Implementation of Continuous Renal Replacement Therapy (CRRT) Key Performance Indicator (KPI) Reports to Standardize and Improve the Quality of CRRT Delivery in Alberta - "QUALITY-CRRT"

Background: Renal replacement therapy (RRT) is a core life support technology used in approximately 1 in 10 ICU patients. RRT can be delivered intermittently or continuously. While intermittent RRT (IRRT) is used selectively in ICU settings, continuous RRT (CRRT) is the dominant initial form used worldwide. CRRT is a continuous method of blood purification that provides slow uninterrupted clearance of uremic toxins and enables acid-base, electrolyte and volume homeostasis while preserving hemodynamic stability. The, "Implementation of Continuous Renal Replacement Therapy (CRRT) Key Performance Indicator (KPI) Reports to Standardize and Improve the Quality of CRRT Delivery in Alberta - QUALITY-CRRT," is a proposed program of research to standardize and change the practice of CRRT in Alberta in order to improve the performance and delivery of this therapy to our most severely critically ill patients.

Last year in Alberta, 55.2% of patients were started on CRRT as an initial form of RRT. Patients receiving CRRT have greater illness severity (mean APACHE II score of 30.4 vs. 18.9), they are more likely to die (mortality of 41.3% vs. 7.3%) and have significantly increased healthcare utilization when compared to their non-CRRT receiving critically ill counterparts. In 2018, Alberta Health Services spent $2,437,097 to operate its CRRT program. However, these costs only include expendable supplies (i.e., fluids, filters, etc.) and do not include program maintenance or machine hardware expenses, thus underrepresenting the true cost of this therapy. In the setting of increasingly constrained healthcare resources, intervention is needed which may eliminate inefficiencies, improve performance, and decrease waste while ameliorating provider satisfaction and achieving better patient outcomes. Currently, clinicians do not routinely measure the performance of CRRT in Alberta (or elsewhere for that matter), and as such, are not in a position to understand or identify the inefficiencies or gaps in the quality of care of CRRT provided to critically ill patients.

The performance of CRRT may be measured by monitoring key performance indicators (KPIs). KPIs are necessary and can facilitate improved reliability of care, homogenize complex interventions, and provide a platform to measure and monitor performance and the impact of practice changes, and compliance with evidence-based standards. KPIs can be further used as targets for continuous quality improvement initiatives aimed at evaluating new or revised care processes, implementing new protocols or interventions, reducing variability in the delivery of healthcare and stimulating innovative research. The lack of validated and routinely reported KPIs for CRRT, however, are viewed as an important knowledge-to-care gap and may be associated with greater risk for suboptimal quality of CRRT delivery, and has been identified as a research priority.

To date, no Canadian program that has aimed to implement KPIs of CRRT care and to safeguard patients with the high-quality delivery of this complex technology. A focused program aimed to implement an inventory of KPIs for CRRT in order change practice and standardize care across a healthcare system to align with evidence-based best practices has the potential to transform the delivery of CRRT to critically ill patients. The proposed program of research will build upon previous phases of work that have identified and prioritized KPIs for CRRT care in order to implement these CRRT KPIs to change practice to provide effective, validated and standardized CRRT and ultimately to improve the quality of care to critically ill patients receiving CRRT by changing practice in order to decrease variation between all provincial CRRT programs so as to align with evidence-based CRRT best practices guidelines, therapies and prescriptions.

The Proposed Trial: QUALITY CRRT is an innovative, population-level, interrupted time series aimed to evaluate the effectiveness, safety and cost of implementing a multi-faceted CRRT quality assurance and improvement program in ICU settings. It will further explore the reach of QUALITY CRRT by extending the ongoing work on public and patient/family understanding of participation in low-risk ICU research trials focused on generating and implementing best practices. This work will provide insights into the perceived value of such research for Canada's healthcare system as well as to demonstrate feasibility, to build capacity for future population-level pragmatic trials focused on health systems innovations and quality improvement/assurance in ICU settings, and to continue to engage the public in the healthcare and critical care research processes.