Authors (including presenting author) :
YCP Wong(1) ; WTA Yeung(1) ; OKA LEE(1); PO Lei(1) ; PK Chan(1) ; YC Chiu (1); SY Chu(1) ; SC Chin (1); WS Shum(1)
Affiliation :
(1)Intensive Care Unit, Ruttonjee and Tang Shiu Kin Hospitals, Hospital Authority, Hong Kong
Introduction :
Continuous renal replacement therapy (CRRT) is labor intensive and requires advanced nursing knowledge and skills. However, the high turnover of ICU nurses due to retirement, take care of children, health issue, adaptation issue etc. created the problem of shortage of experience ICU nurses. Our department, 40% of registered nurses (RN) are less than 2-year post-registration experiences. Also there is an increasing demand of CRRT from 185 CRRT days in 2017 to 248 CRRT days in 2018 and 297 CRRT days till July 2019. The obstacles for CRRT were identified in our department, includes variation of regimen, complicated workflow and insufficient training of nurses.
Objectives :
A continuous quality improvement project is carried out to
1. standardize the regimen
2. enhance workflow
3. provide structured training to nurses in the intensive care unit,
4. to enhance nursing competence.
Methodology :
1. Questionnaires was set and distributed to nurses to identify obstacles of safe CRRT care, which includes variation of regimen, lack of standard guideline, complicated workflow and insufficient training.
2. Workgroup included ICU doctor, nurses and nephrologist was set up to carry out discussion and conduct literature review to modify the existing regime. New protocols were designed to standardize the practice. Nurse led protocol included i) electrolyte replacement, ii) standardized blood taking schedule and iii) standardized blood and replacement flow were developed. A standardize CRRT doctor prescription form was designed to guide the new practice
3. Department journal club applied the evidence-based practice to introduce the new update practice on the termination of CRRT procedure
4. A single page CRRT nursing observation form was made to allow easy observation. The practice of safety check was introduced to ensure safety and nursing competence during CRRT. New safety checklist was designed to ensure the procedure safety. A single page CRRT nursing observation form was made to allow easy observation. Safety checklist was introduced to ensure safety and nursing competence during CRRT. Micro-teaching on the new practice, new form and safety check was conducted to all nursing staffs.
5. 4-hour lecture to talk on theory, 2-hour demonstration sessions and 2-hour trouble shooting stimulation workshop was arranged to beginner nurse with 1-year post-registration experience. A period of 6 months bedside supervised practice was arranged to them. Another 1-hour theory enhancement and 2-hour trouble shooting stimulation workshop was introduced to experienced nurses.
Result & Outcome :
Patient outcome showed 80% electrolyte imbalance (Potassium) was corrected within 8 hours of the commencement of the new CRRT regime. Besides, the CRRT circuit half-life is prolonged from 12 hours to 48 hours. Procedure audit showed 100% compliance and CRRT related error was reduced significantly. The new method shortened the timing of capping procedure from 15 minutes to 5 minutes. No catheter associated blood-stream infection was seen after the new method was launched.
During training session, Pre-test was performed to identify knowledge gaps among two groups of nurses (beginner and experienced nurses) before lecture. Post-test to assess for knowledge improvement with 70% to 98% passing rate. After the 6-months bedside supervised practice, majority of the beginner nurses expressed confidence to perform the CRRT procedure independently. 90% of experienced nurse expressed the theory enhancement session and simulation workshop were useful.
By standardizing the CRRT regimen, improving workflow and providing structured training, patient safety and nursing staff competency are achieved.
