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Building a continuous renal replacement therapy program in a community hospital

Maxwell, Thomas MSN, MA, RN-BC

doi: 10.1097/01.CCN.0000602712.74465.f7
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Abstract: Continuous renal replacement therapy (CRRT) is a high-risk therapy used to treat acute kidney injury. Community hospitals lack the patient volume to adequately develop staff CRRT competency. This article will cover lessons learned developing a CRRT program at a small community hospital with low patient census requiring CRRT.

Continuous renal replacement therapy (CRRT) is a high-risk therapy used to treat acute kidney injury. Community hospitals lack the patient volume to adequately develop staff CRRT competency. This article will cover lessons learned developing a CRRT program at a small community hospital with low patient census requiring CRRT.

Thomas Maxwell is an advanced nurse clinician at Virtua Hospital, Voorhees, N.J.

The author has disclosed no financial relationships related to this article.

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Acute kidney injury (AKI) occurs in approximately 20% of patients admitted to the ICU and is associated with increased morbidity and mortality.1,2 The prevalence of renal replacement therapy (RRT) for AKI is approximately 23%.2 RRT can be applied intermittently with intermittent hemodialysis, or continuously with continuous renal replacement therapy (CRRT). CRRT is the preferred mode of RRT in critically ill patients, especially in patients with hemodynamic instability.2,3 (See CRRT treatment modes.)4 Indications for CRRT include hyperkalemia, metabolic acidosis, fluid overload, and signs of uremia.2,5

CRRT removes metabolic waste, solutes, and excess fluid over a 24-hour period while the native kidneys recover. The patient's healthcare provider orders the treatment mode, therapy fluid type, treatment intensity, and blood and ultrafiltrate rates based on the patient's individualized needs.6 The nurse is responsible for acknowledging the CRRT order; gathering all supplies; setting up and discontinuing the dialysis circuit; monitoring lab values, acid-base imbalances, electrolyte replacement, hemodynamic parameters, and fluid balance; and titrating blood flow and ultrafiltrate rates as prescribed. Other nurse expectations include managing catheters, troubleshooting alarms, monitoring circuit pressure trends for clotting/clogging, and completing hourly device and safety checks.

Adding to the complexity of CRRT management are the therapy's inherent complications. The most common complications are electrolyte imbalances, hypotension, blood stream infections, anemia, hypothermia, and hemorrhage.7,8 Coupled with these inherent risks is the possibility of human error leading to adverse events. Human error can take place during CRRT circuit setup, fluid balance calculations, machine rate changes, lab results review, electrolytes or fluid administration, and evaluation of the patient's response to therapy.8 Because of the high risk and complexity of CRRT initiation and management, it is recommended that clinical nurses complete an introductory course, have frequent exposure to the therapy, participate in a refresher course on setup and troubleshooting, and complete annual competency evaluations.9,10 This article will outline a CRRT training program developed for a nonteaching community hospital that uses CRRT in the ICU.

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Setting

The community health system consists of three accredited nonprofit acute care hospitals. The training program described in this article pertains to one hospital within the health system. The program hospital ICU houses 24 private rooms and employs 75 full-time, part-time, and per diem RNs. ICU leadership consists of a nursing director, assistant nurse manager, and advanced nurse clinician. The advanced nurse clinician is responsible for staff education and training, quality and patient outcomes, and validating RN competence.

Traditionally, patients requiring intermittent hemodialysis are transferred to another hospital in the health system secondary to lack of an inpatient dialysis suite. Therefore, the RNs at the author's community hospital were not accustomed to routinely caring for patients requiring intermittent or continuous dialysis or managing a hemodialysis catheter. Prior to introducing the CRRT program, the ICU nurses only performed peritoneal dialysis. Approximately 10% of the ICU RNs had prior CRRT experience from other places of employment, although with a different CRRT device.

The program hospital also has the lowest case mix index of all three hospitals within the health system, which lessens its acuity level compared with the other hospitals. The other two hospitals have a larger patient population with renal and cardiac disorders, so those RNs are accustomed to routinely managing high-risk, low-frequency therapies, such as intra-aortic balloon pump counterpulsation. One hospital had a collaborative CRRT program already in place. The health system decided to use a critical care managed model in which the ICU RN assumes full responsibility of CRRT and provides total care to the patient at all hospitals. A 1:1 nurse-to-patient ratio is maintained for CRRT. On average, the program hospital experiences approximately 16 12-hour shifts per month with patients requiring CCRT.

