Quality Indicators for Continuous Renal Replacement Therapy in Critically Ill Patients

• Author / Creator

  Rewa, Oleksa G

• Critical care nephrology is a rapidly growing and developing field within critical care medicine. It encompasses the entire spectrum of mild acute kidney injury (AKI), usually represented by a change in biochemical markers (i.e., serum creatinine and urea) or alterations in clinical parameters (i.e., urine output). There currently exists no specific treatment for AKI; therapy consists of supportive care and prevention of further kidney insults. However, despite these measures, kidney injury can at times progress to overt kidney failure. When this occurs, kidney dialysis is often necessary, occurring in the form of renal replacement therapy (RRT). RRT may take many different forms, from intermittent RRT (IRRT) to continuous RRT (CRRT). Each form may be more or less appropriate, depending on the severity of illness and complexity of the patient. For our sickest patients, therapy is delivered in a continuous fashion, analogous to our own intrinsic kidney function. This provides a more gradual form of RRT, which may be better tolerated by more critically ill patients. CRRT is a complex, costly and highly specialized form of life-sustaining therapy, reserved for our most advanced intensive care units (ICUs) and our most critically ill patients. CRRT must be delivered with utmost care, to ensure the safe and high quality delivery of this life-sustaining therapy. However, there currently exist no routine markers to measure the quality of the delivery and performance of CRRT, nor to benchmark its delivery. This is an important gap in the field of critical care nephrology, and one that this research program sought to address. The first objective of this program was to review the current state of evidence for quality and safety within critical care nephrology. To accomplish this, I conducted a review of the literature to evaluate what quality and safety measures have already been developed and evaluated. I identified that while there have been advances in better defining AKI and that numerous organizations exist to continue to advance quality within critical care nephrology, the quality of care received by patients either at risk of or who have developed AKI remains suboptimal. Additionally, I found that evidence-informed quality indicators (QIs) for CRRT care have not been rigorously evaluated. The results of this review informed the second objective of my research program, which was to identify which QIs currently exist in the literature. To identify potential QIs for CRRT care, I performed a systematic review. I initially screened 8,374 citations from five citation databases as well as from the grey literature. Ultimately 133 studies fulfilled eligibility, and a total of 18 potential QIs across the Donabedian framework of measures of quality were identified. However, these QIs where characterized by heterogeneous definitions, varying quality of derivation and limited evaluation. I concluded that further study was needed in order to develop a concise inventory of QIs that may be applied to CRRT care. This, in turn, informed the third objective of my research program, which was to develop a prioritized list of the most important of these QIs which may be utilized across any CRRT program. To develop this prioritized list, I embarked on a modified Delphi process. A Delphi process is a structured communication method which relies on a panel of experts, consisting of several rounds where experts respond to questions and then have anonymized summary of responses from previous rounds, with the purpose of converging on the ‘correct’ answer. I conducted two internet-based rounds and a third in-person meeting for my modified Delphi process, and ultimately arrived at a prioritized list of 13 QIs for CRRT care. These 13 QIs consisted of two QIs relating to CRRT structure (filter life and specialized care team), seven QIs relating to CRRT processes (delivered dose, downtime, fluid management, medication adjustment, time from prescription to therapy, therapy prescription and small solute clearance) and four QIs of CRRT outcomes (adverse events, bleeding, catheter dysfunction, catheter line-associated bloodstream infections). However, there was disagreement on the precise definitions of these QIs, and uncertainty on which of these may be most easily operationalized in clinical and educational practices. In summary, this research program first evaluated the current state of quality within critical care nephrology, and then developed a prioritized list of 13 QIs for CRRT care. While consensus existed on the importance of these 13 QIs, future work will be required to better define the QIs, to establish benchmarks for bedside care and to operationalize these QIs into our healthcare data management systems. This will in turn create a CRRT Quality Dashboard that may be used to ensure the safe and high-quality delivery of CRRT care to critically ill patients.

• Subjects / Keywords

  • Intensive Care
  • Quality
  • Critical Care
  • Continuous Renal Replacement Therapy
  • Dialysis

• Graduation date

  Spring 2018

• Type of Item

  Thesis

• Degree

  Master of Science

• DOI

  https://doi.org/10.7939/R3BC3TD1P

• License

  This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.