Journal Departments

Controversies in Nephrology Nursing

Who Should Provide Continuous Renal Replacement Therapies?
Christy Price Rabetoy, Department Editor

Nephrology Nurses Are Better Prepared to Provide CRRT
Kathy Ellis, BSN, CNN, MHS
Acute Dialysis Unit Director, Ochsner Medical Center
New Orleans, LA
2007 President-Elect, ANNA’s Fleur de Lis Chapter

Models
There are basically two models for providing CRRT: (1) the critical care nurses assume full responsibility, and (2) responsibilities are shared between acute care nephrology nurses and critical care nurses. Our hospital employs the latter model, which I believe best supports optimal care. A literature review did not reveal evidence-based data to support either model; however, I believe there is convincing argument for shared responsibility if we examine four domains in CRRT planning: training, proficiency, capacity, and quality.

CRRT Training. Numerous logistical challenges exist in training critical care nurses in the principles and processes of CRRT, both initially and over time:

If CRRT is outsourced, an inherent conflict of interest exists for contractors to share their expertise with hospital staff. Consequently, training may be cursory or so complicated that retention is difficult and performance inconsistent.
Classroom inservices are inadequate to assure clinical competencies, so rotation through the dialysis unit is essential. Inservices can be logistically challenging and costly, particularly in larger programs.
Part-time, PRN, float, and agency staff scheduled to work in ICU are difficult to train in CRRT.
Critical care nurses are less motivated to embrace more responsibility in a high acuity setting, where they are already stretched thin or have multiple assignments. Without motivation, there is less learning readiness.

CRRT Proficiency. Practice is essential to cement training, improve efficiency, and build confidence. Numerous barriers, however, block practice opportunities.

The volume of patients requiring CRRT is unpredictable, and larger ICUs have numerous nurses competing for limited practice opportunities.
Nurses needing more exposure may not be available when opportunities arise due to time off, random scheduling, or fixed assignment areas.
Hospital continuing education programs do not provide sufficient CRRT data to stay abreast of practice trends, thus creating the need for outside symposia. Critical care nurses, however, do not routinely attend symposia providing the most CRRT information. Acute care nephrology nurses do.

CRRT Capacity. The criteria for CRRT always include hemodynamic instability, and the mortality is typically high. This dictates that critical care nurses focus more on the patient without distraction of the concomitant tasks of CRRT such as equipment/water treatment set-up, preparing dialysate, priming, testing, and disinfection. Set-up time alone (barring complications) can take an hour or more. Critical care nurses cannot possibly absorb these responsibilities without impacting quality.

CRRT Quality Management. Finally, there is a need to tie outcome data to variables of case mix and interventions so they can be analyzed and reported. Anecdotal evidence and opinions are insufficient if we are to support the larger agenda of promoting evidence-based practice. It is unreasonable to expect dynamic ICUs to commit the time needed for analyzing subpopulations within a relatively small dimension of their practice. Nephrology nurses, on the other hand, are committed to the entire renal replacement spectrum so motivation is higher and quality measures are more likely to be complete, reliable, and valid.

Summary
Although critical care nurses are fully capable of learning CRRT, there are substantial, irrefutable challenges to achieving and sustaining proficiency. There is also diminished opportunity and motivation for critical care nurses to advance CRRT practice through quality initiatives, education, or research when it is a small piece of their practice. Consequently, I believe that it is incumbent upon acute care nephrology nurses to clarify the magnitude and value of what we do and to support our critical care colleagues in doing what they do best. The debate as to who should perform CRRT began in an effort to explore the better opportunity for cost-saving; but, in the end, it really boils down to the better opportunity for life-saving. I suspect improving outcomes for patients requiring CRRT will ultimately save hospitals more money than the short-sighted gains from critical care nurses performing tasks outside of universally-applied critical care RN processes.

CRRT Should Be Initiated And Managed By Critical Care Nurses
Kathleen M. Burns, MNEd, BSN, RN, CCRN
Clinical Nurse Specialist, Cardiovascular Intensive Care Unit
Vanderbilt University Medical Center
Nashville, TN

Continuous hemofiltration, continuous hemodialysis, and continuous hemodiafiltration therapies are usually reserved for the most fragile, hemodynamically unstable patients in our care. The prescription and execution of continuous renal replacement therapies (CRRT) must be integrated with patient assessment and management. No aspect of the complex care, ongoing assessment, and therapeutic interventions that these patients require can be separated from the whole because even slight variations in fluid or electrolyte balance can initiate immediate catastrophic events or slow, unrecoverable declines in organ function.

As our medical care and the accompanying skills and technologies grow in complexity, nurses have become more specialized. Safe and optimal use of CRRT requires concurrent advanced hemodynamic and oxygenation assessment, manipulation of fluids and vasoactive infusions, and early recognition of the patient’s intolerance of acute abnormalities. Identification and integration of this information for the critically ill patient is the hallmark of an experienced critical care nurse.

CRRT is a single group of therapies with blood flow, fluid, anticoagulation, and volume ultrafiltration variations, making the management of CRRT systems less complex than that of hemodialysis/plasmaspheresis machines. Knowing how to set up the therapies enables the nurse to comprehend the clinical implications of changing flow rates or solutions and the differences between pre- and post-dilution replacement fluids. Understanding and managing the circuit anticoagulation ensures that systemic bleeding or clotting risks are comprehensively assessed and addressed. When the nurse who is responsible for total care can integrate the clearance, fluid removal, and electrolyte management into the broader picture of medication administration and preload, afterload, cardiac output, and rhythm management, these very vulnerable, very sick patients receive optimum care.

Therapy initiation will occur more quickly in a setting in which the critical care nurse can independently prime the circuit and initiate the therapy. As a member of the multidisciplinary team involved in determining the necessity for CRRT, the critical care nurse will prioritize initiation of the therapy appropriately. If initiation is dependent on the availability of a nephrology nurse, initiation delays are inevitable. In many hospitals, nephrology nurses are available through a call schedule on nights or weekends. In these situations, therapy initiations are likely to be delayed, and ongoing therapy interrupted, for extended periods of time.

For safety reasons, the critical care nurse should be able to address the clinical indicators and alarms of the CRRT system. The ability to troubleshoot is a byproduct of a high level of comfort with the equipment that develops with responsibility for set-up and management. ECRI Health Device Alerts have been issued over the last 2 years reporting patient injury and deaths caused by situations in which CRRT machines’ incorrect-weight-detected alarms were repeatedly silenced and left uncorrected for prolonged periods of time. When critical care nurses are able to interpret the system pressures and alarms, alarm conditions will be corrected, filters will be changed while the circuit blood can still be returned to the patient, and the dialysis therapy will be optimized because compromised filters will be recognized and more promptly changed.

Although adding CRRT machine set-up to the ever expanding responsibilities of the critical care nurse initially causes a few whimpers, one of the worst scenarios for a diehard critical care nurse is to have something attached to a patient that the nurse does not know how to troubleshoot. To be responsible for a patient, but not to be able to do anything except silence an alarm and call for help causes frustration not only to the nurse, but also to the patient and his or her family. They need to know that someone is ALWAYS there to fix things.

Critical care nurses should not be responsible for intermittent or extended hemodialysis treatments or for plasmaphoresis procedures. These are specialty practices. CRRT is a continuous therapy that is used on critically ill patients. It should be set up and managed by the critical care nurse who is continuously with the patient, and who must integrate this therapy into the total therapeutic plan for the patient.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.