# Design of Breakdown and Checklist for Continuous Renal Replacement Therapy

Authors: Shujuan Wang; Yan Kang; Xiaoqing Wang; Lanling Wei; Yanan Zhu; Huilin Yuan
Journal: Scientific Programming
 (2021)

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## Abstract

Objective. This study aimed to improve the quality of continuous renal replacement therapy (CRRT). Methods. A pool of candidate indicators was established using literature retrieval, panel discussion, and experience summary. The first round of consultation was performed with the selected 18 experts by the Delphi method. Then, the checklist was modified according to the experts’ opinions for the second round of consultation to prepare the final checklist. Results. The positivity coefficients of experts in the two rounds of consultation were 100% and 88.9%, respectively, with the authority coefficient of 0.88. The Kendall coordination coefficients of the primary and secondary indicators were 0.296 and 0.303, respectively (P<0.05). Finally, the breakdown and checklist were prepared, which involved 16 primary indicators and 56 secondary indicators. Conclusion. The scientific and reasonable breakdown and checklist prepared based on a consultation can provide scientific guidance for nursing during CRRT, reduce the incidence of adverse events, and improve work efficiency and satisfaction of medical care.


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## Body

## 1. Introduction

Continuous renal replacement therapy (CRRT), a continuous therapy for blood purification for around 24 hours a day to replace the damaged kidney, is the general term for continuously and slowly removing water and solutes [1]. Given the promising therapeutic effect and prognosis of CRRT, it has been widely used to treat critically ill patients. However, the multiple treatment modes have complicated the preparation and operation, bringing difficulties to homogeneous management in clinical work [2, 3]. In 2010, a total of 2.618 million people received renal replacement therapy (RRT) worldwide. It is estimated that by 2030, the number of people using RRT will be more than double to 5.439 million, with the highest growth rate in Asia (by 968,000 increased to 2.162 million) [4]. CRRT is the main approach for patients to maintain life, which can prolong the survival time and improve the quality of life. Meanwhile, CRRT has the characteristics of high technical content, substantial expertise, and high risk. Therefore, actively exploring intervention methods to improve the quality of CRRT care and developing a scientific and reasonable management plan are of practical significance to prolong the survival period of hemodialysis patients and improve the quality of life of patients. Therefore, we prepared the Breakdown and Checklist for CRRT to better cooperate with clinical work, improve the work efficiency, realize homogeneous management, and reduce the incidence of adverse events [5]. Their clinical application has obtained promising therapeutic effects, which are reported as follows.


## 2. Research Methods

### 2.1. Preliminary Design

A CRRT team was established to select the relevant literature articles about CRRT checklist from Chinese and English databases according to the research objectives and prepare an item pool for the breakdown and checklist according to the high-risk steps during operation and in combination with the clinical experience based on the adverse events of CRRT [6–9]. Four experts (two directors and associate chief physicians of the nephrology, one chief nurse, and one supervisor nurse) evaluated the rationality of the sorted pool, gave reasons for adding or removing items, and prepared the initial lists, including the breakdown and checklist [10–13].


### 2.2. Preparation of Consultation Questionnaire

The consultation questionnaire was prepared according to the first draft of the revised breakdown and checklist (three parts): (1) letter to experts, in which the research objective, content, and significance were briefly introduced; (2) CRRT breakdown and checklist evaluation form, which was used to solicit expert opinions and suggestions on the setting and importance of the breakdown and checklist; (3) expert situation questionnaire, which was used to collect experts’ general information, judgment basis, and familiarity with the research content.


### 2.3. Selection of Experts

The number of consultant experts should be determined based on the amount of research. It was reported [14] that the number of experts was generally set as 15–30 to ensure the reliability of the inquiry results. Inclusion criteria of consultant experts in this study: (1) the clinicians and nurses in grade A class three hospitals, with over 10 years of experience in the field of renal replacement therapy; (2) with the bachelor degree or above, intermediate title or above; (3) with sufficient understanding of the study and can actively complete the expert consultation; and (4) with a willingness to participate in this study, were included. After screening, 18 experts from 5 provinces and municipalities were selected.


