Provision of intermittent renal replacement service outside an ICU is safe and effective

Introduction

Renal failure following cardiac surgery prolongs the ICU stay [1]. We developed a service in this tertiary cardiothoracic centre to provide intermittent renal replacement therapy (RRT) in designated high-dependency units (HDU) outside the ICU for cardiothoracic patients who have isolated renal failure. This has reduced the ICU length of stay and costs, and allowed other patients to be admitted to the ICU. The service is provided by ICU nurses and supported by the Outreach team, whose remit is to facilitate ICU discharge and to educate ward nurses in critical care skills.

Methods

A retrospective analysis of the ICU database identified all patients who had received intermittent RRT outside critical care during an 18-month period in 2006–2007. We reviewed patient demographics, diagnosis, number of episodes of RRT performed outside the ICU; daily SOPRA scores and RRT-related complications. The discharge from the ICU and the institution of RRT were led by an intensivist. An established nurse-led Outreach team was responsible for the daily assessment and nursing supervision of these patients. Each episode of RRT was provided by an ICU nurse on a 12-hour shift. The clinical risk management database was reviewed to identify any patient safety incidents (PSI) relating to this service.

Results

There were 127 episodes in the study period of RRT in ward areas (111 episodes in transplant HDU, 15 episodes in cardiac surgery HDU and one episode in cardiology HDU). There were two PSIs with minor patient impact only.

Conclusion

The 127 episodes of RRT outside the ICU reduced the demand for ICU beds. These patients were successfully discharged from the ICU (critical care level 3) to HDU (level 2) beds with the support of the critical care Outreach team. There was a low rate of complications. We believe that an established critical care Outreach service can facilitate early and safe discharge from the ICU of cardiothoracic patients with isolated renal failure requiring intermittent RRT.