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Setting Up a Continuous Venovenous Hemofiltration Educational Program: A Case Study in Program Development
I
0899-5885/98 $8.oo
+ .oo
Renal Replacement Therapies
Setting Up a Continuous Venovenous Hemofiltration Educational Program A Case Study in Program Development Kay Clevenger, RN, MSN
Continuous venovenous hemofiltration (CWH) offers distinct advantages for the critically ill patient. CWH is an efficient mode of dialysis for the hemodynamically unstable critically ill patient. However, the implementation of a CWH program requires a staff of highly trained critical care nurses. This article offers a practical strategy for preparing nurses for the technical aspects and care considerations of the patient receiving CVVH. For definitions and explanations of CWH, refer to Continuous Venous to Venous Hema.filtration: Implementing and Maintaining a Program: Examples and Alternatives by Maureen Craig elsewhere in this issue.
CVVH Committee and Course Development
A committee was formed to develop the CWH program. The Staff Development From the Clarian Health/Indiana University Hospital, Cardiopulmonary Care Center, and Medical Intensive Care Units, Indianapolis, Indiana
Coordinator for Critical Care and Special Projects Coordinator initially served as cochairpersons of the committee. The nephrologist/Medical Director of the Medical ICUs was an active member. Most importantly, two staff nurses from each unit utilizing CWH were asked to join the committee. This included the acute dialysis unit, medical ICUs, surgical ICU/open heart recovery, and bone marrow transplant unit. They served as our clinical experts and instructors for the CVVH Skills Laboratory. The buddy system of two staff nurses has worked very well. They serve as support to each other while teaching at the stations. Also, at least one person attends the committee meeting and keeps the other colleagues updated. The nurses also serve as great resources for discussing clinical issues that come up. While developing the course, the committee divided into two sub-groups. The Staff Development Coordinator was responsible for the educational portion of the course. The educational sub-group developed the program, objectives, skills lab checklists, and
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 10 I Number 2 / June 1998
235
236
CLEVENGER
evaluations. The Special Projects Coordinator was responsible for the flowsheet and policy/procedures (P&P). The flowsheet/P&P sub-group revised the current flowsheet, documentation guidelines, and policy procedures. After the initial .groundwork was laid for the course, the committee then focused on developing the content for each skills lab station and determining the content of the didactic portion presented by the nephrologist. Prior to the first course, we performed a dryrun of the CVVH Skills Laboratory. This was an invaluable experience-it helped us to work the kinks out before having a live audience. Other benefits of the practice skills laboratory included increasing the confidence of the instructors and avoiding repetition of content from station to station. However, repetition of essential concepts was necessary to move nurses successfully on to the next station. After each course, we closely reviewed the evaluations and have made several revisions based upon the results. For the initial year, the committee met several times developing the course. Also, we offered the CVVH course eight times in the first year in order to send staff members through a CVVH qualifying course. Initially, our nephrologist and dialysis nurses did a tremendous amount of one-on-one teaching. As our CVVH program further developed, we organized the CVVH Committee and Course. Most staff nurses attending the course in the first year had previous experience caring for a CVVH patient. Therefore, we were able to present a 4-hour course, offering two sessions in 1 day. This assisted in scheduling staff for the course-staff nurses split the day between the course and the unit and shared a patient assignment. Extended programs of 5 hours offered the more novice nurse additional time during the skill laboratory period. The CVVH Committee meetings are primarily used for course preparation and evaluation. We have revised our pretest/posttest several times based on feedback given by participants and the frequency of missed
test questions. The Committee meets on a quarterly basis to also address clinical issues. Committee representatives are clearly identified by the staff and personnel. This facilitates questions and clinical issues communicated from the staff directly into committee discussion. The clinical managers also identify issues for the committee to work on.