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Super users as change agents

Ongoing support following initial education leads to a successful CRRT program. Super users can receive additional training and then offer frontline peer-to-peer support.11 At the program hospital, six RNs were identified as super users—three for day shift and three for night shift. Super users were chosen based on their clinical proficiency, past CRRT experience, availability, approachability, patience, enthusiasm for the program, and ability to manage difficult patient situations.12 Super users are expected to be influential and positive change agents.

Staff members were anxious about and skeptical of the impending change. The identified barriers to change were lack of CRRT experience, decreased awareness of the advantages of CRRT for patients, and fear of CRRT-related complications.

Everett Rogers' Diffusion of Innovations model served as the framework to drive the innovation.13 The model describes how a new idea or product over time diffuses through a population with the result being acceptance of the new idea or product. Rogers' model relies heavily on existing communication channels and near-peer opinions to diffuse the innovation. Communication channels include email, staff meetings, daily huddles, leadership rounding, workshops and lectures, and visits from interest groups. Five adopter categories exist in the Diffusion of Innovations model.13 (See Diffusion of Innovations adopter categories.)13 At the studied hospital, innovators and early adopters were chosen to serve as super users.

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CRRT training program

A health system-wide CRRT task force was established to determine device selection, initial training hours, ongoing support, training dates, and go-live dates. Representation from each hospital consisted of advanced nurse clinicians, clinical RNs, nursing leadership, and physicians; and the task force was led by the assistant vice president for patient care. All decisions were made by consensus taking into consideration patient acuity, RN skill mix at each hospital, and budgetary restraints.

The task force decided to use the train-the-trainer method with the vendor providing 16 hours of training to the super users. The remaining clinical RNs would receive 4 hours of CRRT training. The modes taught were CVVH, CVVHD, and SCUF. The vendor also offered an 8-hour session to new users, but the task force consensus was that all users complete the 4-hour session. The 4-hour session included didactic instruction, hands-on skill training with return demonstration, and a multiple-choice test. The vendor supported the super users teaching the 4-hour class over the course of 1 week, with training responsibilities gradually shifting from the vendor to the super users. By the end of the training week, the super users were teaching 100% of the content. Ongoing support following initial training was provided by the advanced nurse clinician at the point of care and by the vendor's regional educator via unit-based refresher courses.

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The advanced nurse clinician facilitated integration of the concepts and skills taught through bedside rounding and mentoring. Just-in-time training (JITT) was also used at the bedside to promote discussion and reflection.10 JITT provides training at the point of care when it is actually needed; for example, reviewing how to perform a blood return. Another form of JITT is the use of the touch-screen monitor for access to instructional videos and written instructions for operating and troubleshooting. The advanced nurse clinician also provided prompting for novice RNs during initial setup, treatment monitoring and guided RNs through alarm troubleshooting. Prompting is the use of verbal or visual prompts to assist a learner in acquiring a new skill. For example, an instructor might verbally prompt the user to assess the hemodialysis catheter when there is a low-access pressure alarm. The advanced nurse clinician has flexible hours and supported and mentored night shift by being available at the beginning or end of the shift.

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Additional education

Eight months after go-live, the staff reported that 4 hours of training did not prepare them to meet expectations. The volume of patients requiring CRRT was less than anticipated to afford adequate experience for all ICU RNs to improve and maintain the skill. For some RNs, the initial experience in the ICU was weeks or months removed from the vendor education. Many facilities limit CRRT training to a core group of nurses in order to increase exposure for each nurse.9 More frequent exposure allows the repetition adult learners need to learn a skill. Over time, the core group grows resulting in a larger pool of resource RNs to mentor novice CRRT users.

The advanced nurse clinician identified a knowledge/practice gap through direct observation, medical record and alarm audits, and staff feedback. The low volume of patients requiring CRRT coupled with staff volume of 75 RNs resulted in skill dilution; the volume of patients did not support RN competency at managing CRRT. The advanced nurse clinician identified practice gaps that included unnecessary cartridge changes, excessive catheter manipulation, increased alarms, and disruptions in treatment.

