Standardization of Continuous Renal Replacement Therapy Targets High Value Care: An Evidence Based Approach

From the 2018 HVPAA National Conference

Joshua Tseng (Cedars-Sinai Medical Center), Ronald Halbert (Cedars-Sinai Medical Center), Nareg Minissian (Cedars-Sinai Medical Center), Hector Rodriguez (Cedars-Sinai Medical Center), Shrinath Barathan (Cedars-Sinai Medical Center), Patricia Hain (Cedars-Sinai Medical Center), Rodrigo Alban (Cedars-Sinai Medical Center)

Background

Continuous renal replacement therapy (CRRT) is an essential tool in the management of renal failure in critically ill patients, but it is a resource-intensive, costlier modality of dialysis.  Its usage is highly variable due to the heterogeneity of patients and healthcare providers and the paucity of evidence to guide practice.

Objectives

At our institution, we assessed utilization patterns of CRRT and established evidence-based guidelines to standardize its process flow and promote meaningful use.

Methods

A multidisciplinary task force was organized in October 2015 to assess CRRT utilization patterns. Interventions were implemented throughout fiscal year (FY) 2016, including the creation of evidence-based guidelines that: clarified each healthcare provider’s role in the initiation, maintenance and cessation of CRRT; defined indications to start therapy with a focus on patient goals of care; described situations where it would be medically inappropriate; mandated daily cross-disciplinary communication between medical teams and key stakeholders; and provided guidance on discontinuing CRRT.  Additional measures to minimize excess laboratory tests and promote awareness of CRRT were also implemented.  Comparisons between preintervention (FY 2014-2015) and postintervention (FY 2016-2017) cohorts were made with the independent samples t-test for continuous variables, and Pearson’s chi-squared test for categorical variables.

Results

A total of 1,342 patients received CRRT from 2014 to 2017. The number of patients on CRRT increased from 182 in 2014 to 435 in 2017, while the total number of days on CRRT increased from 1272 days to 2505 days.  The majority were male (62.7%) and surgical patients (54.1%), while 45.9% were medical.

The mean duration of CRRT decreased by 11.3% from the preintervention period to the postintervention period (7.43 vs 6.59 days, p=.03).  Similarly, the average direct cost of CRRT decreased by 9.8% ($11,642 vs $10,506, p<.01).  This led to a savings of $1,136 per patient, or an estimated annual savings of $481,664 after the intervention.

Discharge disposition of patients on CRRT changed from the preintervention period to the postintervention period.  The proportion of patients expiring on CRRT decreased from 60.3% to 47.5%, while the proportion of patients transitioning to comfort care increased from 3% to 8.6% (p<.01).

Discharge disposition of patients on CRRT also varied by age.  Compared to patients aged 18-45, those over the age of 80 had the highest mortality rate (63.9% vs 43.8%), and the lowest rate of discharge to home (4.6% vs 34.2%, p<.01).

Conclusion

Our institution targeted high value care in continuous renal replacement therapy with a series of interventions that standardized its process flow. These interventions included a set of evidence-based guidelines that established provider roles, mandated daily cross-disciplinary communication, encouraged appropriate patient selection for therapy, and emphasized patient goals of care. Our interventions were associated with a decrease in the average duration of treatment per patient a decrease in the average direct cost per patient, as well as an increase in the proportion of patients transitioning to comfort care.

Implications for the Patient

Our institution promoted meaningful use of CRRT through these series of interventions.

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