### 2.4. Expert Consultation

The consultation questionnaire was prepared according to the initial breakdown and checklist and sent to 12 experts by e-mail or field distribution from January to May 2018 for two rounds of an expert consultation. The questionnaires of the first round were collected and analyzed based on the summarized expert opinions and suggestions. Then, the contents were adjusted and distributed for the second round of consultation to make the breakdown and checklist more scientific, reasonable, and consistent.


### 2.5. Statistical Methods

Excel 2016 and SPSS 19.0 were used for data analysis and calculation of expert positivity coefficient, authority, arithmetic mean of various indicators, coefficient of variation, and coordination coefficient of opinions. The coordination of opinions was expressed by the Kendall coordination coefficient.P<0.05 was considered statistically significant. The indicators with the average score of importance and reliability >3 points, coefficient of variation <25%, and the full-score rate >20% were retained and then modified and selected through panel discussion based on expert opinions and comprehensive consideration of all scientific indicators.


## 2.1. Preliminary Design

A CRRT team was established to select the relevant literature articles about CRRT checklist from Chinese and English databases according to the research objectives and prepare an item pool for the breakdown and checklist according to the high-risk steps during operation and in combination with the clinical experience based on the adverse events of CRRT [6–9]. Four experts (two directors and associate chief physicians of the nephrology, one chief nurse, and one supervisor nurse) evaluated the rationality of the sorted pool, gave reasons for adding or removing items, and prepared the initial lists, including the breakdown and checklist [10–13].


## 2.2. Preparation of Consultation Questionnaire

The consultation questionnaire was prepared according to the first draft of the revised breakdown and checklist (three parts): (1) letter to experts, in which the research objective, content, and significance were briefly introduced; (2) CRRT breakdown and checklist evaluation form, which was used to solicit expert opinions and suggestions on the setting and importance of the breakdown and checklist; (3) expert situation questionnaire, which was used to collect experts’ general information, judgment basis, and familiarity with the research content.


## 2.3. Selection of Experts

The number of consultant experts should be determined based on the amount of research. It was reported [14] that the number of experts was generally set as 15–30 to ensure the reliability of the inquiry results. Inclusion criteria of consultant experts in this study: (1) the clinicians and nurses in grade A class three hospitals, with over 10 years of experience in the field of renal replacement therapy; (2) with the bachelor degree or above, intermediate title or above; (3) with sufficient understanding of the study and can actively complete the expert consultation; and (4) with a willingness to participate in this study, were included. After screening, 18 experts from 5 provinces and municipalities were selected.


## 2.4. Expert Consultation

The consultation questionnaire was prepared according to the initial breakdown and checklist and sent to 12 experts by e-mail or field distribution from January to May 2018 for two rounds of an expert consultation. The questionnaires of the first round were collected and analyzed based on the summarized expert opinions and suggestions. Then, the contents were adjusted and distributed for the second round of consultation to make the breakdown and checklist more scientific, reasonable, and consistent.


## 2.5. Statistical Methods

Excel 2016 and SPSS 19.0 were used for data analysis and calculation of expert positivity coefficient, authority, arithmetic mean of various indicators, coefficient of variation, and coordination coefficient of opinions. The coordination of opinions was expressed by the Kendall coordination coefficient.P<0.05 was considered statistically significant. The indicators with the average score of importance and reliability >3 points, coefficient of variation <25%, and the full-score rate >20% were retained and then modified and selected through panel discussion based on expert opinions and comprehensive consideration of all scientific indicators.


## 3. Results

### 3.1. Basic Data of Experts

Basic data of the selected 18 experts are shown in Table1.Table 1
Basic data of experts.
General conditionNumberProportion (%)Age30–40316.741–50950.0≥51633.3Education backgroundBachelor1055.6Master527.8Ph.D.316.7TitleIntermediate316.7Subsenior950.0Senior633.3Years of working10–20211.121–301266.7≥31422.2FieldsMedicine633.3Clinical care950.0Administration316.7


### 3.2. Expert Positivity Coefficient

The response rate of consultation questionnaire was used to calculate the expert positivity coefficient. As reported previously [15], the experts were considered highly positive when the expert positivity coefficient was higher than 70%. 18 questionnaires were released for either round of expert consultation, and 18 and 16 were collected in the first and second rounds, with the response rate of 100% and 88.9%, respectively, indicating high positivity of experts.