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A proposal for a refresher course and additional education hours was submitted to unit leadership for approval. The plan was to develop a core group of users. Approval was granted to provide an additional 4 hours of training to 18 RNs. The course curriculum was designed relative to identified practice gaps. The staff completed a pre- and postcourse self-evaluation. A 5-point Likert scale using Benner's novice to expert framework was used to allow for reflection and quantify perceived level of skill.14 (See Pre- and post-CRRT self-assessment.) All RNs reported a perceived increase in skill. (See Self-assessment of perceived skill.)

Courses were limited to one or two nurses to ensure adequate hands-on practice and demonstration of skills, and to tailor the instruction to meet the needs of the learner. Participants were required to teach back and demonstrate the concepts and skills. Following the refresher course, the advanced nurse clinician spent time at the bedside with the RN to reinforce the learning. As CRRT users became more proficient, the advanced nurse clinician resorted to rounding. The rounds assisted with troubleshooting, took advantage of teachable moments, discussed clinical issues, and taught how to prevent and manage adverse events.10 After 6 months of training, the advanced nurse clinician observed increased independence among RNs in managing CRRT and staff participating in peer-to-peer consultations to troubleshoot complications. The increased skill can be attributed to the refresher course and shift to a core group of users. The core group approach allows each RN to have additional exposure to CRRT therapy. The CRRT program continues to evolve and an annual competency is under development. The percentage of competent to expert CRRT users is approximately 25%. The target goal is to have 50% of the staff trained to perform at the competent level or better.10

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Lessons learned

Offering CRRT in a community hospital has its challenges secondary to the low volume of patients requiring CRRT, but these challenges can be overcome with leadership support and strategic planning. Priority is given to staff with CRRT experience because they require less training. New staff who have experience at larger teaching hospitals usually just need to have CRRT skill validation completed with the advanced nurse clinician. Next, choose innovators and early adopters to build the core group of users. RN turnover is a constant, so new users are proactively identified and trained to replace experienced users.

A community hospital with a low volume of patients requiring CRRT can consider having a core group of RNs complete an 8-hour new user session with the vendor. In hindsight, this may have been the better option for the program hospital, as it would have allowed for more hands-on training and more frequent exposure to CRRT. The ICU has been providing CRRT for approximately 2 years, and the early and late majority now inquire about taking the refresher course. The trepidation of the late majority RNs has waned as the treatment has become commonplace and there are more experienced CRRT users on the unit to support novice users.

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Limitations

A limitation to super users providing peer support is the ability to provide support when needed. Red action alarms on the CRRT machine require immediate interventions in order to avoid circuit clotting. The super users have a two-patient assignment and may not be available when needed. The advanced nurse clinician spending time at the bedside with the RN following the didactic and hands-on training expedites the learning. User confidence is increased through questioning, reflection, and advanced nurse clinician-supported live experiences, decreasing some of the burden on the super users for support. There was a positive increase in perceived skill by the nurses following the refresher course.

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A drawback of having a core group is the probability that an experienced user will not be on the schedule when a patient requiring CRRT is on the unit. In such an instance, the advanced nurse clinician would be available to provide support, but this need has diminished as the core group grew. Initially, the weekends were the biggest challenge. The unit leadership and staff identified six RNs on each weekend—three day shift and three night shift—as CRRT users. This ensured that there would be an adequate number of experienced users available through the weekend shifts available for patients requiring CRRT, despite staff cancellations and scheduled time off. When considering a CRRT program at a community hospital, determine if the patient volume will support staff development and sustainability of competencies, and validate that leadership support and finances are available to provide refresher courses beyond the initial vendor training to develop and sustain CRRT competency.

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Conclusion

Developing and implementing a CRRT program is a dynamic process that requires ongoing evaluation and revisions in training. The expected outcome is preparing nurses to independently deliver quality patient care. A key to success is high-frequency exposure to the high-acuity skill. Proficiency is difficult to attain with minimal exposure to the skill following initial education. A low volume of patients requiring CRRT in a community hospital may prevent staff from becoming highly proficient. Interventions to overcome this limitation are to use a core CRRT user group, provide a refresher course, and mentor CRRT RNs at the bedside. Advantages of the CRRT program at the studied hospital include improved nurse autonomy and satisfaction, fewer delays in treatment, and less risk of complications from transferring unstable patients.

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REFERENCES

1. Khadzhynov D, Schmidt D, Hardt J, et al The incidence of acute kidney injury and associated hospital mortality. Dtsch Arztebl Int. 2019;116(22):397–404.
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Keywords:

acute kidney injury; continuous renal replacement therapy (CRRT); dialysis; ICU; super users; training program

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