Program The program is 5 hours in length, including a welcome/introduction and break. The program is divided into a 1-hour presentation, a 3-hour Skills Laboratory, and a one-half hour posttest/evaluation (Box 1). Objectives reflect the content presented during the entire course (Box 2). A 1-hour didactic lecture is presented by a nephrologist and includes a question/ answer session. The course participants are
Box 1. CONTINUOUS VENOVENOUS HEMOFILTRATION (CVVH) PROGRAM
15 minutes 1 hour 15 minutes 3 hours
30 minutes
Welcome/Introduction Course Facilitator Continuous Venovenous Hemofiltration Presentation Nephrologist Break CWH Skills Lab (45 minutes at each station): I. Routine Initiation and Maintenance of CWH Therapy Acute Dialysis Staff Nurses II. Troubleshooting and Emergency Situations of CWH Therapy Surgical ICU/Open Heart Recovery Staff Nurses Ill. Flowsheet, Policy and Procedures and Orders Bone Marrow Transplant Staff Nurses IV. Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Medical ICU Staff Nurses PostTest Evaluations and Awarding of Contact Hours Course Facilitator
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
Box 2. CONTINUOUS VENOVENOUS HEMOFILTRATION (CVVH) OBJECTIVES By the end of the course, the participant will be able to: 1. Define CVVH. 2. Discuss two indications for the initiation of CWH. 3. State two advantages of selecting CWH over other renal replacement therapies. 4. Identify three potential complications of CWH. 5. Identify two possible interventions for hemodynamic instability when placing a patient on CWH. 6. Describe how to initiate the flowsheet and the steps needed in the continuous calculation of the flowsheet. 7. Compare and contrast the equipment setup responsibilities of the ICU nurse and the dialysis nurse. 8. Identify the responsibilities of each member of the CWH team. 9. Demonstrate skills in a lab setting-refer to objectives in skills lab checklist.
then divided into four groups and rotate through the four Skills Laboratory stations. Approximately 45 minutes is spent at each station, where participants gain hands-on experience with the equipment and flowsheet. Each station has two staff nurse instructors who present specific content, answer questions, and direct participants in handson activities. The Skills Laboratory checklist is signed off at the end of each station and turned in at the end of the course (Table 1). CVVH Skills Lab
PURPOSE: To verify competency in the care of the patient receiving CWH therapy. As a participant in the CWH course, you will be asked to demonstrate competency in the skills thought to be critical to practice in the care of the patient receiving CWH therapy. The skills lab is not to replace check-off of your performance in the clinical unit. If you have any questions about the skill, ask your unit resource or staff development coordinator. OBJECTIVES: At the end of the skills lab the participant will be able to demonstrat~
237
or verbally identify the following skills in a lab setting: A. Initiation and maintenance of CWH B. Flushing the system C. Reconnecting the patient to CWH after a procedure D. Troubleshooting mechanical problems 1. Low ultrafiltrate production 2. Pressure monitor alarm 3. Bubble detector alarm 4. Filtrate pump alarm 5. Access failure 6. Change in ultrafiltrate color E. Strategies for emergency situations 1. Catheter dislodgement 2. Codes 3. Air emboli 4. Fluid and electrolyte imbalance A pretest and participant letter are distributed to course participants approximately 2 weeks prior to the course. Pretests are turned in at the beginning of the course. A participant packet is distributed at the beginning of the course (see Box 3). A diagram of our CWH system is included (Figure 1). At the end of the program, a posttest is given. This is a 20-question, multiple choice test and is the same as the pretest. To successfully complete the course, 80 percent is required on the posttest, along with successful completion of the Skills Laboratory stations. Participants review the posttest results with the pretest and are able to note the usual marked improvement. All tests are turned
Box 3. CONTENTS OF PARTICIPANT PACKET • • • • • • • • •
Program CWH diagram Objectives Skills lab checklist Physician's Preprinted orders Flowsheet Documentation guidelines for f\owsheet Policies and procedure Evaluation Article
238
CLEVENGER
Table 1.
SKILLS LABORATORY CHECKLIST
STATION I. Routine Initiation and Maintenance of CWH Therapy Competency Demonstrated
Initial
Date 1. Verbally identifies parts of the system 2. Verbally identifies routine maintenance of the system 3. Verbally identifies roles/responsibilities of CWH team members STATION II: Troubleshooting and Emergency Situations of CWH Therapy
A. Identify/demonstrate appropriate troubleshooting measures for the following problems: Competency Demonstrated
Initial
Date 1. 2. 3. 4. 5. 6.
Filtrate pump alarms, reading "low flow" Low ultrafiltrate production Bubble detector alarm Pressure monitor alarm High filter pressure Ultrafiltrate becomes pink in color B. Verbally identify the nursing responsibilities in the event of an emergency situation while the patient is receiving CWH therapy, for the following situations: Competency Demonstrated
Initial
Date 1. 2. 3. 4.