### 3.3. Expert’s Authority

The expert’s authority coefficient (Cr) was calculated based on the reason of judgment (Ca) and degree of familiarity (Cs). Generally, it is believed that the authority coefficient not lower than 0.7 can be acceptable [16–18]. The expert’s authority coefficient in the first round of consultation was 0.85 (Ca = 0.89, Cs = 0.82), while Ca in the second round of consultation was 0.91 (Cs = 0.85, Cr = 0.88). The authority coefficients in both rounds were >0.7, indicating the high authority of the experts.


### 3.4. Coordination Degree of Opinions

The coefficient of variation and Kendall coordination coefficient were used to test the coordination of experts. The coefficients of variation were 0.03–0.36 and 0.00–0.23 in the first and second rounds of expert consultation, respectively, while the Kendall coordination coefficients were 0.296 and 0.303, respectively, showing statistical significance (P<0.05).


### 3.5. Consultation Results

The items were classified as very important (5 points), important (4 points), general (3 points), unimportant (2 points), and very unimportant (1 point). The experts were asked to score according to the degree of importance and gave the corresponding opinions in the columns of “suggestions on revision” and “items suggested to be added.” The indicators with the mean score >3 points, coefficient of variation <25%, and full-score rate >20% were retained, then deleted, and modified based on expert opinions.In the first round of consultation, the primary indicators had the mean value of importance of 3.28–5.00 points, the coefficient of variation of 0.082–0.181, and full-score rate of 10%–100%, which were 4.02–5.00, 0.000–0.284, and 30%–100% points, respectively, as for the secondary indicators. According to the screening conditions and expert opinions, the primary indicator “evaluation of hemofiltration tube” was merged into the primary indicator “preparation prior to operation.”According to the screening conditions, and in accordance with the experts’ opinions and panel discussion, the primary indicator “evaluation of hemofiltration tube” was merged into “preparation prior to operation.” The item “following the doctor’s advice” under the secondary indicator “termination” was removed, and the secondary indicator “doctor’s advice after termination” was added. The secondary indicators “date” and “wearing gloves” were removed. Moreover, “final treatment” and “evaluating patients’ tolerance, and whether sedation or restraint is required” were added. As suggested by the experts, the warning signs “Caution: Use with caution in the case of liver dysfunction!” and “Note: Total calcium/free calcium >2.5 ⟶ citrate accumulation” was added.In the second round of consultation, the average value of importance of the primary indicators was 4.12–5.00, the coefficient of variation was 0.000–0.208, and the full-score rate was 33.63%–100%, which were 3.85–5.00, 0.000–0.227, and 30%–100%, respectively, for secondary indicators. As suggested by the experts, the warnings were bolded in red. The item “evaluate the bleeding and coagulation of the patients” was changed to “check whether there are bleeding spots on the skin and mucosa and evaluate the bleeding and coagulation of the patients.” Finally, the breakdown and checklist were prepared, which involved 16 primary indicators and 56 secondary indicators, respectively, whose consultation results are shown in Table2.Table 2
Results of the second round of consultation.
