I want to thank the planning committee for the opportunity to leave minus 33 in Chicago and be standing in a 70 degree, a little bit of rain, but it's much better than minus 33 with ice. So I'm honored to be here and to be on this stage with some phenomenal people. I'm going to talk a little bit about quality improvement and how we can use it in CRT and maybe what we should and shouldn't be doing, specifically looking at how we deliver care. These are my disclosures and none have any implication into this talk today. So the big question that was posed to me when I got the title of this talk is, what are the quality indicators that we should be using? And if I knew all of these answers, I probably would be a lot richer than I am right now, but I do have an insight to maybe what we should be looking at or what we can look at. So why are there challenges here? Why don't we have a very clear cut? In CRT, we should be doing A, B, and C. Some of that is very clear in this systematic review done by Dr. Rewa, who has been a leader in quality improvement in critical care that looks specifically at how many studies related to CRRT and then how many actually talked about quality improvement. And you can see here, 133. So about 1% of the studies that are out there address quality improvement. And so for quality improvement in renal replacement therapy, we are in our infancy stage. We are still trying to figure out what's the best way to measure efficacy, safety in this arena. Second challenge here is that all CRRT programs, from institution, from unit to unit, are heterogeneous. No one program looks the same. So it's really hard to measure quality improvement when you have a significant delivery system among hospitals and within your own hospital. The other challenge that's really true in pediatrics is that we're going to care from 1 kilo to 200 kilos. And so we already know that one size does not fit all, which is why we are heterogeneous. We know that we have to adapt according to our patients. But that does not preclude us from having to use quality improvement and implementing it to ensure that we really are delivering safe care. Quality improvement is all about the delivery of care. It's about how do we provide care. Because we know that when we deliver great care, we change patient outcomes. Quality improvement is about standardizing your practices, looking at variation in practices, and then the ability to achieve predictable, consistent results. And so that's when we're looking at quality improvement. This is what we're going to look at from a CRRT angle. I do want to highlight practice variation. When I started in quality improvement, it was like the evil thing on my shoulder was like practice variation is very bad. It creates horrible outcomes. And I believed that for a long time until I got a little deeper into quality improvement. I do understand that it's costly. It creates silos. It creates poor delivery of care. It creates workflow problems. But I think it's important to recognize that not all practice variation is bad. Practice variation could be the signal that what you're doing isn't working for your patient. So if you're always coming off of your standard, it's a true signal that we need to look at that standard. And so while I believe that practice variation has its place, we do have to remember that it also can help guide us where we're going. Quality improvement always starts with standardization. I do want to highlight that standardization does not mean that we have hard and fast rules about how we prescribe. It's more, what is the minimum care that you're going to deliver every single patient that you give CRT to? It creates guardrails. It creates that safe boundary that when you're outside of that boundary, everybody in the room is empowered and informed to challenge you. If one of our nephrologists come in and prescribe a dialysate rate that is really inconsistent with what we have listed as our standards, everybody in that room is informed to know what the standards are, and they are empowered to ask the question, why are we doing this different? And that's what guidelines, that's the key piece of guidelines, is keeping us all on the same page. I also want to highlight quality improvement in mortality, and I want to make sure that we somewhat keep those separated. These are all great studies that look at different quality improvements, that look at filter life, and they're looking at dose, looking at anticoagulation. But the thing about quality improvement is there is no published study that says, if you have a prolonged filter life, you have a changed mortality for a patient. There's no study that says, if you get this patient on quicker and faster, that you're going to change that patient's outcome. But what we do know is, when we do those things, we are improving the care. So how do we choose the quality improvement indicators that we want to pick for our program? Good quality improvement indicators, or KPIs, really have five different qualities. A good quality indicator has about three of these. A great quality indicator can cover all five. So we want to be able to measure effectiveness, efficiency, safety, patient-centered care, and timeliness. If you can find a quality indicator that can cover and measure all of those things, those are your ideal ones. Again, remembering that we are in our infancy in quality improvement. So what are the benchmarks? We don't have a ton of benchmarks. We extrapolate from the current quality improvement data, and we extrapolate from the research data. And that's what we're left with in this moment. I am very hopeful about our future as we look at this, though. So I'm going to go through top three. They're my top three that, when people call me and say, what should you do, these are the top three that I would tell you to do. I know the first question you're going to ask me is, I have this beautiful dashboard that has 16 measures on it. So why am I only going to talk about the top three? Why am I going to limit myself to top three? More data does not translate to better outcomes. You could measure all 16 of these indicators, but if you're not using that data to drive change, then you haven't used your resources appropriately. Resources are limited. You've got to use them wisely. It's very hard in this culture to get quality improvement work and get it approved. So when they give you money, you want to use it wisely. And good things take time. Quality improvement is all about taking time and measuring over a time. So don't rush the process. So my first one is Filter Life. As you can see, these are four articles. Filter Life is in almost every single research study about CRRT, and it's always in the quality improvement literature. So you can find whatever you need. The other reason I love Filter Life is because it is sort of an umbrella term. It encompasses so many other things and is affected by so many other things. Dr. Kash just told you that anticoagulation affects Filter Life. So we have this umbrella term that we can use for our measure that we can use for a multitude of studies. So this is a fantastic article that was done by Cordoza and colleagues, really looking at... They started with Filter Life, and what they found were gaps in restarts and starts. So they started with measuring their Filter Life, and then they did a deep dive into their data, and what they discovered is they had this huge delay in care. And through multitude of interventions, was able to reduce that time off CRRT. So started with Filter Life. We