Catheter dislodgement Codes Air emboli Fluid and electrolyte imbalance
STATION Ill: Flowsheet and Orders Competency Demonstrated
Date
Initial
1. Verbally identifies how to initiate the flowsheet 2. Demonstrates the hourly calculation of the flowsheet 3. Verbally identifies an understanding of the order sheet STATION IV: Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Competency Demonstrated
Date 1. Demonstrates flushing the system 2. Demonstrates taking the patient off of CWH and recirculating the system 3. Demonstrates reinitiating CWH therapy 4. Demonstrates discontinuing CWH therapy
Initial
Replacement FluldA Contains 0.9% saline & 1O mmol/l KCL
Replacement Fluid B Contains 0.45% saline + 55 mmoVL NaHC03 Drip Chamber Catches clots & air
Heparin Heparinization is used to maintain filter patency
Single dual lumen venous catheter
Blood Line Clamp Occludes system should air be detected
Pulls blood from one lumen at 200 cc/hr and pumps it through to filter
Monitor A pressure transducer connected to a cardiac monitor is used to monitor pressure within the system Pressure Transducer
Semi-permeable membrane filter pulls wastes from the bioo:d hydrostatic pressure
Blood Pump
U ltrafiltrate Pump IV pump is set at 999 cc/hr to pull 1 liter of ultrafiltrate per hour
Ultraflltrate Collection Device Foley catheter bag is used to collect ultrafiltrate
Figure 1. Continuous venovenous hemofiltration.
240
CLEVENGER
back in. A form is placed in the employee file indicating the posttest score and completion of the Skills Laboratory stations (see Table 2). The participant completes the program by turning in the evaluation form (see Table 3 and evaluation below in text). These are introduced in the beginning of the course and completion/comments are encouraged. Continuous Venovenous Hemofiltration (CVVH) EVALUATION • What did you like best about this course? • Any suggestions for modification of this course? • Comments concerning the environment, content, presenters, and learning methods not already mentioned: • Overall, I would rate this course (on a 15 scale, with 5 being best) _ __ • Suggestions for topics/speakers for future staff development offerings:
Committee. Once again, we are in the process of revising because of the purchase of new equipment (see list below in text). CVVH Policies and Procedures • Maintenance of hemofiltration • Interruption and reinitiation of hemofiltration • Termination of hemofiltration • Troubleshooting and emergency procedures for hemofi.ltration • Flushing a hemofilter
Physician Orders We have developed preprinted orders that are initiated by the nephrologist/renal fellow. Once it is decided that the patient will be placed on CVVH, the renal physicians are responsible for all fluid management.
Flowsheet and Documentation Guidelines Policy and Procedures We have revised our policy and procedures multiple times since starting our CVVH program. The revisions are done by the CVVH
Table 2. CLARIAN HEALTH/INDIANA UNIVERSITY HOSPITAL CONTINUOUS VENOVENOUS HEMOFILTRATION (CWH) COURSE
NAME ___________
We have also revised our flowsheet multiple times since the beginning of our CVVH program. This has been a joint effort between the nephrologist, dialysis nurses, and ICU nurses. The documentation guidelines are concise and clearly explain how to document on the flowsheet. We have also color coded (shaded in gray) the columns that coincide with our formula: Replacement Fluid = Total Output-Total Input-Desired Fluid Loss.
UNIT ---------_ DATE __________
Item
Annual Competency Process Score
CVVH Posttest Station I Station II Station Ill Station IV
Facilitator • To be placed in Employee's Personnel File
Comments
The annual competency process has been the most challenging task that the CVVH Committee faces. We average caring for 40 to 50 CVVH patients annually. We've struggled with the question, "How do we assure competency of multiple nurses working in three different units in the care of our CVVH patients?" We will now be including in our annual ICU competency blitz (see Table 4
241
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
Table 3. CLARIAN HEALTH/INDIANA UNIVERSITY HOSPITAL CONTINUOUS VENOVENOUS HEMOFILTRATION (CWH) EVALUATION Please circle the number which best indicates your evaluation of the quality of both the content and the speaker for each of the following topics. KEY: 5 = Excellent 4 =Good 3 =Average 2 =Fair 1 =Poor
Topic
Continuous Venovenous Hemofiltration Presentation CWH Flowsheet CWH P and Ps CWH Skills Lab: I. Routine initiation and maintenance of CWH therapy II. Troubleshooting and emergency situations of CWH therapy Ill. Flowsheet and orders IV. Procedure to interrupt, recirculate, reinitiate, and discontinue CWH therapy
Content Was the content adequate to learn the objectives?
Speaker Rate the speakers' effectiveness/teaching methods
2 3 4 5 2 3 4 5 2 3 4 5
2 3 4 5 2 3 4 5 2 3 4 5
2 3 4 5
2 3 4
5
3 4
5
2 3 4 2 3 4
5 5
2
3 4 5
2 3 4 5 2 3 4 5
Objective
1. 2. 3. 4. 5. 6. 7.
