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Intervention doubled rate of appropriate continuous renal replacement therapy dosing in ICU
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A series of interventions improved the rate of appropriate continuous renal replacement therapy dosing for patients hospitalized with acute kidney injury, according to a published study.
“[Renal replacement therapy] RTT is the only U.S. Food and Drug Administration-approved therapy for AKI, and continuous RRT (CRRT) is generally the preferred modality in the ICU given that it is associated with less hemodynamic instability compared with intermittent therapy,” Benjamin R. Griffin, MD, of the division of renal diseases and hypertension in the department of medicine at the University of Colorado Anschutz Medical Campus, and colleagues wrote. They add that clinical practice guidelines call for a CRRT dose of 20 mL/kg/h 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,” they wrote.
Researchers implemented a variety of interventions between January 2016 and October 2017 to improve CRRT dosing practice patterns for adults treated at the University of Colorado Hospital. Interventions consisted of three primary modifications, including changes to the electronic medical record so that it included calculated average 24-hour dose in real time; changes to the CRRT procedure note to include comments on dosing; and changes to the CRRT order set so that it displayed calculations. In addition, yearly educational sessions were provided for renal fellows regarding CRRT-specific dosing targets.
The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 mL/kg/h to 25 mL/kg/h. Also considered were CRRT flowsheet accuracy, documentation of rates of delivered dose and nursing satisfaction. Variability in CRRT dosing was assessed before and after the intervention.
Researchers found that, before the intervention, 33% of daily CRRT sessions achieved the target dose. This increased to 66% following the intervention. Furthermore, researchers observed significant reductions in week-to-week variation in dosing.
“There remain several important barriers to achieving 100% compliance with dosing recommendations,” they wrote. “A major hurdle was the difficulty predicting downtime for a particular day. Patients often were temporarily taken off CRRT for operating room visits, radiology or because of circuit clotting. If the provider over- or underestimated time off, the dose often fell out of range. Circuit loss especially was difficult to anticipate. These data suggest that additional quality improvement interventions, such as to prolong circuit life, are necessary.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
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