CRRT/SLEDD Competency Management

1. CRRT/SLEDD Competency Management • What knowledge and skills are essential? • What resources are needed to support the program? Staff? • Print, on-line, personnel, 24/7 on-call or on-site • Collaboration • Change of practice or DME or disposables?

2. CRRT Competency Management • Organize your CRRT competency assessment • Determine critical competencies to evaluate annually • Tie critical competencies to annual performance reviews • Understand JCAHO expectations • National Patient Safety Goals • Develop your CRRT competency assessment program • Design a compliant, consistent, and effective competency assessment program • Validate CRRT competency • Validate clinical proficiency • 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 • Keep up with new CRRT competencies • Verify and document new—and existing—competencies, including those for new equipment

3. CRRT Treatment Responsibilities:Points to Remember • Nephrology Nurse • Initiate treatment based on individual patient needs as assessed by the nephrologist • Bedside Nurse • Do not infuse other medications or blood products directly into the CRRT system • Cooling effects of CRRT may prevent temperature elevation • Adjust patient fluid removal rate hourly to maintain net UFR • Changes in net URF

4. Before TreatmentEquipment/Supplies • Nephrology Nurse • CRRT Equipment/Circuit • Bedside Nurse • Order dialysis fluid; citrate and any replacement solutions • IV tubing for each infusion pump • 3-way stopcocks • Extracorporeal circuit warmer • Extracorporeal circuit prime • Telephone at bedside

5. Before TreatmentEquipment/Supplies • Nephrology Nurse • Review and note CRRT orders • Verify consent • Notify bedside nurse of treatment orders and initiation time • Set-up and prime CRRT circuit with heparinized normal saline • Prime other lines in CRRT circuit • Verify catheter placement • Bedside Nurse • Review, clarify, and note CRRT • Draw baseline labs per CRRT orders • Explain procedure and answer questions as needed • Check cannulated limb for circulation

6. Treatment Initiation • Nephrology Nurse • Assess patient’s condition *fluid and electrolyte • Prep catheter ports • Aspirate appropriate blood volume from catheter and flush w/saline • Prime CRRT circuit w/priming solution and attach blood lines of equipment to catheter(s) • Start citrate drip • After 5’ w/stable VS, start replacement fluid and ultrafiltration • Change catheter site dressing if needed • Bedside Nurse • Assess patient’s condition *fluid and electrolyte • Baseline VS, Wt, PAWP (if applicable), CVP, BP, edema, lung/heart sounds, lab values • VS q 30’ x 2 then q 1 h • Monitor and document starting AP, VP, DFR, RFR, BFR, URF and infusion pump rates

7. 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

8. 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

9. 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

10. CRRT Treatment Responsibilities:q 1 hour • Bedside Nurse • Monitor system for kinks, loose connections, patient bleeding • Evaluate changes in pressure reading VP or AP • Evaluate hemofilter and venous chamber for clotting or fibrin • Evaluate color of ultrafiltrate (no pink-tinged fluid) • Document arterial pressure (AP), venous pressure, BFR, and intake/output

11. CRRT Treatment Responsibilities:q 2 hr into treatment/ q 6 hr thereafter • Bedside Nurse • Check circuit ionized Ca++ (sample from venous port) and patient’s ionized Ca++ (sample from site other than CRRT circuit) • Recheck CRRT circuit/patient ionized Ca++ after any changes in anticoagulation – reference optimal ranges specified • Notify nephrology nurse if circuit clots

12. CRRT Treatment Responsibilities:q 24 hr • Bedside Nurse • Assess patient’s fluid/electrolyte balance and overall condition, PAWP (if applicable), CVP, edema, lungs, heart • Evaluate serum chemistry for changes • Monitor serum calcium and pH for signs of citrate toxicity • Monitor for s/s of sepsis or local infection • Monitor for s/s of hypothermia • Assess and monitor patient’s nutritional status – daily weight, albumin, bowel patterns, skin turgor, muscle wasting • Monitor the integrity of the access dressing – change per protocol

13. 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

14. Safety/Quality • Protocols • Order sets • Solutions • Stability, expirations, FRF/dialysate, medication management, compounding • Managing complications • Anticoagulation • Access (where, size) • Time out?