8. 9.
Define CWH Discuss two indications for the initiation of CWH State two advantages of selecting CWH over other renal therapies Identify three potential complications of CWH Identify two nursing interventions required for hemodynamic instability when placing a patient on CWH Describe how to initiate the flowsheet and the steps needed in the continuous calculation of the flowsheet Compare/contrast the equipment set-up responsibilities of the ICU nurse and the dialysis nurse Identify the responsibilities of each member of the CWH team Demonstrate skills in a lab setting-refer to objective in skills lab checklist
2
Rating
2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3
4
5
2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5
242
CLEVENGER
STATION I. Routine Initiation and Maintenance of CWH Therapy Competency Demonstrated Date
Initial
1. Verbally identifies routine maintenance of the system 2. Verbally identifies roles/responsibilities of CWH team members STATION II. Flowsheet Competency Demonstrated Initial
Date 1. Verbally identifies how to initiate the flowsheet 2. Demonstrates the hourly calculation of the flowsheet
STATION Ill. Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Competency Demonstrated Initial
Date 1. Demonstrates flushing the system 2. Demonstrates taking the patient off of CWH and recirculating the system (includes reinitiating and discontinuing)
STATION IV. Troubleshooting and Emergency Situations of CWH Therapy A. Identify/demonstrate appropriate troubleshooting measures for the following problems: Competency Demonstrated Date 1. 2. 3. 4. 5. 6.
Filtrate pump alarms, reading "low flow" Low ultrafiltrate production Bubble detector alarm Pressure monitor alarm High filter pressure Ultrafiltrate becomes pink in color
Initial
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
and checklist below). In the past, we have had staff nurse committee members check staff off at mock stations. Also, we have required successful completion of the written test annually. We have developed a CVW/Resource Manual for each unit that contains the CVVH diagram, policy and procedures, and multiple articles.
243
A recent addition has been the development of the ICU Clinical Log. Staff nurses are responsible for logging the date and number of hours spent caring for each CVVH patient. This assists in determining how to assign staff to CVVH patients, helping to document competency. In addition, this information is utilized as input in the annual evaluation process of each staff member.
Name _ _ _ _ _ Unit _ _ _ _ _ __
~
Date-------
CLARIAN HEALTHnNDIANA UNIVERSITY HOSPITAL Continuous Venovenous Hemoflltratlon (CVVH) Competency Checklist PURPOSE: To verify competency in the care of the patient receiving CWH therapy. OBJECTIVES: At the completion of the competency assessment, the participant will be able to demonstrate or verbally identify the following skills (via a written assessment and simulated skills): A. Initiation and maintenance of CWH B. Documents correctly on CWH flowsheet C. Flushing the system D. Reconnecting the patient to CWH after a procedure E. Troubleshooting mechanical problems 1. Low ultrafiltrate production 2. Pressure monitor alarm 3. Bubble detector alarm 4. Filtrate pump alarm 5. Access failure 6. Change in ultrafiltrate color F. Strategies for emergency situations 1. Catheter dislodgement 2. Codes 3. Air emboli 4. Fluid and electrolyte imbalance
SUMMARY
The key to developing a successful CVVH course is the involvement of the clinical experts-the staff nurses. It is an ongoing process that requires continual improvement. The CVVH course will help to assure the competency of the ICU nurse in caring for the critically ill patient on CVVH.
244
CLEVENGER
ACKNOWLEDGMENTS
A special r.hank you to my mentor and coach of CVVH Therapy, Dr. William Macias. He has made a difference for our patients at Indiana University Hospital. Dr. Macias has also been a special teacher for many of us, and his passion for this therapy has been contagious. A special r.hank you to Dr. Michael Kraus, who has carried on the high educational and clinical standards for the CVVH patients and the ICU nurses.
A special thank you to Catherine Tonn Coscia, RN, CCRN, who staned the ball rolling, serving as co-chairperson of the CVVH Committee. Also, !.hanks for mentoring me in this therapy. A special thank you to the staff nurses who have served as CVVH Committee Members and are so dedicated to the educational and clinical standards r.hat we hold high for our ICU patients. A special thank you to the dialysis and ICU nurses, who provide exceptional care to these patients.
