PICU Collaboration Drives Outcomes for Complex Cases
The best of both worlds
Bradley Warady, MD, Division Director of Pediatric Nephrology, shares how synergies between nephrology and intensive care unit teams are improving Acute Kidney Injury care
Any hospital admission can be distressing for a child, but when pediatric patients face severe kidney injury and the need for dialysis, it becomes even more complex. We take innovative approaches to care for these critically ill children, and seeking positive outcomes for them and their families guides all we do in the nationally ranked Division of Pediatric Nephrology at Children’s Mercy Kansas City.
In the roughly 10% of pediatric intensive care unit (PICU) patients who develop severe acute kidney injury (AKI), we put patient and family needs front and center with a truly multidisciplinary, outcomes-focused approach to treatment. From the attending physicians to the nursing staff to the multiple support services, as well as the parents and family members, patient and dialysis management is comprehensive and collaborative.
In the last eight years, we have significantly reduced the time between initial consult and dialysis initiation for ICU AKI patients in need of kidney replacement therapy, which is crucial for these children who don’t have a moment to spare. Recently, we have cared for an increasing number of infants who come out of the Fetal Health Center with significant kidney abnormalities and AKI, as well as other organ related issues. Historically, these children may not have survived; but now, with terrific management from nephrology, intensive care, nutrition and a variety of other disciplines, many of these children are not only surviving, but even those who have progressed to end-stage kidney disease ultimately receive home dialysis, a successful kidney transplant and an enhanced quality of life long sought by all those involved in the child’s complex care.
In the last eight years, we have significantly reduced the time between initial consult and dialysis initiation for ICU AKI patients in need of kidney replacement therapy.
What are the not-so-secret ingredients to our accomplishments with our AKI patients? Interdisciplinary collaboration, mutual respect, training, and constructive feedback. Children with AKI require high quality care from a variety of disciplines, and the nephrologists and intensivists must be on the same page—they must be partners—and coordinate every aspect of patient care together. In creating this recipe for success, Vimal Chadha, MD, who serves as the Co-Director of the Acute Kidney Injury Program, is making sure it all comes together. Along with his counterpart in the PICU, he oversees the activities of the AKI program’s team members. He has bimonthly meetings with coordinators, associate program directors, dialysis nurses and dialysis managers to share ideas and review difficulties they may be facing. They work together to develop specific, patient-centered and often innovative plans for the care of the routine and not-so-routine cases.
It is also imperative to underscore the roles the incredible PICU nurses play as important members of the AKI team. We have specially trained a cohort of 40 ICU nurses who, along with our dialysis nurses, provide all varieties of acute kidney replacement care, since they are always at the bedside and are well versed in the care of the most critically ill patients.
To ensure our nurses stay up to date on AKI topics and dialysis techniques, Dr. Chadha coordinates an annual two-day “boot camp” with presentations, open discussion and hands-on experience with dialysis equipment. In 2021, we implemented simulation lab events, which are intended to enhance the capacity of our nurses to rapidly recognize problems that can arise and the potential solutions to institute when performing dialysis. The team also collaborates with other organizations on multi-center trials designed to further enhance the care of children with AKI.
The unique co-management of the AKI program between the PICU physicians and Nephrology has been a key to the program’s growth and success. Embracing and leaning on everyone’s expertise, unique perspectives and diverse experiences have made it the best possible program with the best possible results. Once you get past specialties, titles and siloed processes and view each other as sources of wisdom and partners who can all grow and learn together, the doors open up and the possibilities are endless. That, in conjunction with a thirst for ongoing learning and the generation of research-backed knowledge, primes us for continued success and ensures that an increasing number of critically ill kids will go on to live full, healthy lives.