Can't believe they do CRRT this way...

Venting some frustration here. Less than 6 months ago I started working at a new facility. They use the same Prisma machines that my last place had, however there are several things that are routinely done at the new place that seem sloppy to me. Maybe others will agree?

1. My biggest issue is with the replacement sol'n. They only hang 1 liter of fluid at a time. With replacement fluid rates often running at 1L/hr, or 1.5 L/hr, in my opinion, this is completely inefficient. Changing bags every hour, or every 1/2 hr-45 min is crazy, especially when about 50% of the time my hospital pairs these patients. I am used to the method of hanging 3 seperate one liter bags on the multi-pronged replacement hook-->connected to a set of stopcocks with IVPB tubing--->connected to the main replacement line and secured evenly to the side of the machine. Of course when I suggested (and implemented this), it was brought to my attention and I was scolded. When I mentioned to management that this method does work safely, can save alot of time for the bedside nurses, and could save the unit money by making the more "stable" CRRT patient more-easily "paired with another patient", I was ignored. When I then suggested they look into purchasing larger volume replacement sol'n bags, I was again politely ignored. Funny thing is how my hospital preaches about having the nurses suggest "process improvement" ideas - well apparently they dont, unless maybe its something trivial and cute. UGH..whatever.

2. Often times I find effluent bags in unsanitary conditions, draining into dirty toilets. Once I discovered a bag draped on the side of the toilet with the tip under water, and unflushed stool inside. They dont stock new effluent bags, except in new filter sets at this place.

3. Have started my shift several times with Calcium carelessly infusing into the filter, and citrate infusing into the patient, instead of vice-versa. Wrote that incident up when my filter clotted.

4. Found heparin 25000 unit bags infusing instead of citrate, 160 ml/hr. Who knows for how long. Pt's PTT off the chart. Corrected the problem. Wrote that up as well.

Bottom line: I'm starting to be viewed as the CRRT bad guy, whistle blower, and "know-it-all", but ....these ppl have no idea what they are doing! I'm not one of these ppl who comes to a place and tries to change around the status quo for my own gratification; I just want to make a few things more efficient and safe.

All this, combined with various other sloppy non CRRT issues/practices is making me want to take my nursing license intact and run back to my old job.

To address your first problem...why would you give a CRRT patient 1-1.5 liters of replacment IV Fluid an hour? Yes...sometimes these patients are on massive amounts on vasopressors and other meds and will add up to >1 liter, but we only give a 100ml NS flush per hour through the machine to help preserve the lines and filiter. Also we can just change the flilter. Are your machines ot codes "red" and "blue" for venous and arterial return. And for the dialysate solutions? I have done CRRT a hundred times and never found that to be a problem (but I have never had the citrate in teh bicarb and the bicarb in the citrate.). I have run calcium gluconate after the fitler. Why would that be a problem?

I honsetly don't know what effluent bags your talking about. We run the lines into the sink or tolitel and put tape or a plastice mat so we don't trip. Our nephrolgists have CLEARLY written our protocol with the nurses input, and we (there are onlyabout 6 people in my unit that are CRRT trained and our a usually 1:1.) But We also have orders to check PTT and CaI plus a chemcomp q 6 hrs and prn for ectopy and that is only the start of our orders,. Our paitents are so sick they would be a 1:1 without CRRT.

U run citrate on a pump?????

Hey everyone!

At our hospital CRRT is always one to one and we always use 3 liter bags! I think we would go crazy, especially if you are taking two patients. I am also surprised that you don't stock effluent bags...do you reuse old ones?

To address your first problem...why would you give a CRRT patient 1-1.5 liters of replacment IV Fluid an hour? Yes...sometimes these patients are on massive amounts on vasopressors and other meds and will add up to >1 liter, but we only give a 100ml NS flush per hour through the machine to help preserve the lines and filiter. Also we can just change the flilter. Are your machines ot codes "red" and "blue" for venous and arterial return. And for the dialysate solutions? I have done CRRT a hundred times and never found that to be a problem (but I have never had the citrate in teh bicarb and the bicarb in the citrate.). I have run calcium gluconate after the fitler. Why would that be a problem?

I honsetly don't know what effluent bags your talking about. We run the lines into the sink or tolitel and put tape or a plastice mat so we don't trip. Our nephrolgists have CLEARLY written our protocol with the nurses input, and we (there are onlyabout 6 people in my unit that are CRRT trained and our a usually 1:1.) But We also have orders to check PTT and CaI plus a chemcomp q 6 hrs and prn for ectopy and that is only the start of our orders,. Our paitents are so sick they would be a 1:1 without CRRT.

U run citrate on a pump?????

to clarify: our replacement solutions often do run at 500ml - 1.5 L/hr thru the prisma machine. Think some of the renal docs do that to help add extra pressure to the filter, thus making it last longer. They also sometimes add things like potassium, mag, and various other lytes to the replacement sol'n, depending on the pt's labs and the doc's preference.

Our filters are not able to be changed separately...we have to change out the entire setup if the filter clots off (unfortunately).

It wasn't an issue with a mixup of bicarb and citrate, it was calcium chloride and citrate. Normally the citrate is supposed to run into the access line, infused via separate IV pump, and the calcium chloride into the patient. The two in this case were reversed, thus causing the blood to clot in the filter.