Address reprint requests to Kay Clevenger, RN, MSN Indiana University Hospital 550 N. University Boulevard UH 6420 Indianapolis, IN 46202-5250
0899-5885/98 $8.oo
+ .oo
Renal Replacement Therapies
Setting Up a Continuous Venovenous Hemofiltration Educational Program A Case Study in Program Development Kay Clevenger, RN, MSN
Continuous venovenous hemofiltration (CWH) offers distinct advantages for the critically ill patient. CWH is an efficient mode of dialysis for the hemodynamically unstable critically ill patient. However, the implementation of a CWH program requires a staff of highly trained critical care nurses. This article offers a practical strategy for preparing nurses for the technical aspects and care considerations of the patient receiving CVVH. For definitions and explanations of CWH, refer to Continuous Venous to Venous Hema.filtration: Implementing and Maintaining a Program: Examples and Alternatives by Maureen Craig elsewhere in this issue.
CVVH Committee and Course Development
A committee was formed to develop the CWH program. The Staff Development From the Clarian Health/Indiana University Hospital, Cardiopulmonary Care Center, and Medical Intensive Care Units, Indianapolis, Indiana
Coordinator for Critical Care and Special Projects Coordinator initially served as cochairpersons of the committee. The nephrologist/Medical Director of the Medical ICUs was an active member. Most importantly, two staff nurses from each unit utilizing CWH were asked to join the committee. This included the acute dialysis unit, medical ICUs, surgical ICU/open heart recovery, and bone marrow transplant unit. They served as our clinical experts and instructors for the CVVH Skills Laboratory. The buddy system of two staff nurses has worked very well. They serve as support to each other while teaching at the stations. Also, at least one person attends the committee meeting and keeps the other colleagues updated. The nurses also serve as great resources for discussing clinical issues that come up. While developing the course, the committee divided into two sub-groups. The Staff Development Coordinator was responsible for the educational portion of the course. The educational sub-group developed the program, objectives, skills lab checklists, and
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 10 I Number 2 / June 1998
235
236
CLEVENGER
evaluations. The Special Projects Coordinator was responsible for the flowsheet and policy/procedures (P&P). The flowsheet/P&P sub-group revised the current flowsheet, documentation guidelines, and policy procedures. After the initial .groundwork was laid for the course, the committee then focused on developing the content for each skills lab station and determining the content of the didactic portion presented by the nephrologist. Prior to the first course, we performed a dryrun of the CVVH Skills Laboratory. This was an invaluable experience-it helped us to work the kinks out before having a live audience. Other benefits of the practice skills laboratory included increasing the confidence of the instructors and avoiding repetition of content from station to station. However, repetition of essential concepts was necessary to move nurses successfully on to the next station. After each course, we closely reviewed the evaluations and have made several revisions based upon the results. For the initial year, the committee met several times developing the course. Also, we offered the CVVH course eight times in the first year in order to send staff members through a CVVH qualifying course. Initially, our nephrologist and dialysis nurses did a tremendous amount of one-on-one teaching. As our CVVH program further developed, we organized the CVVH Committee and Course. Most staff nurses attending the course in the first year had previous experience caring for a CVVH patient. Therefore, we were able to present a 4-hour course, offering two sessions in 1 day. This assisted in scheduling staff for the course-staff nurses split the day between the course and the unit and shared a patient assignment. Extended programs of 5 hours offered the more novice nurse additional time during the skill laboratory period. The CVVH Committee meetings are primarily used for course preparation and evaluation. We have revised our pretest/posttest several times based on feedback given by participants and the frequency of missed
test questions. The Committee meets on a quarterly basis to also address clinical issues. Committee representatives are clearly identified by the staff and personnel. This facilitates questions and clinical issues communicated from the staff directly into committee discussion. The clinical managers also identify issues for the committee to work on.
