#3123 INCREASING THE USE OF REGIONAL CITRATE ANTICOAGULATION FOR CKRT IN A LARGE TERTIARY CENTER: A QUALITY IMPROVEMENT PROJECT
Authors: Fong Jie Ming Nigel , Ramirez Maria Erika , Reddy Kundan Saripalli , Kong Yik Hang Aaron , Koh Ting Ting Serence , Chua Weiyan , Rahman Ratna Bte Abdul , Ho Wan Qi , Kaushik Manish , Choong Hui Lin Lina 
Published: June 2023

Abstract

Background and Aims
To maintain Continuous Kidney Replacement Therapy (CKRT) circuit patency, KDIGO recommends Regional Citrate Anticoagulation (RCA) as the first-line anticoagulation strategy. In a randomized controlled trial, RCA was associated with increased filter life, reduced circuit downtime, and reduced bleeding, as compared with heparin anticoagulation [1]. RCA-CKRT uptake in our institution, a 1800-bed tertiary center with seven intensive care units (ICU), was low at only 10% of all CKRT sessions. We conducted a Quality Improvement project to increase the uptake of RCA-CKRT in medical and surgical intensive care units in our institution.

Method
Following established Quality Improvement methodology, we delineated a process map and performed a root-cause analysis. Multiple plan-do-study-act (PDSA) cycles were conducted. A bespoke CKRT audit dashboard was created to automatically compile electronic CKRT prescription records and circuit monitoring data. The primary outcome measure, the percentage of all CKRT sessions that utilise RCA, was monitored monthly. Qualitative and quantitative feedback was monitored.

Results
Problem analysis (Figure 1) identified that the top root causes contributing to low RCA-CKRT uptake rate were (1) renal physicians defaulting to ‘old habits’ of non-RCA CKRT, (2) nursing staff having inadequate experience and concerns of increased workload, (3) ICU team being uncomfortable with RCA-CKRT, especially fear of citrate toxicity. Multiple PDSA cycles were conducted. In PDSA cycle 1, inclusion and exclusion criteria for default RCA use were standardized. A poster was created to set out these criteria, along with a visual guide explaining how RCA works, and how to identify citrate toxicity. The poster was designed to be eye-catching and easy to understand for non-renal physicians, and was placed prominently in ICU and renal work areas. PDSA cycles 2-4 were educational efforts, including a peer review learning for the renal department, incorporating RCA into ICU resident didactic teaching, and an RCA refresher course for ICU nurses. Through these four PDSA cycles, all three top root causes identified were addressed in turn. Continuous feedback was sought from all stakeholders and acted on in a timely manner. For example, it was identified that some prescribers and nursing staff had the misconception that switching from non-RCA to RCA-CKRT would require changing the entire filter circuit, leading to reluctance to switch to RCA once a CKRT circuit was running. A clarification was promulgated and added to the poster. Over a 12-month period, the percentage of all CKRT sessions utilizing RCA increased from a baseline of 10.5% ± 7.7% (mean ± SD; median 9.8%) to 22.5% ± 14.6% (median 21.5%; p = 0.022) (Figure 2). This included a 3-month period after PDSA cycle 1 during which supplies of RCA-CKRT fluid were disrupted due to COVID-19 supply chain issues. Excluding the months of supply disruption, the uptake of RCA-CKRT would have been 25.3% ± 15.8% (median 25.0%).

Conclusion
A quality improvement project successfully increased the uptake of RCA-CKRT from 10.5% to 22.5% in a complex tertiary care setting. Understanding key barriers at each stage of a complex process, availability of real-time audit data, and attention to stakeholder feedback were key factors that enabled successful change. Unexpected events (in this case a supply chain disruption) may threaten a loss of momentum for change, but can be overcome with continual stakeholder engagement and additive PDSA cycles.