Hello, everyone, and thank you again for this opportunity to be in this class. I'm going to be talking now about team-based care and how it applies to AKI and why we need to really think about what is the mission of Caring for Patients and how do we incorporate team-based care. Again, these are my potential conflicts of interest. None of these have any impact on my conversations today. To start thinking about team-based care, every one of us has been in a situation where you're standing and you're all by yourself. Can you imagine what CPR would look like today if we didn't have a CPR team? Can you imagine standing in that room, taking care of that patient all by yourself? We don't do that anymore, and we really need to think about why and how do we shift the paradigm. In the good old days, we had an all-knowing doctor, maybe had an assistant, maybe a nurse, maybe some other person to help care for them, but our doctor here is all-knowing, takes care of everything from cancer to an infection in the toe. But if we look at this picture, I want you to think about what's missing from the environment that we live in today. There's no ventilators. There's no dialysis. There's no IV infusion pumps. There's not even monitors. The medications that was available in these days was very limited, and the minimal nutrition. We didn't really even think about nutrition and how it would affect our patients and how it changes their outcome. So it was both easier and harder, but today, this is today's AKI patient. Sometimes we can't see the patient for all of the technology that we are now taking care of. You can see this patient is on an oscillator, is on dialysis, has ECMO, probably pharesis, has about 16 or 17 pumps in the back. This is what we deal with on a day-to-day basis, and this is why we need to shift from a primary team to a collaborative team. And throughout the history of CRRT or AKI care, there has been multiple opinions and publications about who should be caring for these type of patients. Should it be nephrology nurses who are dialysis experts? Should it be intensivists who can take care of very critical patients? Should it be a nephrologist? Should it be critical care nursing? And in this day and age, these questions are no longer relevant, because the answer is all of these disciplines. And we need to think about what does team-based care mean. It means at the center of everything we now do is the patient, and we're all members of the team, whether you're in nephrology, whether you're a respiratory therapist, whether you're an ICU doctor, whether you're an ICU nurse, you're all a part of one team. So what does team-based care mean? In 2012, Mitchell and colleagues kind of published this standard definition, and it means coming together to provide collaborative work regarding a patient and their caregivers, to accomplish shared goals within and across settings to achieve coordinated, high-quality care, meaning that it brings us all together. Each and every one of us in this session have an expertise that is unique to us. And when we put us all in the same room, we have expertise and skills of all different professionals. It helps us align care. We need to move away from competing care. What is the priority, and how do we compete for what we want for this patient? It needs to be a collaborative, mutual respect. Each and every discipline has a specialty that is equal to the other. Collaboration. We need to reach out to our subspecial services to be able to tap into this knowledge that I don't have. I don't know a lot about rheumatology. And it would be foolish of me to think about doing care and rheumatology without collaborating. And it creates a knowledge sharing. When I collaborate with rheumatology, I learn from rheumatology as they learn from us. So this is what team-based care is as we move forward. What's the ideal team? We get this question all the time, right? We're all sitting in a conference room trying to figure out how to put together the right AKI CRT team. And Baldwin, in 2021, just recently published an article in seminars and dialysis about nursing care. Like, what does it mean to be in nursing? And how do we care for AKI and CRT? And they put together sort of this is the minimum team that you need to have. We need to think about how we partner with lab. And the laboratory people are a key piece of us being able to make informed decisions. Nurses, pharmacists, physicians, nephrologists, respiratory therapists. And most recently, I think two that have traditionally been not as in not we have not engaged as well is rehabilitation, our OT, PT specialist. How do we get these people who are critically ill to not lose as much ground when it comes to physical abilities and nutrition? So engaging our dieticians, what we do with dialysis can change what a person needs from a nutritional standpoint. But what you will see is that under each of these, one specialty is more specialties. So critical care, general care, emergency, clinic, outpatient nurses. You can see that in subspecialist, again, reaching out to all those different subspecialists, OT, PT that we've talked about. So why isn't team-based care the standard? It's because it's about resources. It's about people and money. We're all competing for resources. So we need to be able to say, we need these resources so that we can improve the outcome of the patients who have AKI in our hospital. And we now have data looking at how we apply team-based care and how it influences outcomes. This is a study that was published in 2011, looking at the decline in renal function in chronic kidney disease when we applied a multidisciplinary team approach. The interventions were either a multidisciplinary team or a primary care person. And the variables that they looked at was the GFR, the LDL, hemoglobin A1c, and the percentage of time that the blood pressure was at goal, obviously very focused on the CKD measurement. What other data is out there? This is a study that was published by Odom and colleagues, looking at the role of a pharmacist on cardiac outcomes in renal patients. And you can see when they applied a team-based care, so just having a pharmacist, a part of their team, reduced blood pressure, lowered LDL, improved A1c. From a heart failure, there was a reduction in all-cause mortality and heart failure events along with the hospitalization rates. So just by having a pharmacist on the team to look at medications, make recommendations, we can improve the outcome. And this is a study that looks at the impact of having a pharmacist on the critical care team and the effects of outcome. And if you look deep into this study, you can see that there was a reduction in ventilator-associated pneumonias. There was a reduction in medication errors. There was a 85% greater chance of receiving neuromuscular functioning recovery and spontaneous ventilation and an overall decrease in the accumulative fluid balances, as well as a 25% reduction in inappropriate concentrations. But overall, 66% reduction in adverse drug events just by having a pharmacist on this team. And I think one of the real powerful pieces of this study is being able to translate those outcomes into dollars, because this is how we get the attention of our colleagues and our administrators of how we need to build a team. And depending on which variable you're looking at, $3,000, a reduction in sedation drug cost, $9,000 a year, or a 0.15 full-time equivalent pharmacist, $67,000, $95,000 by reducing adverse drug events. So this is a powerful study that we can all benefit from and shows how, if we use team-based care, we can improve the outcomes. This is a study that Molly Vega out of Texas Children's published in 2018 looking at nutritional markers. And by having someone studying nutritional markers, which means she's now a part of that team, they were able to improve overall nutrition for all of their CRT patients. Went from 22% of their patients meeting goal by day five to 77%, all by having a pharmacist. And sometimes it's all about having that unique eye, that unique expertise to look at something on a deeper level. In 2014, Owen colleagues looked at a specialized CRR team approach to patients undergoing CRRT. Using a propensity score matched analysis, they showed that by implementing a team of a nephrologist, an intensivist, a CRRT nurse, and a critical care nurse, they were able to reduce the number of CRRT days. They reduced the downtime, they reduced the transfusions, and they increased the filter life, all statistically significant. So in the end, I think the debate is over. The debate about who or how we should care for these patients is over, because we should all be a part of this care. We certainly need more research to fully understand who are the essential team members, who are the essential team members, which members are nice to have, which members are absolutely essential to improving outcome. And no matter what team you put together, collaboration improves outcome.

team-based care

AKI patients

complex interventions

healthcare professionals

collaborative care