Program The program is 5 hours in length, including a welcome/introduction and break. The program is divided into a 1-hour presentation, a 3-hour Skills Laboratory, and a one-half hour posttest/evaluation (Box 1). Objectives reflect the content presented during the entire course (Box 2). A 1-hour didactic lecture is presented by a nephrologist and includes a question/ answer session. The course participants are
Box 1. CONTINUOUS VENOVENOUS HEMOFILTRATION (CVVH) PROGRAM
15 minutes 1 hour 15 minutes 3 hours
30 minutes
Welcome/Introduction Course Facilitator Continuous Venovenous Hemofiltration Presentation Nephrologist Break CWH Skills Lab (45 minutes at each station): I. Routine Initiation and Maintenance of CWH Therapy Acute Dialysis Staff Nurses II. Troubleshooting and Emergency Situations of CWH Therapy Surgical ICU/Open Heart Recovery Staff Nurses Ill. Flowsheet, Policy and Procedures and Orders Bone Marrow Transplant Staff Nurses IV. Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Medical ICU Staff Nurses PostTest Evaluations and Awarding of Contact Hours Course Facilitator
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
Box 2. CONTINUOUS VENOVENOUS HEMOFILTRATION (CVVH) OBJECTIVES By the end of the course, the participant will be able to: 1. Define CVVH. 2. Discuss two indications for the initiation of CWH. 3. State two advantages of selecting CWH over other renal replacement therapies. 4. Identify three potential complications of CWH. 5. Identify two possible interventions for hemodynamic instability when placing a patient on CWH. 6. Describe how to initiate the flowsheet and the steps needed in the continuous calculation of the flowsheet. 7. Compare and contrast the equipment setup responsibilities of the ICU nurse and the dialysis nurse. 8. Identify the responsibilities of each member of the CWH team. 9. Demonstrate skills in a lab setting-refer to objectives in skills lab checklist.
then divided into four groups and rotate through the four Skills Laboratory stations. Approximately 45 minutes is spent at each station, where participants gain hands-on experience with the equipment and flowsheet. Each station has two staff nurse instructors who present specific content, answer questions, and direct participants in handson activities. The Skills Laboratory checklist is signed off at the end of each station and turned in at the end of the course (Table 1). CVVH Skills Lab
PURPOSE: To verify competency in the care of the patient receiving CWH therapy. As a participant in the CWH course, you will be asked to demonstrate competency in the skills thought to be critical to practice in the care of the patient receiving CWH therapy. The skills lab is not to replace check-off of your performance in the clinical unit. If you have any questions about the skill, ask your unit resource or staff development coordinator. OBJECTIVES: At the end of the skills lab the participant will be able to demonstrat~
237
or verbally identify the following skills in a lab setting: A. Initiation and maintenance of CWH B. Flushing the system C. Reconnecting the patient to CWH after a procedure D. Troubleshooting mechanical problems 1. Low ultrafiltrate production 2. Pressure monitor alarm 3. Bubble detector alarm 4. Filtrate pump alarm 5. Access failure 6. Change in ultrafiltrate color E. Strategies for emergency situations 1. Catheter dislodgement 2. Codes 3. Air emboli 4. Fluid and electrolyte imbalance A pretest and participant letter are distributed to course participants approximately 2 weeks prior to the course. Pretests are turned in at the beginning of the course. A participant packet is distributed at the beginning of the course (see Box 3). A diagram of our CWH system is included (Figure 1). At the end of the program, a posttest is given. This is a 20-question, multiple choice test and is the same as the pretest. To successfully complete the course, 80 percent is required on the posttest, along with successful completion of the Skills Laboratory stations. Participants review the posttest results with the pretest and are able to note the usual marked improvement. All tests are turned
Box 3. CONTENTS OF PARTICIPANT PACKET • • • • • • • • •
Program CWH diagram Objectives Skills lab checklist Physician's Preprinted orders Flowsheet Documentation guidelines for f\owsheet Policies and procedure Evaluation Article
238
CLEVENGER
Table 1.
SKILLS LABORATORY CHECKLIST
STATION I. Routine Initiation and Maintenance of CWH Therapy Competency Demonstrated
Initial
Date 1. Verbally identifies parts of the system 2. Verbally identifies routine maintenance of the system 3. Verbally identifies roles/responsibilities of CWH team members STATION II: Troubleshooting and Emergency Situations of CWH Therapy
A. Identify/demonstrate appropriate troubleshooting measures for the following problems: Competency Demonstrated
Initial
Date 1. 2. 3. 4. 5. 6.
Filtrate pump alarms, reading "low flow" Low ultrafiltrate production Bubble detector alarm Pressure monitor alarm High filter pressure Ultrafiltrate becomes pink in color B. Verbally identify the nursing responsibilities in the event of an emergency situation while the patient is receiving CWH therapy, for the following situations: Competency Demonstrated
Initial
Date 1. 2. 3. 4.