IndicatorsValue of importanceCoefficient of variationFull-score rate (%)Patient information5.00 ± 0.000.000100Basic information5.00 ± 0.000.000100Diagnosis5.00 ± 0.000.000100Evaluation prior to operation4.33 ± 0.620.14266.67CBP blood pathway4.73 ± 0.590.12580.00Coagulation indicators prior to operation4.93 ± 0.260.05287.77Treatment mode4.87 ± 0.350.07280.00Mode selection4.67 ± 0.490.10566.67Filter selection4.60 ± 0.630.13766.67Pipeline preflushing4.47 ± 0.640.14353.54Selection of preflush4.40 ± 0.830.18860.00Preparation of preflush4.53 ± 0.740.16466.67Anticoagulation method4.47 ± 0.740.16660.00Anticoagulation with heparin4.80 ± 0.410.08680.00Anticoagulation with 4% citric acid4.87 ± 0.350.07286.67Replacement fluid4.27 ± 0.590.13933.68Rate of front replacement fluid4.87 ± 0.350.07260.00Rate of rear replacement fluid4.80 ± 0.410.08680.00Rate of dialysate4.00 ± 0.920.23140.00Plasma exchange4.40 ± 0.740.16740.00Plasma separation rate4.87 ± 0.350.07286.67Blood flow rate4.53 ± 0.640.14160.00Initial blood flow rate4.33 ± 0.720.16740.00Target blood flow rate4.27 ± 0.800.18740.00Fluid balance4.33 ± 0.900.20860.00The set ultrafiltration volume4.87 ± 0.350.07286.67Target dehydration volume5.00 ± 0.000.000100Detection indicators4.60 ± 0.510.11060.00APTT-INR4.13 ± 0.830.20240.00Arterial blood gas analysis4.20 ± 0.680.16140.00Others4.93 ± 0.260.05290.005% sodium bicarbonate4.73 ± 0.460.09786.6710% potassium chloride4.87 ± 0.350.07290.005% CaCl24.87 ± 0.350.07290.0010% sodium chloride4.67 ± 0.620.13286.67Preparation prior to operation4.20 ± 0.410.09940.00Checking of doctor’s advice5.00 ± 0.000.000100Patient preparation4.67 ± 0.490.10566.67Preparation of materials4.60 ± 0.630.13766.67Preparation of drugs4.80 ± 0.410.08680.00Other preparations4.47 ± 0.740.16660.00Evaluation of hemofiltration tube4.80 ± 0.410.08680.00Pipeline preparation4.73 ± 0.590.12580.00Checking tight type of the AVF tube4.93 ± 0.260.05290.0Installing the pipeline according to the showed order4.27 ± 0.960.22730.00Checking the four pressure monitoring sensors and all clamps4.60 ± 0.510.11060.00Setting the preflushing volume and the related parameters5.00 ± 0.000.000100Adjusting the fluid level of the arteriovenous pot and removing the air bubbles from the filter4.47 ± 0.640.14360.00In the case of preflushing outside the membrane, check the direction of the filter, and reverse it if necessary4.84 ± 0.350.07286.67Operation process4.48 ± 0.570.13386.67Checking the quality of preflushing, and making sure that it has been completed4.41 ± 0.380.09060.00Checking the smoothness of the hemofiltration tube4.64 ± 0.520.11390.00Pressing the button “Stop” before introducing the blood to make sure that the pump is stopped and the patient connection interface is displayed4.04 ± 0.740.18440.00Observing the hemodynamic changes before and during the connection4.14 ± 0.580.14760.00Adjusting the replacement dialysis volume, blood flow rate, ultrafiltration volume, and other parameters5.00 ± 0.000.000100Properly fixing the hemofiltration tube4.83 ± 0.310.06660.00Treatment process4.12 ± 0.350.08286.67Observing the changes in heart rate, blood pressure, and hemodynamic stability of each patient4.23 ± 0.270.06490.00Checking whether there are bleeding spots on the skin and mucosa and evaluating the bleeding and coagulation of the patients4.37 ± 0.320.07290.00Paying attention to the evaluation of the dehydration amount, urine volume, and water intake4.21 ± 0.510.12480.00Paying attention to the changes in various assay values4.14 ± 0.350.08686.67Evaluating patients’ tolerance and whether sedation or restraint is required4.45 ± 0.320.07260.00Dealing with various alarms in time and paying attention to the changes of various parameters5.00 ± 0.000.000100Paying attention to the conditions of the skin to prevent pressure sores4.12 ± 0.430.10060.00Paying attention to the conditions of edema of the lower extremity to prevent thrombus of lower extremity veins4.30 ± 0.300.07286.67Assisting patients in proper bed movement to prevent thrombus of lower extremity veins3.85 ± 0.710.18040.00Termination4.55 ± 0.540.12660.00Indications after termination4.81 ± 0.240.05080.00Doctor’s advice after termination5.00 ± 0.000.00100Observation of the changes in heart rate and blood pressure of the patient4.84 ± 0.110.02090.00Prompt reminding of adjusting the amount of the pumped insulin and antibiotics4.31 ± 0.320.12640.00Final treatment4.51 ± 0.530.07060.00


