title: An Institutional Change in Continuous Renal Replacement Therapy.
abstract: BACKGROUND
  Critically ill patients with acute kidney injury may require parenteral nutrition (PN) and continuous renal replacement therapy (CRRT). Introduction of a phosphate-free premixed renal replacement fluid without system-wide education in May 2011 resulted in increased incidence of hypophosphatemia, necessitating change in practice. Changes included (1) maximizing phosphate in PN, (2) modifying the CRRT order set, and (3) developing a CRRT competency evaluation for nutrition support team members. This study evaluates the effect of these changes on the incidence of hypophosphatemia.
  
  
  METHODS
  Phosphate levels and predicated probability of hypophosphatemia were evaluated for patients receiving PN and CRRT over 3 time periods: prior to implementing the changes (preimplementation), during change implementation (intermediate), and following implementation (postimplementation). Hypophosphatemia was defined as a serum phosphate level <2.5 mg/dL. Generalized linear mixed models were applied for statistical analysis.
  
  
  RESULTS
  The retrospective study includes 336 measures from 49 patients. Patients in the intermediate and postimplementation periods were not significantly different from each other and had significantly higher mean phosphate levels than patients in the preimplementation period ( P < .0001). They were also less likely to develop hypophosphatemia compared with preimplementation patients (intermediate: odds ratio [OR], 0.07; 95% confidence interval [CI], 0.03-0.18, P < .0001; postimplementation: OR, 0.09; 95% CI, 0.03-0.27, P < .0001).
  
  
  CONCLUSIONS
  Modifications in phosphate dosing together with CRRT education reduced the incidence of hypophosphatemia in PN patients receiving CRRT. Communication of significant changes in clinical care should be shared with all services prior to implementation. Communication and planning between services caring for complex patients are necessary to prevent systems-based problems.
authors: 1 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
authors: Rebecca A
authors: RA
authors: Busch
authors: 2 Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA.
authors: Caitlin S
authors: CS
authors: Curtis
authors: 3 Clinical Nutrition Services, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA.
authors: Cassandra E
authors: CE
authors: Kight
authors: 1 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
authors: Glen E
authors: GE
authors: Leverson
authors: 1 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
authors: Yue
authors: Y
authors: Ma
authors: 4 Section of Nephrology, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
authors: Laura
authors: L
authors: Maursetter
authors: 1 Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.|5 Veteran Administration Surgical Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.
authors: Kenneth A
authors: KA
authors: Kudsk
mesh_terms: D058186:Acute Kidney Injury / Q000628:therapy; D000328:Adult; D000368:Aged; D016638:Critical Illness / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D005217:Fat Emulsions, Intravenous / Q000032:analysis; D005947:Glucose / Q000032:analysis; D006801:Humans; D017674:Hypophosphatemia / Q000453:epidemiology* / Q000628:therapy; D015994:Incidence; D008875:Middle Aged; D010288:Parenteral Nutrition; D010710:Phosphates / Q000097:blood; D017582:Renal Replacement Therapy / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D005217:Fat Emulsions, Intravenous; D010710:Phosphates; D005947:Glucose
keywords: hypophosphatemia; parenteral nutrition; phosphate; renal replacement fluids; renal replacement therapy