Catheter dislodgement Codes Air emboli Fluid and electrolyte imbalance
STATION Ill: Flowsheet and Orders Competency Demonstrated
Date
Initial
1. Verbally identifies how to initiate the flowsheet 2. Demonstrates the hourly calculation of the flowsheet 3. Verbally identifies an understanding of the order sheet STATION IV: Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Competency Demonstrated
Date 1. Demonstrates flushing the system 2. Demonstrates taking the patient off of CWH and recirculating the system 3. Demonstrates reinitiating CWH therapy 4. Demonstrates discontinuing CWH therapy
Initial
Replacement FluldA Contains 0.9% saline & 1O mmol/l KCL
Replacement Fluid B Contains 0.45% saline + 55 mmoVL NaHC03 Drip Chamber Catches clots & air
Heparin Heparinization is used to maintain filter patency
Single dual lumen venous catheter
Blood Line Clamp Occludes system should air be detected
Pulls blood from one lumen at 200 cc/hr and pumps it through to filter
Monitor A pressure transducer connected to a cardiac monitor is used to monitor pressure within the system Pressure Transducer
Semi-permeable membrane filter pulls wastes from the bioo:d hydrostatic pressure
Blood Pump
U ltrafiltrate Pump IV pump is set at 999 cc/hr to pull 1 liter of ultrafiltrate per hour
Ultraflltrate Collection Device Foley catheter bag is used to collect ultrafiltrate
Figure 1. Continuous venovenous hemofiltration.
240
CLEVENGER
back in. A form is placed in the employee file indicating the posttest score and completion of the Skills Laboratory stations (see Table 2). The participant completes the program by turning in the evaluation form (see Table 3 and evaluation below in text). These are introduced in the beginning of the course and completion/comments are encouraged. Continuous Venovenous Hemofiltration (CVVH) EVALUATION • What did you like best about this course? • Any suggestions for modification of this course? • Comments concerning the environment, content, presenters, and learning methods not already mentioned: • Overall, I would rate this course (on a 15 scale, with 5 being best) _ __ • Suggestions for topics/speakers for future staff development offerings:
Committee. Once again, we are in the process of revising because of the purchase of new equipment (see list below in text). CVVH Policies and Procedures • Maintenance of hemofiltration • Interruption and reinitiation of hemofiltration • Termination of hemofiltration • Troubleshooting and emergency procedures for hemofi.ltration • Flushing a hemofilter
Physician Orders We have developed preprinted orders that are initiated by the nephrologist/renal fellow. Once it is decided that the patient will be placed on CVVH, the renal physicians are responsible for all fluid management.
Flowsheet and Documentation Guidelines Policy and Procedures We have revised our policy and procedures multiple times since starting our CVVH program. The revisions are done by the CVVH
Table 2. CLARIAN HEALTH/INDIANA UNIVERSITY HOSPITAL CONTINUOUS VENOVENOUS HEMOFILTRATION (CWH) COURSE
NAME ___________
We have also revised our flowsheet multiple times since the beginning of our CVVH program. This has been a joint effort between the nephrologist, dialysis nurses, and ICU nurses. The documentation guidelines are concise and clearly explain how to document on the flowsheet. We have also color coded (shaded in gray) the columns that coincide with our formula: Replacement Fluid = Total Output-Total Input-Desired Fluid Loss.
UNIT ---------_ DATE __________
Item
Annual Competency Process Score
CVVH Posttest Station I Station II Station Ill Station IV
Facilitator • To be placed in Employee's Personnel File
Comments
The annual competency process has been the most challenging task that the CVVH Committee faces. We average caring for 40 to 50 CVVH patients annually. We've struggled with the question, "How do we assure competency of multiple nurses working in three different units in the care of our CVVH patients?" We will now be including in our annual ICU competency blitz (see Table 4
241
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
Table 3. CLARIAN HEALTH/INDIANA UNIVERSITY HOSPITAL CONTINUOUS VENOVENOUS HEMOFILTRATION (CWH) EVALUATION Please circle the number which best indicates your evaluation of the quality of both the content and the speaker for each of the following topics. KEY: 5 = Excellent 4 =Good 3 =Average 2 =Fair 1 =Poor
Topic
Continuous Venovenous Hemofiltration Presentation CWH Flowsheet CWH P and Ps CWH Skills Lab: I. Routine initiation and maintenance of CWH therapy II. Troubleshooting and emergency situations of CWH therapy Ill. Flowsheet and orders IV. Procedure to interrupt, recirculate, reinitiate, and discontinue CWH therapy
Content Was the content adequate to learn the objectives?
Speaker Rate the speakers' effectiveness/teaching methods
2 3 4 5 2 3 4 5 2 3 4 5
2 3 4 5 2 3 4 5 2 3 4 5
2 3 4 5
2 3 4
5
3 4
5
2 3 4 2 3 4
5 5
2
3 4 5
2 3 4 5 2 3 4 5
Objective
1. 2. 3. 4. 5. 6. 7.
8. 9.