## 3.1. Basic Data of Experts

Basic data of the selected 18 experts are shown in Table1.Table 1
Basic data of experts.
General conditionNumberProportion (%)Age30–40316.741–50950.0≥51633.3Education backgroundBachelor1055.6Master527.8Ph.D.316.7TitleIntermediate316.7Subsenior950.0Senior633.3Years of working10–20211.121–301266.7≥31422.2FieldsMedicine633.3Clinical care950.0Administration316.7


## 3.2. Expert Positivity Coefficient

The response rate of consultation questionnaire was used to calculate the expert positivity coefficient. As reported previously [15], the experts were considered highly positive when the expert positivity coefficient was higher than 70%. 18 questionnaires were released for either round of expert consultation, and 18 and 16 were collected in the first and second rounds, with the response rate of 100% and 88.9%, respectively, indicating high positivity of experts.


## 3.3. Expert’s Authority

The expert’s authority coefficient (Cr) was calculated based on the reason of judgment (Ca) and degree of familiarity (Cs). Generally, it is believed that the authority coefficient not lower than 0.7 can be acceptable [16–18]. The expert’s authority coefficient in the first round of consultation was 0.85 (Ca = 0.89, Cs = 0.82), while Ca in the second round of consultation was 0.91 (Cs = 0.85, Cr = 0.88). The authority coefficients in both rounds were >0.7, indicating the high authority of the experts.


## 3.4. Coordination Degree of Opinions

The coefficient of variation and Kendall coordination coefficient were used to test the coordination of experts. The coefficients of variation were 0.03–0.36 and 0.00–0.23 in the first and second rounds of expert consultation, respectively, while the Kendall coordination coefficients were 0.296 and 0.303, respectively, showing statistical significance (P<0.05).


