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An Institutional Change in Continuous Renal Replacement Therapy
Rebecca A Busch1, Caitlin S Curtis2, Cassandra E Kight3
11 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
Insights
Implementing phosphate adjustments and continuous renal replacement therapy (CRRT) education significantly reduced hypophosphatemia in critically ill patients receiving parenteral nutrition (PN). These changes improved patient safety by preventing low phosphate levels.
Area of Science:
- Nephrology
- Critical Care Medicine
- Nutritional Support
Background:
- Critically ill patients with acute kidney injury often require parenteral nutrition (PN) and continuous renal replacement therapy (CRRT).
- A change to phosphate-free CRRT fluid led to increased hypophosphatemia.
- Interventions included optimizing phosphate in PN, modifying CRRT orders, and CRRT education for the nutrition support team.
Purpose of the Study:
- To evaluate the impact of practice changes on the incidence of hypophosphatemia in patients receiving PN and CRRT.
- To assess the effectiveness of multidisciplinary interventions in preventing a common complication.
Main Methods:
- Retrospective study analyzing phosphate levels and hypophosphatemia incidence across three periods: preimplementation, intermediate, and postimplementation.
- Hypophosphatemia defined as serum phosphate <2.5 mg/dL.
- Generalized linear mixed models used for statistical analysis.
Main Results:
- The study included 336 measures from 49 patients.
- Post-intervention periods showed significantly higher mean phosphate levels compared to preimplementation.
- The likelihood of developing hypophosphatemia was significantly reduced post-intervention (OR 0.07-0.09).
Conclusions:
- Phosphate dosing modifications and CRRT education effectively reduced hypophosphatemia incidence.
- Emphasizes the need for inter-service communication and planning for complex patient care.
- Highlights the importance of system-wide education before implementing clinical practice changes.
Background:
Critically ill patients with acute kidney injury may require parenteral nutrition (PN) and continuous renal replacement therapy (CRRT). Introduction of a phosphate-free premixed renal replacement fluid without system-wide education in May 2011 resulted in increased incidence of hypophosphatemia, necessitating change in practice. Changes included (1) maximizing phosphate in PN, (2) modifying the CRRT order set, and (3) developing a CRRT competency evaluation for nutrition support team members. This study evaluates the effect of these changes on the incidence of hypophosphatemia.
Methods:
Phosphate levels and predicated probability of hypophosphatemia were evaluated for patients receiving PN and CRRT over 3 time periods: prior to implementing the changes (preimplementation), during change implementation (intermediate), and following implementation (postimplementation). Hypophosphatemia was defined as a serum phosphate level <2.5 mg/dL. Generalized linear mixed models were applied for statistical analysis.
Results:
The retrospective study includes 336 measures from 49 patients. Patients in the intermediate and postimplementation periods were not significantly different from each other and had significantly higher mean phosphate levels than patients in the preimplementation period ( P < .0001). They were also less likely to develop hypophosphatemia compared with preimplementation patients (intermediate: odds ratio [OR], 0.07; 95% confidence interval [CI], 0.03-0.18, P < .0001; postimplementation: OR, 0.09; 95% CI, 0.03-0.27, P < .0001).
Conclusions:
Modifications in phosphate dosing together with CRRT education reduced the incidence of hypophosphatemia in PN patients receiving CRRT. Communication of significant changes in clinical care should be shared with all services prior to implementation. Communication and planning between services caring for complex patients are necessary to prevent systems-based problems.
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