Process based quality improvement using a continuous renal replacement therapy dashboard

The prevalence of continuous renal replacement therapy (CRRT) utilization in critically ill patients with acute kidney is increasing. In comparison to published and on-going trials attempting to answer questions surrounding the optimal timing of CRRT initiation, anticoagulation, and modality, a paucity of literature describes the quality of the therapy delivered.

We conducted a single-center process improvement project to determine if a methodology to assess the quality of CRRT delivery could lead to improvement in CRRT delivery outcomes. We developed three broad categories of objective CRRT metrics to assess longitudinally, enabling creation of a CRRT Dashboard. Following the objective categories of "filter", "prescription", and "fluid balance" over time allowed us to perform quarterly analyses, target provider based CRRT education, and address variation from our standard of care. From 2012 to 2017, 184 critically ill patients received CRRT.

We report a mean filter life of 56 + 28.4 h, a 60-h filter life of 62%, and unplanned filter changes of 15%. Compared to a minimum target prescription of 2000 ml/1.73 m2/hour, we report the mean prescribed dose (2300 ml/1.73 m2/hour) and the rate of patients receiving at least the minimum prescription (98%). Finally, using a 10% deviation in the acceptable range of desired daily patient fluid balance, we report 83% CRRT patient days achieving an acceptable stipulated fluid goal.

We report the implementation of a quality dashboard and adopting quality improvement strategies provided a platform for measuring adherence to our institutional standards and the delivery of CRRT, specifically on the process of the care.