## 3.5. Consultation Results

The items were classified as very important (5 points), important (4 points), general (3 points), unimportant (2 points), and very unimportant (1 point). The experts were asked to score according to the degree of importance and gave the corresponding opinions in the columns of “suggestions on revision” and “items suggested to be added.” The indicators with the mean score >3 points, coefficient of variation <25%, and full-score rate >20% were retained, then deleted, and modified based on expert opinions.In the first round of consultation, the primary indicators had the mean value of importance of 3.28–5.00 points, the coefficient of variation of 0.082–0.181, and full-score rate of 10%–100%, which were 4.02–5.00, 0.000–0.284, and 30%–100% points, respectively, as for the secondary indicators. According to the screening conditions and expert opinions, the primary indicator “evaluation of hemofiltration tube” was merged into the primary indicator “preparation prior to operation.”According to the screening conditions, and in accordance with the experts’ opinions and panel discussion, the primary indicator “evaluation of hemofiltration tube” was merged into “preparation prior to operation.” The item “following the doctor’s advice” under the secondary indicator “termination” was removed, and the secondary indicator “doctor’s advice after termination” was added. The secondary indicators “date” and “wearing gloves” were removed. Moreover, “final treatment” and “evaluating patients’ tolerance, and whether sedation or restraint is required” were added. As suggested by the experts, the warning signs “Caution: Use with caution in the case of liver dysfunction!” and “Note: Total calcium/free calcium >2.5 ⟶ citrate accumulation” was added.In the second round of consultation, the average value of importance of the primary indicators was 4.12–5.00, the coefficient of variation was 0.000–0.208, and the full-score rate was 33.63%–100%, which were 3.85–5.00, 0.000–0.227, and 30%–100%, respectively, for secondary indicators. As suggested by the experts, the warnings were bolded in red. The item “evaluate the bleeding and coagulation of the patients” was changed to “check whether there are bleeding spots on the skin and mucosa and evaluate the bleeding and coagulation of the patients.” Finally, the breakdown and checklist were prepared, which involved 16 primary indicators and 56 secondary indicators, respectively, whose consultation results are shown in Table2.Table 2
Results of the second round of consultation.
IndicatorsValue of importanceCoefficient of variationFull-score rate (%)Patient information5.00 ± 0.000.000100Basic information5.00 ± 0.000.000100Diagnosis5.00 ± 0.000.000100Evaluation prior to operation4.33 ± 0.620.14266.67CBP blood pathway4.73 ± 0.590.12580.00Coagulation indicators prior to operation4.93 ± 0.260.05287.77Treatment mode4.87 ± 0.350.07280.00Mode selection4.67 ± 0.490.10566.67Filter selection4.60 ± 0.630.13766.67Pipeline preflushing4.47 ± 0.640.14353.54Selection of preflush4.40 ± 0.830.18860.00Preparation of preflush4.53 ± 0.740.16466.67Anticoagulation method4.47 ± 0.740.16660.00Anticoagulation with heparin4.80 ± 0.410.08680.00Anticoagulation with 4% citric acid4.87 ± 0.350.07286.67Replacement fluid4.27 ± 0.590.13933.68Rate of front replacement fluid4.87 ± 0.350.07260.00Rate of rear replacement fluid4.80 ± 0.410.08680.00Rate of dialysate4.00 ± 0.920.23140.00Plasma exchange4.40 ± 0.740.16740.00Plasma separation rate4.87 ± 0.350.07286.67Blood flow rate4.53 ± 0.640.14160.00Initial blood flow rate4.33 ± 0.720.16740.00Target blood flow rate4.27 ± 0.800.18740.00Fluid balance4.33 ± 0.900.20860.00The set ultrafiltration volume4.87 ± 0.350.07286.67Target dehydration volume5.00 ± 0.000.000100Detection indicators4.60 ± 0.510.11060.00APTT-INR4.13 ± 0.830.20240.00Arterial blood gas analysis4.20 ± 0.680.16140.00Others4.93 ± 0.260.05290.005% sodium bicarbonate4.73 ± 0.460.09786.6710% potassium chloride4.87 ± 0.350.07290.005% CaCl24.87 ± 0.350.07290.0010% sodium chloride4.67 ± 0.620.13286.67Preparation prior to operation4.20 ± 0.410.09940.00Checking of doctor’s advice5.00 ± 0.000.000100Patient preparation4.67 ± 0.490.10566.67Preparation of materials4.60 ± 0.630.13766.67Preparation of drugs4.80 ± 0.410.08680.00Other preparations4.47 ± 0.740.16660.00Evaluation of hemofiltration tube4.80 ± 0.410.08680.00Pipeline preparation4.73 ± 0.590.12580.00Checking tight type of the AVF tube4.93 ± 0.260.05290.0Installing the pipeline according to the showed order4.27 ± 0.960.22730.00Checking the four pressure monitoring sensors and all clamps4.60 ± 0.510.11060.00Setting the preflushing volume and the related parameters5.00 ± 0.000.000100Adjusting the fluid level of the arteriovenous pot and removing the air bubbles from the filter4.47 ± 0.640.14360.00In the case of preflushing outside the membrane, check the direction of the filter, and reverse it if necessary4.84 ± 0.350.07286.67Operation process4.48 ± 0.570.13386.67Checking the quality of preflushing, and making sure that it has been completed4.41 ± 0.380.09060.00Checking the smoothness of the hemofiltration tube4.64 ± 0.520.11390.00Pressing the button “Stop” before introducing the blood to make sure that the pump is stopped and the patient connection interface is displayed4.04 ± 0.740.18440.00Observing the hemodynamic changes before and during the connection4.14 ± 0.580.14760.00Adjusting the replacement dialysis volume, blood flow rate, ultrafiltration volume, and other parameters5.00 ± 0.000.000100Properly fixing the hemofiltration tube4.83 ± 0.310.06660.00Treatment process4.12 ± 0.350.08286.67Observing the changes in heart rate, blood pressure, and hemodynamic stability of each patient4.23 ± 0.270.06490.00Checking whether there are bleeding spots on the skin and mucosa and evaluating the bleeding and coagulation of the patients4.37 ± 0.320.07290.00Paying attention to the evaluation of the dehydration amount, urine volume, and water intake4.21 ± 0.510.12480.00Paying attention to the changes in various assay values4.14 ± 0.350.08686.67Evaluating patients’ tolerance and whether sedation or restraint is required4.45 ± 0.320.07260.00Dealing with various alarms in time and paying attention to the changes of various parameters5.00 ± 0.000.000100Paying attention to the conditions of the skin to prevent pressure sores4.12 ± 0.430.10060.00Paying attention to the conditions of edema of the lower extremity to prevent thrombus of lower extremity veins4.30 ± 0.300.07286.67Assisting patients in proper bed movement to prevent thrombus of lower extremity veins3.85 ± 0.710.18040.00Termination4.55 ± 0.540.12660.00Indications after termination4.81 ± 0.240.05080.00Doctor’s advice after termination5.00 ± 0.000.00100Observation of the changes in heart rate and blood pressure of the patient4.84 ± 0.110.02090.00Prompt reminding of adjusting the amount of the pumped insulin and antibiotics4.31 ± 0.320.12640.00Final treatment4.51 ± 0.530.07060.00


