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

doi:10.1053/j.ajkd.2019.06.013

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

Research output: Contribution to journal › Article › peer-review

20 Scopus citations

Abstract

Rationale & Objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25 mL/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 25 mL/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 25 mL/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.

Original language	English (US)
Pages (from-to)	727-735
Number of pages	9
Journal	American Journal of Kidney Diseases
Volume	74
Issue number	6
DOIs	https://doi.org/10.1053/j.ajkd.2019.06.013
State	Published - Dec 2019
Externally published	Yes

Bibliographical note

Funding Information:
Benjamin R. Griffin, MD, Amanda Thomson, RN, Mark Yoder, RN, Isaiah Francis, MPH, Sophia Ambruso, DO, Adam Bregman, MD, Michelle Feller, RN, Shannon Johnson-Bortolotto, RN, Christine King, RN, Deborah Bonnes, RN, Lisa Dufficy, PharmD, Chaorong Wu, PhD, Anip Bansal, MD, Darlene Tad-y, MD, Sarah Faubel, MD, and Diana Jalal, MD. Research idea and study design: BRG, AT, MY, MF, SJB, CK, DB, LD, DT, SF, DJ; data acquisition: BRG, IF, SA, ABregman, ABansal; data analysis/interpretation: BRG, AT, DJ; statistical analysis: CW, BRG, DT, DJ; supervision or mentorship: DT, SF, DJ. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135. This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health (UL1TR002537). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication. The authors declare that they have no relevant financial interests. Received January 17, 2019. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form June 20, 2019.

Funding Information:
The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135 . This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health ( UL1TR002537 ). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication.

Publisher Copyright:
© 2019 National Kidney Foundation, Inc.

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

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Griffin, B. R., Thomson, A., Yoder, M., Francis, I., Ambruso, S., Bregman, A., Feller, M., Johnson-Bortolotto, S., King, C., Bonnes, D., Dufficy, L., Wu, C., Bansal, A., Tad-y, D., Faubel, S., & Jalal, D. (2019). Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative. American Journal of Kidney Diseases, 74(6), 727-735. https://doi.org/10.1053/j.ajkd.2019.06.013

Griffin, BR, Thomson, A, Yoder, M, Francis, I, Ambruso, S, Bregman, A, Feller, M, Johnson-Bortolotto, S, King, C, Bonnes, D, Dufficy, L, Wu, C, Bansal, A, Tad-y, D, Faubel, S & Jalal, D 2019, 'Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative', American Journal of Kidney Diseases, vol. 74, no. 6, pp. 727-735. https://doi.org/10.1053/j.ajkd.2019.06.013

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title = "Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative",

abstract = "Rationale & Objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25 mL/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 25 mL/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 25 mL/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",

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

note = "Funding Information: Benjamin R. Griffin, MD, Amanda Thomson, RN, Mark Yoder, RN, Isaiah Francis, MPH, Sophia Ambruso, DO, Adam Bregman, MD, Michelle Feller, RN, Shannon Johnson-Bortolotto, RN, Christine King, RN, Deborah Bonnes, RN, Lisa Dufficy, PharmD, Chaorong Wu, PhD, Anip Bansal, MD, Darlene Tad-y, MD, Sarah Faubel, MD, and Diana Jalal, MD. Research idea and study design: BRG, AT, MY, MF, SJB, CK, DB, LD, DT, SF, DJ; data acquisition: BRG, IF, SA, ABregman, ABansal; data analysis/interpretation: BRG, AT, DJ; statistical analysis: CW, BRG, DT, DJ; supervision or mentorship: DT, SF, DJ. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135. This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health (UL1TR002537). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication. The authors declare that they have no relevant financial interests. Received January 17, 2019. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form June 20, 2019. Funding Information: The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135 . This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health ( UL1TR002537 ). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication. Publisher Copyright: {\textcopyright} 2019 National Kidney Foundation, Inc.",

year = "2019",

month = dec,

doi = "10.1053/j.ajkd.2019.06.013",

language = "English (US)",

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T1 - Continuous Renal Replacement Therapy Dosing in Critically Ill Patients

T2 - A Quality Improvement Initiative

AU - Griffin, Benjamin R.

AU - Thomson, Amanda

AU - Yoder, Mark

AU - Francis, Isaiah

AU - Ambruso, Sophia

AU - Bregman, Adam

AU - Feller, Michelle

AU - Johnson-Bortolotto, Shannon

AU - King, Christine

AU - Bonnes, Deborah

AU - Dufficy, Lisa

AU - Wu, Chaorong

AU - Bansal, Anip

AU - Tad-y, Darlene

AU - Faubel, Sarah

AU - Jalal, Diana

N1 - Funding Information: Benjamin R. Griffin, MD, Amanda Thomson, RN, Mark Yoder, RN, Isaiah Francis, MPH, Sophia Ambruso, DO, Adam Bregman, MD, Michelle Feller, RN, Shannon Johnson-Bortolotto, RN, Christine King, RN, Deborah Bonnes, RN, Lisa Dufficy, PharmD, Chaorong Wu, PhD, Anip Bansal, MD, Darlene Tad-y, MD, Sarah Faubel, MD, and Diana Jalal, MD. Research idea and study design: BRG, AT, MY, MF, SJB, CK, DB, LD, DT, SF, DJ; data acquisition: BRG, IF, SA, ABregman, ABansal; data analysis/interpretation: BRG, AT, DJ; statistical analysis: CW, BRG, DT, DJ; supervision or mentorship: DT, SF, DJ. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135. This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health (UL1TR002537). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication. The authors declare that they have no relevant financial interests. Received January 17, 2019. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form June 20, 2019. Funding Information: The study was funded by a University of Colorado Clinical Effectiveness and Patient Safety Grant for Residents and Fellows (CEPS-RF) award; CEPSRF-2016001. Dr Griffin is supported by a National Research Service Award Institutional Predoctoral Training Grant (T32), grant number T32 DK 007135 . This study was supported in part by The University of Iowa Clinical and Translational Science Award granted with funds from the National Institutes of Health ( UL1TR002537 ). None of these funding sources had a role in study design; data collection, analysis, or reporting; or the decision to submit for publication. Publisher Copyright: © 2019 National Kidney Foundation, Inc.

PY - 2019/12

Y1 - 2019/12

N2 - Rationale & Objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25 mL/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 25 mL/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 25 mL/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.

AB - Rationale & Objective: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25 mL/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 25 mL/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 25 mL/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.

KW - Quality improvement

KW - acute kidney injury (AKI)

KW - best practices

KW - continuous renal replacement therapy (CRRT)

KW - critical care

KW - dialysis dose

KW - electronic health record (EHR)

KW - evidence-based medicine

KW - guideline implementation

KW - inpatient care

KW - intensive care unit (ICU)

KW - nursing practice

KW - quality of care

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

Abstract

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Keywords

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