J. Tseng1, N. Minissian2, R. J. Halbert2, P. Hain2, T. Griner2, H. Rodriguez2, S. Barathan2, R. F. Alban1 1Cedars-Sinai Medical Center,Department Of Surgery,Los Angeles, CA, USA 2Cedars-Sinai Medical Center,Los Angeles, CA, USA
Introduction:
Continuous Renal Replacement Therapy (CRRT) is widely used to manage renal failure in critically ill patients. Though CRRT utilization has increased nationwide, it is significantly costlier in comparison to intermittent hemodialysis. Furthermore, the indications for initiation, maintenance, and cessation lack consensus and are not standardized. In order to target high value care at our institution, we organized a multidisciplinary task force to evaluate current utilization patterns of CRRT, standardize its usage, and assess the outcomes of our intervention.
Methods:
A multidisciplinary task force consisting of intensivists, nursing staff, and nephrologists was established in October 2015 to assess and promote high value utilization of CRRT. This team created a set of evidence-based guidelines to standardize the initiation, maintenance, and termination of continuous dialysis. Other interventions were implemented to improve transparency regarding CRRT, mandate daily communication between medical teams and ancillary staff, encourage goals of care discussion, revise electronic order sets, and curb excess lab orders related to dialysis. Patients receiving CRRT from fiscal years 2013 to 2017 before and after the intervention were compared.
Results:
The total volume of patients on CRRT increased by 104% (216 to 440) from 2013 to 2016, and decreased to 326 patients in 2017. Similarly, the total number of CRRT days increased by 120% (1490 to 3285) from 2013 to 2016, and decreased to 1879 days in 2017. Prior to our intervention, the average duration of CRRT peaked at a mean of 7.69 ± 7.46 days, or a median of 8 (IQR 3-10) in 2015. After our intervention, the average duration of CRRT decreased to a mean of 5.76 ± 4.50, or a median of 4 (IQR 3-8) in 2017 (p=0.018). Solid organ transplant patients utilized continuous dialysis for longer durations compared to non-transplant patients. The total direct cost of CRRT per case decreased from $12167.44 in 2013 to $10545.96 in 2017, translating to 13% cost savings. Upon termination of CRRT, the proportion of patients who expired on CRRT decreased from 26.4% in 2013 to 5.8% in 2016, while the proportion of patients expected to transition to hospice care increased from 21.7% to 53.1%. An increasing number of patients were enrolled in hospice upon hospital discharge after our intervention, from 0.4% in 2014 to 8.8% in 2017 (p<0.001).
Conclusion:
By establishing a task force to critically review utilization of continuous, standardize its usage, and promote daily communication regarding patient progress and goals of care, we significantly reduced the cost and duration of CRRT. In addition, our intervention was also associated with fewer patients expiring on continuous dialysis, and more patients transitioned to comfort care measures. Solid organ transplant patients utilize CRRT at higher rates than non-transplant patients, and may be the focus of further efforts to achieve high value care.