## 4. Discussion

### 4.1. Reliability of Consultation Results

We performed two rounds of expert consultation based on document retrieval, clinical needs, and brainstorming of the CRRT team to ensure the scientificity and practicability of the breakdown and checklist. All the selected experts were familiar with the knowledge of CRRT and can provide clinical opinions combining theoretical and practical experience. The response rate of either round of consultation was 100%, and the suggestions on modification were given, indicating that the experts highly supported this study. In the first round of consultation, the expert’s authority coefficients were 0.85 and 0.88 in the first round, both of which were larger than 0.7, indicating the high authority. After two rounds of consultation, the Kendall coordination coefficient of the secondary indicators was 0.303 (P<0.05), indicating that the experts had high consistency on the contents of the breakdown and checklist, with only small divergences. Therefore, the consultation results of this study had a certain degree of reliability [16].


### 4.2. Scientificity of Consultation Results

In this study, the breakdown (involving 11 items of patient information, evaluation prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, test indicators, and others) and checklist (involving 5 items of preparation prior to operation, preparation of pipeline, operation process, treatment process, and termination of operation) were prepared according to the mature domestic practice [6, 7], studies of domestic scholars [8], and the related documents [9]. Given the multiple CRRT treatment parameters and modes, there would be errors in communication between doctors and nurses, doctors shifting, and operation preparation [3]. The checklist can be used to check patient information, examination prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, and detection indicators, which the doctors and nurses should confirm to reduce the incidence of information transmission errors to “zero.” The complicated CRRT treatment procedures, as well as their unskilled and irregular operations, can delay the treatment. The breakdown can be used to guide the whole operation process and enable the nurses of different levels, especially junior nurses, to operate in accordance with the standard and norms, and gradually complete the preparation prior to operation, pipeline preparation, operation, treatment, and termination to ensure that the nurses can efficiently complete the preparation prior to operation, thus avoiding omissions due to the complicated process and numerous steps.


### 4.3. Significance of the Preparation of Breakdown and Checklist for Continuous Renal Replacement Therapy (CRRT)

CRRT, with professional theory and skills and high operational risks, has proposed higher requirements for the overall quality of nurses; however, in the application of CRRT technology, nursing is the key to successful treatment [19]. Firstly, the breakdown and checklist can realize the homogeneous management of the whole process from the doctor’s advice to the end of treatment, examine and monitor the nurse operation procedures, and guide the junior nurses. The incidence of adverse events has been reduced from 9.1% to 1.4% (X2 = 4.955, P=0.026). Secondly, the checklist can improve the work efficiency, and the breakdown can make the doctor’s advice clearer, thus effectively avoiding time delays due to doctor’s advice, while the checklist can ensure the preparation of items at one time and the orderly advancement of the treatment process, thus avoiding the waste of time due to omissions in the complicated process. In terms of handover, the breakdown and checklist should be used to show the entire process to the successor to improve the efficiency and save handover time. Finally, the breakdown and checklist can improve the satisfaction of doctors and nurses, further clarify their responsibilities, and improve the effectiveness of communication between doctors and nurses [2]. Meanwhile, they can also help doctors and nurses to comprehensively understand the conditions of patients and the setting and adjustment of parameters during treatment. Moreover, it can improve the tacit understanding and truly reflect the treatment process of the integration of healthcare. Since their application, the satisfaction of medical care has been increased from 87% to 97.8% (X2 = 7.263, P=0.026).


