(384) Nutritional Delivery to Pediatric Patients While Using Continuous Renal Replacement Therapy

Introduction: Continuous renal replacement therapy (CRRT) is used in critically ill children with acute renal failure. CRRT can lead to malnutrition by removing essential proteins and micronutrients. Malnutrition is associated with worse outcomes, including increased length of stay and mortality. CRRT guidelines suggest the importance of early nutrition and ensuring high protein intake. After evaluating our CRRT patients, we found sub-optimal adherence to the guidelines. This Quality Improvement project aimed to increase the percentage of patients achieving 75% of their goal protein and caloric intake by day 5 of CRRT initiation by 15% by August 2023.

Methods: A multidisciplinary group of dietitians, nurses, nephrologists, and intensivists identified a knowledge gap in nutritional goals through surveys and a fishbone diagram. Outcome metrics were percentage of goal protein and calorie delivery by day 5 of CRRT initiation. Our interventions included educating bedside nurses, dietitians, and intensivists, implementing a nutrition checklist on rounds, and utilizing CRRT-specific nutrition notes in the EMR. Our process metrics included the completion of the nutrition checklist and EMR-notes.

Results: A total of 18 CRRT patients were evaluated pre-implementation (Jan 2021 to Dec 2021) and 11 post-implementation (Oct 2022 to July 2023). The number of patients meeting at least 75% of goal protein by day five of CRRT initiation increased to 82% from 72%. Those meeting at least 75% of goal caloric intake increased to 72% from 62%. The nutritional initiation checklist and CRRT EMR-nutrition notes were completed 72% and 100% of the time, respectively. Those that did not meet the goal protein intake (n=2) were receiving enteral nutrition. Common reasons for not meeting nutritional goals with enteral nutrition include procedure interruptions, vasoactive medications, and slow up-titration to goal feeds.

Conclusions: Implementing an educational program, a CRRT nutrition checklist and new CRRT-specific EMR nutrition notes have increased the percentage of patients meeting goal caloric and protein intake. Future Plan-Do-Study-Act cycles will aim to improve checklist compliance and reduce enteral feed interruptions.