Define CWH Discuss two indications for the initiation of CWH State two advantages of selecting CWH over other renal therapies Identify three potential complications of CWH Identify two nursing interventions required for hemodynamic instability when placing a patient on CWH Describe how to initiate the flowsheet and the steps needed in the continuous calculation of the flowsheet Compare/contrast the equipment set-up responsibilities of the ICU nurse and the dialysis nurse Identify the responsibilities of each member of the CWH team Demonstrate skills in a lab setting-refer to objective in skills lab checklist
2
Rating
2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3
4
5
2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5
242
CLEVENGER
STATION I. Routine Initiation and Maintenance of CWH Therapy Competency Demonstrated Date
Initial
1. Verbally identifies routine maintenance of the system 2. Verbally identifies roles/responsibilities of CWH team members STATION II. Flowsheet Competency Demonstrated Initial
Date 1. Verbally identifies how to initiate the flowsheet 2. Demonstrates the hourly calculation of the flowsheet
STATION Ill. Procedure to Interrupt, Recirculate, Reinitiate, and Discontinue CWH Therapy Competency Demonstrated Initial
Date 1. Demonstrates flushing the system 2. Demonstrates taking the patient off of CWH and recirculating the system (includes reinitiating and discontinuing)
STATION IV. Troubleshooting and Emergency Situations of CWH Therapy A. Identify/demonstrate appropriate troubleshooting measures for the following problems: Competency Demonstrated Date 1. 2. 3. 4. 5. 6.
Filtrate pump alarms, reading "low flow" Low ultrafiltrate production Bubble detector alarm Pressure monitor alarm High filter pressure Ultrafiltrate becomes pink in color
Initial
SETIING UP A CONTINUOUS VENOVENOUS HEMOFILTRATION EDUCATIONAL PROGRAM
and checklist below). In the past, we have had staff nurse committee members check staff off at mock stations. Also, we have required successful completion of the written test annually. We have developed a CVW/Resource Manual for each unit that contains the CVVH diagram, policy and procedures, and multiple articles.
243
A recent addition has been the development of the ICU Clinical Log. Staff nurses are responsible for logging the date and number of hours spent caring for each CVVH patient. This assists in determining how to assign staff to CVVH patients, helping to document competency. In addition, this information is utilized as input in the annual evaluation process of each staff member.
Name _ _ _ _ _ Unit _ _ _ _ _ __
~
Date-------
CLARIAN HEALTHnNDIANA UNIVERSITY HOSPITAL Continuous Venovenous Hemoflltratlon (CVVH) Competency Checklist PURPOSE: To verify competency in the care of the patient receiving CWH therapy. OBJECTIVES: At the completion of the competency assessment, the participant will be able to demonstrate or verbally identify the following skills (via a written assessment and simulated skills): A. Initiation and maintenance of CWH B. Documents correctly on CWH flowsheet C. Flushing the system D. Reconnecting the patient to CWH after a procedure E. Troubleshooting mechanical problems 1. Low ultrafiltrate production 2. Pressure monitor alarm 3. Bubble detector alarm 4. Filtrate pump alarm 5. Access failure 6. Change in ultrafiltrate color F. Strategies for emergency situations 1. Catheter dislodgement 2. Codes 3. Air emboli 4. Fluid and electrolyte imbalance
SUMMARY
The key to developing a successful CVVH course is the involvement of the clinical experts-the staff nurses. It is an ongoing process that requires continual improvement. The CVVH course will help to assure the competency of the ICU nurse in caring for the critically ill patient on CVVH.
244
CLEVENGER
ACKNOWLEDGMENTS
A special r.hank you to my mentor and coach of CVVH Therapy, Dr. William Macias. He has made a difference for our patients at Indiana University Hospital. Dr. Macias has also been a special teacher for many of us, and his passion for this therapy has been contagious. A special r.hank you to Dr. Michael Kraus, who has carried on the high educational and clinical standards for the CVVH patients and the ICU nurses.
A special thank you to Catherine Tonn Coscia, RN, CCRN, who staned the ball rolling, serving as co-chairperson of the CVVH Committee. Also, !.hanks for mentoring me in this therapy. A special thank you to the staff nurses who have served as CVVH Committee Members and are so dedicated to the educational and clinical standards r.hat we hold high for our ICU patients. A special thank you to the dialysis and ICU nurses, who provide exceptional care to these patients.
Address reprint requests to Kay Clevenger, RN, MSN Indiana University Hospital 550 N. University Boulevard UH 6420 Indianapolis, IN 46202-5250