## 4.1. Reliability of Consultation Results

We performed two rounds of expert consultation based on document retrieval, clinical needs, and brainstorming of the CRRT team to ensure the scientificity and practicability of the breakdown and checklist. All the selected experts were familiar with the knowledge of CRRT and can provide clinical opinions combining theoretical and practical experience. The response rate of either round of consultation was 100%, and the suggestions on modification were given, indicating that the experts highly supported this study. In the first round of consultation, the expert’s authority coefficients were 0.85 and 0.88 in the first round, both of which were larger than 0.7, indicating the high authority. After two rounds of consultation, the Kendall coordination coefficient of the secondary indicators was 0.303 (P<0.05), indicating that the experts had high consistency on the contents of the breakdown and checklist, with only small divergences. Therefore, the consultation results of this study had a certain degree of reliability [16].


## 4.2. Scientificity of Consultation Results

In this study, the breakdown (involving 11 items of patient information, evaluation prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, test indicators, and others) and checklist (involving 5 items of preparation prior to operation, preparation of pipeline, operation process, treatment process, and termination of operation) were prepared according to the mature domestic practice [6, 7], studies of domestic scholars [8], and the related documents [9]. Given the multiple CRRT treatment parameters and modes, there would be errors in communication between doctors and nurses, doctors shifting, and operation preparation [3]. The checklist can be used to check patient information, examination prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, and detection indicators, which the doctors and nurses should confirm to reduce the incidence of information transmission errors to “zero.” The complicated CRRT treatment procedures, as well as their unskilled and irregular operations, can delay the treatment. The breakdown can be used to guide the whole operation process and enable the nurses of different levels, especially junior nurses, to operate in accordance with the standard and norms, and gradually complete the preparation prior to operation, pipeline preparation, operation, treatment, and termination to ensure that the nurses can efficiently complete the preparation prior to operation, thus avoiding omissions due to the complicated process and numerous steps.


## 4.3. Significance of the Preparation of Breakdown and Checklist for Continuous Renal Replacement Therapy (CRRT)

CRRT, with professional theory and skills and high operational risks, has proposed higher requirements for the overall quality of nurses; however, in the application of CRRT technology, nursing is the key to successful treatment [19]. Firstly, the breakdown and checklist can realize the homogeneous management of the whole process from the doctor’s advice to the end of treatment, examine and monitor the nurse operation procedures, and guide the junior nurses. The incidence of adverse events has been reduced from 9.1% to 1.4% (X2 = 4.955, P=0.026). Secondly, the checklist can improve the work efficiency, and the breakdown can make the doctor’s advice clearer, thus effectively avoiding time delays due to doctor’s advice, while the checklist can ensure the preparation of items at one time and the orderly advancement of the treatment process, thus avoiding the waste of time due to omissions in the complicated process. In terms of handover, the breakdown and checklist should be used to show the entire process to the successor to improve the efficiency and save handover time. Finally, the breakdown and checklist can improve the satisfaction of doctors and nurses, further clarify their responsibilities, and improve the effectiveness of communication between doctors and nurses [2]. Meanwhile, they can also help doctors and nurses to comprehensively understand the conditions of patients and the setting and adjustment of parameters during treatment. Moreover, it can improve the tacit understanding and truly reflect the treatment process of the integration of healthcare. Since their application, the satisfaction of medical care has been increased from 87% to 97.8% (X2 = 7.263, P=0.026).


## 5. Conclusion

This study constructs a CRRT nursing management plan; that is, a table, including 16 main indicators and 56 secondary indicators, and the indicators have good internal quality. Through clinical exploration, it has provided scientific basis for the nursing management of CRRT patients and has improved the job satisfaction of medical staff.



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*Source: 3485058-2021-12-01.xml*