Our machines drain effluent into a bag hanging on a hook. The machine uses the bags/hook to calculate the weight and thus the amount of fluid removed. We reuses the bags bc my hospital doesnt stock separate bags, unfortunately. Wish we could just tape the effluent line to the sink.

I understand what you are saying jbp0529-----First the usual rate for replacement fluid is 1000 to 1500 cc/hr and our hospital does use 3L bags. I think its crazy to run 1000 cc bags and Im surprised that your hospital cant see how much time that would save with not only nursing but with pharmacy also since usually the docs mix K+ with the replacement fluid which then has to be mixed by pharmacy.

Second---the citrate and calcium misplacments that were run in the wrong line is a big deal and I would have also written that up. The is a reason that the citrate protocol is run and anyone doing CRRT should know why it is done and HOW to do it properly.

As far as the effulent bags I have to admit that our hospital does the draining of the bags the same way ---into the toilet--- and then reuse them...I personally have always thought that it was not very sanitairy either.

Our CRRT patients are ALWAYS 1:1.

We use the Prisma Flex machine in my unit. Our choise is usually CVVHDF which mean we run both pre- and post replacement fluids. Depending on what we use the dialysis fore we run the prereplacementfluids between 1000-2000 ml/hr sometimes even 3000 ml/hr. The postreplacement always run at 250 ml/hr.

We have 5 liters bags.

We also reuse our effluent bags. We have special drains installed in the wall, so whenever the bag needs to be drained, we connect the bag to the drain. Then gravity does the rest - takes about 2-3 minutes. Bags are changes every 24h.

CRRT patients are staffed 1:1 - but then again, so are all of our patients. Plus 2 ekstra nurses for every 5 patient.

I think your concerns are totally on the money, and the resistance you're encountering is just what they used to call "chickens**t", in the service. We use four three-liter bags of replacement fluid, running a 1.6 liter/hour volume turnover - but we use the B Braun machine. I think your concerns about liability and your practice are totally valid. I'd keep a careful narrative of events, too, in case something untoward occurs. Well done both on your estimation of the hazards, and your efforts to remedy them.

Yikes! If ignorance is bliss then some of your coworkers are in pig heaven! Unfortunately, you will probably have to run the "new person gauntlet" before the staff accepts your input. Regarding your issues:

1. We use 5 liter bags for replacement-scales will take it. We occasionally use custom solutions that we "Y" together on the scale, but as you noted, you need to balance the bags on the scale hooks to avoid alarms. We try to avoid multiple stopcocks as they occasionally get malpositioned and if using "standard" stopcocks, they can impede solution flow (resistance issues) resulting in weight alarms. In terms of flow rates, we use fairly aggressive rates to achieve a UFR of 35-45 mL/min so bigger bags lessen work load.
   
2. Effluent bags are labeled as one time use (we stock the extra bags). That being said, we met with our IC group and came up with some practice/handling procedures. We do not empty bags into the toilet. We have sinks in the rooms and use these. The bags are suspended and drained using bubble tubing. Bags are labeled and discarded daily. We also use deadheads to protect the connection point and do a bit of a scrub on. While the effluent bag is downstream, cavalier handling is probably not a great idea.
   
3. Medication errors are medication errors and should be handled accordingly. Is the issue sloppy practice or a byproduct of nurse staffing patterns?
   
4. CRRT committee? QM committee? I would try to use these forums to drive change. In this environment hopefully you are working with others who will also champion your issues and give you support.

Good luck. Stick with it. It sounds like the patients need you.

You are doing exactly as you should in blowing the whistle. The practices you describe are very bad practice. Those nurses need to know exactly how they are putting their patients at risk.

We went to using the 5L premix bags made by Gambro for Prisma. We had a sentinel event where our pharmacy was making up 3L bags of replacement, but the bag had only 1/3 the strength of the sodium, potassium, and bicarb that was prescribed by the nephrologist. The patient's sodium was only 109 when the code labs got back. (I don't remember others. That one just stands out.) It's more expensive, but it has made it way easier on pharmacy and nursing and greatly decreased the risk of harm to the patient.

We have just bought new PrismaFlex machines from Gambro and they are giving me and a few others the "superuser" training. It will be interesting to know if they mention ugly, true-to-life scenarios.

Our PICU has metal hooks in most of the bathrooms. When I started working there, the effluent bags were positioned on the toilet to drain...sometimes falling into the toilet. Effluent bags are reused. We now use 2 effluent bags per shift. I started hanging the effluent bag on the metal hook (it was there, why not use it?) and connecting suction tubing to the drain spout and dangling the other end over the toilet using the seat to hold it in place. Works like a charm and has been implemented by every nurse who sees the technique.

Where I work, we either have citrate CRRT or "conventional." ( Conventional= 1000cc replacement bags alternated and changed every hour). We have been known to pair up both types of CRRT pts. , depending how sick the paitent is.

In Australia, dialysis aptients are 1:1. We use citrate rarely. We use the suction tubing hooked up to the effluent bags and drain them into a outlet in the wall, and reuse them too.

3 litre exchanges. 5 litre bags. We use Edwards Aquarius machines. As does most hospitals here. They certainly won out over Prisma.

On our unit, we have a drain in the wall of every room to plug in the effluent line to. I guess that is a luxury, from what I'm reading here!