Pediatric CRRT: The Dialysis-Centric Program

Helen Currier BSN, RN, CNN, CENPDirector, Renal & Pheresis ServicesTexas Children’s HospitalHouston, Texas

Did you know . . . .

Do what you do best….

everyone has different strengths.

Getting Started

DME

• The Pediatric Ideal: CRRT Equipment – Separate and accurate pumps and scales for each

component of CRRT– Range of blood flows with a minimum of

20ml/min– Thermoregulation– Maximum safety features

Supplies

• The Pediatric Ideal: CRRT Circuit– Minimum priming volume with low resistance– Exchangeable components– Biocompatible membrane

CRRT Product Line Management

• Financial Management– Group Purchasing Organization (GPO) – Expenses and Billing– Vendor Contract Compliance

• Materials– Supply Chain Management

• movement and storage of CRRT supplies, from point-of-origin to the bedside

– Workflow– Inventory Control

Supply Chain Event Management (SCEM)

• Know non-clinical events and factors that might disrupt CRRT– Distribution Network

• Number and location of suppliers, production facilities, distribution centers, warehouses and customers

– Distribution Strategy• Centralized versus decentralized, direct

shipment, third party logistics.– Information

• Share valuable information, including demand signals, forecasts, inventory and transportation

– Inventory Management• Quantity and location of inventory

• Explore potential scenarios and plan for solutions

Don’t lose your edge . . . .

Monitor for Achieving Therapy Goals

• Patient– Fluid volume balance– Electrolyte balance– Acid/Base balance– Body temperature– Vascular access for CRRT– Anticoagulation– Nutritional

management

• Device– Blood flow rate– CRRT solutions– Prescribed CRRT Fluid flow

rates to evaluate adequacy of clearance

– Machine circuit pressure alarms

– Integrity of pump tubing segments and/or integrity of transducer or pressure pods

– System to minimize interruption of therapy

Partnership is not a four-letter word

CRRT Competency Management1. Organize your CRRT competency assessment

– Determine critical competencies to evaluate annually – Tie critical competencies to annual performance reviews

2. Understand JCAHO expectations– National Patient Safety Goals

3. Develop your CRRT competency assessment program– Design a compliant, consistent, and effective competency assessment program

4. Validate CRRT competency– Validate clinical proficiency

5. Maintain a consistent CRRT validation system– Ensure that clinical proficiency is assessed and validated in a consistent manner with

our easy to implement skill sheets 6. Keep up with new CRRT competencies

– Verify and document new—and existing—competencies, including those for new equipment

Simulation

• The world is in crisis and the need for superheroes couldn’t be greater . . . .

Nephrology Nurse• How CRRT works• Reason for treatment• When and how to terminate treatment• Equipment operation• Most common alarms• When and how to reach the nephrology team• Fluid balance calculations• Assessment of clotting• How to adjust AP/VP limits, BFR, or UFR• How to verify dialysis fluid or replacement fluid and/or

rate changes

Bedside Nurse: Competencies

• Verbalize– How CRRT works (fluid and solute balance, changes in nutrition

and medications)– Reason for treatment– When and how to terminate treatment– How to troubleshoot alarms (AP, VP, blood leak, error codes, air

detector)– When and how to recirculate the system– How to care for catheter and catheter exit site– When and how to contact nephrologist or nephrology nurse– How to operate extracorporeal circuit warmer

Bedside Nurse: Competencies

• Demonstrate– How to calculate fluid balance– How to assess clotting in the system– How to adjust AP and VP limits, BFR, UFR– How to verify dialysis and replacement fluid

solution and rates– Document continuing care in nursing notes and

flow sheet

Safety Culture: Becoming a Communication Superhero

• Teamwork across hospital units– Cooperation– Coordination

• Handoffs and transitions– Transferring patients

from one unit to another– Shift changes

Staffing Nurses for CRRT• Variations

– Skill mix– Opened vs. Closed– Responsibilities

• Dialysis• Critical Care

• Predictions– FTEs by shift– Budgeting FTEs

• Shortages• Effects

– Clinical Outcomes– Therapy Choice