are now understanding how Filter Life affects all the other pieces of CRRT. It affects dose. It affects fluid removal. It affects anticoagulation. So really starting to understand its influence and how we can impact that. This is a newer article that's looking... Using Filter Life to decide whether or not their anticoagulation protocol was appropriate. Using Filter Life to identify unscheduled changes and do a data deep dive looking at alarms. This was a fantastic article about alarm management. And by starting with Filter Life, alarm management, doing interventions on how to manage alarms, was able to increase Filter Life, and then they translated that to a cost. So the number of filters that were used for each patient went down, which translated to a significant cost improvement for the delivery of care. That'll always get the attention of administrators. We don't have a ton of benchmark data. We already seen this looking at this. This is really the only pediatric multi-center study really looking at Filter Life. It's now 15 years old. But what they showed was that it's 60% at 60 hours. You can use that, or you can use what you have at your institution. If you are just starting, then you will pick, my Filter Life was 16 hours. We're going to try for 20. And so you can set your own goal. Don't have to rely on the literature to get you there. Number two is dose. Again, it's everywhere in the literature. So you have a lot of information you can extrapolate from. The difference using dose in research versus using dose in quality improvement is that we are going to focus on the prescribed. We're going to focus on, did we adhere to our clinical guidelines? And if we didn't, this is a fantastic opportunity for us to understand our variation. Why are we doing it different than what we as a group had a consensus on? The reason we don't look at the dose as far as what is the right dose is these are the two landmark studies that are almost 15, 16 years old now, that there was no increase in survival with an increased dose. The only thing we were able to extrapolate from this data is that probably there is a low end. There's an under dose. And so using that data will help us decide what we want to do from a clinical practice guidelines. And using that exact forum, this is Griffin and colleagues that looked specifically at prescribing. As a group, they sat, they came to consensus, and they decided what their prescribed dose was going to be. And then they decided to measure how many times, what was the percent of time prior to the implementation of these guidelines that we adhered to what we said as a group we were going to. And you can see that they had an increase in adherence. And more specifically, they had a decrease in that under dosing. So while they may still be trying to understand that higher dose, they did eliminate that under dosing, which has been associated with poorer outcomes. And number three is net ultrafiltration. So how we remove fluid with patients on CRRT is my top three. It's been addressed at an ad key. So it was at the 17th ad key that this conversation started. So it's super important. And now there is emerging data that suggests how we ultrafiltrate patients influences outcomes, influences not just survival, but dialysis dependency. My second favorite reason that this is on the forefront of mind is that it really brings home quality improvement in the sense of, are we all speaking the same language? What is fluid removal? Is it something that you do hourly? What is ultrafiltration? Is it the same thing? And what is fluid balance? And to add on to those three questions is, what are we prescribing? Are we prescribing an ultrafiltration? Are we prescribing a fluid balance? Are we prescribing a set rate? All of that can vary from program to program. But if we're not speaking the same language, this is very hard to determine and tease out what's influencing it from a patient standpoint. So this is the data that's been published in 21, really looking at outcomes related to ultrafiltration per kilo per hour. And surprisingly, it's a pretty narrow window. You get greater than 1.75 mLs per kilo per hour. You have an increase in dialysis dependency, and you have a decrease in survival. So surprising how low that number was. Of course, this is adult data. It is retrospective data. It's not a randomized controlled trial. But it definitely starts us thinking about, how are we impacting patient outcomes? And it's not one study. It's multiple studies are starting to really show aggressive ultrafiltration, or even under ultrafiltration is impacting outcomes. So this is why we started using this one as a quality indicator for work that we did at Cincinnati Children's, specifically looking at. We did not come at this from a prescribed. We did not come at this with, these are the rules around it. We merely said, if you asked for this much fluid, did you get this much fluid? You can see very early in the project, it was about 70% of the time we achieved our fluid balance. Our two interventions, we rounded with critical care. We came to a consensus on rounding. That was it. We didn't come up with 3 per kilo per hour. We didn't come up with anything. We merely said, let's talk about it together, and then we'll measure and see how we did. And we went up to 83%, and that was a sustained change almost immediately after just starting an intervention of rounding together. I did put the formula on there. You're welcome to that. It got a little confusing when you have a net fluid removal of zero. Just want to wrap up with some work, and again, I've already highlighted Dr. Rewa out of Canada. This is a project that they have embarked upon that is actually launching quality improvement across Canada, across multiple institutions with some benchmarks. It's the first study that they'll be able to look across institutions and see what's working in one institution that's not working in another institution. I will highlight that my top three are in the middle, which is what they are, the five minimums. So, we are on to something there, but it's really interesting because I think this is the next step is being able to say, what's working down the street that isn't working for me here? Or, am I doing really well, and how do I disseminate that information? I also just want to end with, yes, we can always sit back and hope everything changes magically, but it's not going to. We really need to eliminate this magical thinking that if we just keep doing it the same way, that everything will get better. That's a phrase that really should be leaving most institutions is, we've always done it this way. So, my take-home messages are QI is all about adopting a questioning culture. It is all about empowering everybody having an equal voice and know when to ask and what to ask. Understanding your variation versus just eliminating it is more important than getting rid of it. Knowing why it's happening is key to improving delivery of care. QI work is not a destination. We don't just get there. We get to 100% and we stop. If you get to 100%, it's time to look at something different. And yes, one QI measure can change the outcomes for patients. So, you don't have to do a dashboard. You don't have to do 16 measures. You can do one, and that will take you to the next one. And so, starting there is key. And with that, I will wrap up, and thank you for your attention. We'll take questions. Thank you.

Quality Improvement

Continuous Renal Replacement Therapy

Key Performance Indicators

Patient Care

Healthcare Teams