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Quality Metrics in CRRT: Enhancing Pediatric Care at Birmingham Children's Hospital

Dr. Prabh Nayak, Lead Consultant for CRRT at Birmingham Children’s Hospital, discusses the implementation of quality metrics in Continuous Renal Replacement Therapy (CRRT) for critically ill children. The focus is on maintaining high standards, improving outcomes, ensuring safety, and enhancing educational preparedness. Key areas include circuit life, downtime, timely initiation, safety factors, cost improvements, and service enhancements. The goal is to establish a standardized approach to CRRT initiation and optimize fluid management for better patient outcomes. The future outlook involves exploring biomarkers, pharmacokinetic studies, technology advancements, and collaborative research initiatives.

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Quality Metrics in CRRT: Enhancing Pediatric Care at Birmingham Children's Hospital

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  1. Quality Metrics In CRRT Dr Prabh Nayak Lead Consultant for CRRT, Liver, Kidney & Small Bowel Transplant Birmingham Children’s Hospital, UK

  2. Where are we?

  3. BCH 31 bedded PICU with approx 1500 admissions annually Children’s hospital with all major subspecialities represented (renal, liver, cardiac surgery, ECLS, haem-onc, neurosurgery, trauma, burns, metabolic, transplant) CRRT service model: PIC driven and PIC delivered 50-60 patients receive CVVH/CVVHDF per year

  4. Critically ill pts on CRRT have high mortality

  5. Quality in CRRT To be able to deliver a consistent service with minimal deviation from the standard & minimise variation in practice with minimal complications. Standards & guidelines To the right patient At the right time In the right setting Using the right equipment By the right people Knowledge sharing & improvement

  6. Quality Improvement Metrics Outcomes - Circuit life - Circuit downtime - Time to initiate in time-critical conditions (hyperammonaemia) - Ability to provide intra-operative CRRT cover Safety - Any human factors issues? Cost Improvement Process (Vascath, CVVH solutions) Morbidity and mortality case reviews; Audit against standards Service improvements Educational preparedness: Wet labs, simulation sessions

  7. ‘Standardisation’ of timing of CRRT initiation possible?

  8. Fluid Overload and outcomes Gillespie et al, Pediatr Nephrol (2004) 19:1394-1999 Kaplan-Meier survival estimates, by percentage fluid overload category

  9. Randomised Evaluation of Normal vs Augmented Level (RENAL) therapy • 1500 critically ill adults • CVVHDF • 25 ml/kg/hour • 40 ml/kg/hour

  10. Where speed of initiation is of the essence Change of provision of service Many of these patients retrieved from referring hospitals Pre-primed circuit Senior ready for Vascath insertion Small numbers but ticking time-bombs! Need to decrease the time delay between admission & filtration Hyperammonaemia Year Numbers 2010 5 2011 5 2012 5 2013 7 2014 3 2015 2 Grand Total 27

  11. Build a good ‘CRRT team’

  12. Bridging The Gap: Improving Patient Safety Through Targeted In-Situ Simulation Training Nayak PP, Kidd N, Osborne-Ricketts B, Martin J, Heward Y Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 (=proof of high quality care and excellent outcomes)

  13. Bridging The Gap: Improving Patient Safety Through Targeted In-Situ Simulation Training Nayak PP, Kidd N, Osborne-Ricketts B, Martin J, Heward Y Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 (=proof of high quality care and excellent outcomes)

  14. Collect data, analyse and modify practice

  15. CRRT Database @ BCH

  16. PICANET (Paediatric Intensive Care Audit Network, UK) dataset collection from 2015

  17. What does the future hold? Timing of initiation of CRRT & role of biomarkers? Drug PK studies on extracorporeal circuit Technological innovations in circuit sizes Subspecialised CRRT teams Shared learning from pooled data; multi-centre research

  18. Thank you

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