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

Abstract

<div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="title" id="d483807e298">Rationale and Objective:</h5> <p id="P3">National guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20–25 mL/kg/hr. However, practice patterns nationwide are highly variable and inconsistent prescribing may lead to errors in medication dosing as well as increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="title" id="d483807e303">Study Design:</h5> <p id="P4">Quality improvement study</p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="title" id="d483807e308">Setting and Participants:</h5> <p id="P5">Adult patients treated with CRRT at the University of Colorado Hospital (UCH) between January 2016 and October 2017. </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="title" id="d483807e313">Quality Improvement Activities:</h5> <p id="P6">An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented over the course of one 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, 4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets. </p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="title" id="d483807e318">Outcomes:</h5> <p id="P7">The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20–25 mL/kg/hr. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction. </p> </div><div class="section"> <a class="named-anchor" id="S6"> <!-- named anchor --> </a> <h5 class="title" id="d483807e323">Analytical Approach:</h5> <p id="P8">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 QI interventions. </p> </div><div class="section"> <a class="named-anchor" id="S7"> <!-- named anchor --> </a> <h5 class="title" id="d483807e328">Results:</h5> <p id="P9">Among 837 treatments prior to the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20–25 mL/kg/hr. Following implementation of interventions, 631 out of 952 treatments (66%) achieved this goal. Week-to-week variation in dosing was significantly reduced. </p> </div><div class="section"> <a class="named-anchor" id="S8"> <!-- named anchor --> </a> <h5 class="title" id="d483807e333">Limitations:</h5> <p id="P10">A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems. </p> </div><div class="section"> <a class="named-anchor" id="S9"> <!-- named anchor --> </a> <h5 class="title" id="d483807e338">Conclusions:</h5> <p id="P11">Changes to the EMR and documentation templates as well as education of CRRT providers about dosing were associated with a doubling of the rate of appropriate CRRT dosing and reduction in dosing variability. </p> </div><p id="P12">Continuous renal replacement therapy (CRRT) is a form of continuous dialysis used in critically ill patients, often in the intensive care unit. National guidelines recommend that CRRT be prescribed at a dose of 20–25 mL/kg/hr, however, prescription practices are variable. Inconsistent prescribing patterns among providers may lead to errors in dosing of medications such as antibiotics, and increase rates of blood chemistry abnormalities. This study describes a quality improvement initiative to increase compliance with national guidelines for CRRT dosing. Over the course of one year, multiple interventions to improve compliance were implemented, including modifications to the electronic medical record, modifications to the procedure note and CRRT order templates, and education of providers regarding proper prescribing practices. Following these interventions, the rate of administration of CRRT using dosing consistent with national guidelines doubled from 33% to 66%. </p>