Transcript Document 7794394

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?
CRRT Competency Management
1.
Organize your CRRT competency assessment
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2.
Understand JCAHO expectations
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3.
Validate clinical proficiency
Maintain a consistent CRRT validation system
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6.
Design a compliant, consistent, and effective competency assessment
program
Validate CRRT competency
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5.
National Patient Safety Goals
Develop your CRRT competency assessment program
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4.
Determine critical competencies to evaluate annually
Tie critical competencies to annual performance reviews
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
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Verify and document new—and existing—competencies, including those for
new equipment
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
Before Treatment
Equipment/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
Before Treatment
Equipment/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
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
Nephrology Nurse
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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
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
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
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
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
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
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
Safety/Quality
• Protocols
• Order sets
• Solutions
– Stability, expirations, FRF/dialysate, medication
management, compounding
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Managing complications
Anticoagulation
Access (where, size)
Time out?