-to-week variation in dosing was significantly reduced.

Limitations: A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems.

Conclusions: Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.

Keywords: Quality improvement; acute kidney injury (AKI); best practices; continuous renal replacement therapy (CRRT); critical care; dialysis dose; electronic health record (EHR); evidence-based medicine; guideline implementation; inpatient care; intensive care unit (ICU); nursing practice; quality of care.