New ICU Dialysis Study Points to Successful CRRT Alternative
December 2022 (Updated)
Summary
Converting from an outsourced provider to in-house Tablo hemodialysis in the ICUs at this Michigan hospital has eliminated problematic treatment and supply delays, and significantly reduced costs.
Covenant HealthCare, a 365-bed hospital and Level II trauma center serving the Great Lakes Bay region of Michigan, began offering long-duration dialysis treatment in its ICU units in 2019, to provide kidney support for hemodynamically unstable, critically ill patients. Then came COVID-19, and an already expensive treatment became even more costly and inefficient under the pressures of a pandemic. Covenant was caring for the highest number of COVID-positive patients in the entire state at one point, including acute kidney injury patients requiring dialysis. Under these challenging circumstances, not only were the high-maintenance renal replacement therapy treatments dominating the hospital’s already-strained ICU nursing resources, but inefficient delays in care and treatment costs associated with their outsourced provider had become unsustainable.
The team then heard about the Tablo Hemodialysis System, a first-of-its-kind enterprise solution capable of delivering Adaptive Dialysis (see Box) in their surgical and cardiovascular ICUs, and the high intensity care unit (HICU).
Adaptive Dialysis
A term used to describe the Tablo system’s unique ability to span a wide spectrum of treatment modalities, from 2–24 hours daily, including extended therapy (XT), sustained low efficiency dialysis (SLED), and intermittent hemodialysis (IHD) with or without ultrafiltration (UF). This clinical versatility enables providers the ability to meet the hemodynamic needs of all patients and standardize dialysis with Tablo across the continuum of care, from hospital to home.
“We all fell in love with the ease of use and versatility with Tablo, and with leadership support, we decided to take it on” says Tara Greenleaf Nichols, MSN, RN, Clinical Outcomes Nurse Specialist, Critical Care & Progressive Care at Covenant, who has spent five years on the ICU dialysis team and also assisted with the Tablo nurse training and implementation. “We did a full conversion in our ICUs from an outsourced dialysis provider with other machines, and went live with a fleet of XT consoles in November 2021. Number one, it has been a cost saver for us.”
Sandy Rowe, BSN, RN, is Covenant’s Critical Care Department Educator. “Compared to other machines, seeing what Tablo can do, anywhere it is needed in the hospital, was just phenomenal to me.”
Senthil Ramaiyah, MD, oversees Covenant’s dialysis program. A nephrologist for 10 years, he was so enthusiastic to learn more about Tablo that he participated in an Outset Medical super-user class, a four-hour in-person session usually attended by nurses, prior to the facility’s go-live. “Tablo came to us just at the right time, when COVID hit, things were falling apart and our dialysis services were stretched. It was the perfect storm,” he says.
“The old system of outsourcing these services is not working. Patient care is being affected. Tablo has changed the game. It is the first major dialysis innovation we’ve had.” – Senthil Ramaiyah, MD
“We are already looking at the progression of our program and where we can go with it in the future. The old system of outsourcing these services is not working. Patient care is being affected. Tablo has changed the game. It is the first major dialysis innovation we’ve had,” he continues.
Converting to an in-house ICU dialysis model with Tablo has already had a positive impact on three key problems for the Covenant team: control of patient care, costs and staff shortages.
In-House Control Over Patient Care and Costs
The cost savings since bringing in Tablo in just the last three months has already been significant, according to the Covenant team. “We were seeing a very large expense when we had an outsourced program,” says Toni Yursco, RN, ICU/Hemodialysis Nurse Manager. “My dialysis program as a whole is very expensive, so that addition of one-on-one nursing plus the cost of the procedure itself was pretty great. I think that’s how we were sold on Tablo, as we would be able to cut cost in a couple of different areas.”
When the opportunity came to convert to in-house dialysis using Tablo, the Covenant team was excited to take over. “It gives our nurses the ability to take ownership of the whole process,” says Toni. “We now have the ability to set that patient up right away. We don’t have to deal with uncontrollable delays in getting a machine or the supplies to the bedside. There have been a lot of benefits to the nurses, who are already a patient’s care manager, in taking the total package and delivering care at the bedside. Our staff really likes to be in charge of everything. And, they were excited to learn something new and take on a new process, which isn’t always the way that things go.”
Tara describes the less-than-optimal situation in their ICU when an outsourced provider was managing their dialysis services. “The cartridges and dialysate fluid were very expensive. Nurses from the contracted company would come to the bedside, set our previous machines up, do the priming, hook the patient up, and then our ICU nurses would manage treatment at the bedside, including hourly calculations. The outsourced provider would also assist with alarms and do the tear-down after the treatments. When there were problems during treatment such as clotting, we would need to reach out to the provider to come and troubleshoot, as these machines were complex and not so user-friendly. There could be quite a delay before they could get to us. Per our contract, they’d have up to four hours to come to our bedside, but that’s four hours of the patient being off the machine.”
Tara says that her team appreciates the clinical versatility of Tablo XT, in which they can easily stop fluid removal and just clean the patient’s blood if they need to. “The overall function of the machine is so user-friendly, it’s easy for the nurses, and it’s easy on the patients as we can make those adjustments very quickly ourselves and not have to wait for somebody to help us,” she says. Unlike traditional dialysis machines, Tablo XT allows for on-demand rapid adjustment to dialysate sodium and buffer. This greatly simplifies the dialysate changes, compared to the process required with other machines to stop treatment, order, change, and hang liters of sterile dialysate bags every time these parameters are adjusted. (For more information on Tablo XT, see the Covenant HealthCare study announced at ASN Kidney Week 2022 below, this recent Nephrology Times paper and a Tablo XT interim analysis study, published in the Journal of the American Society of Nephrology in November 2021.)
New Covenant HealthCare Tablo Study Announced at ASN Kidney Week 2022
Review the study abstract here.
RESULTS
A total of 228 treatments were completed in 60 ICU patients with 60% COVID positive. Mean age was 62 yrs (range, 29-88). Total treatment success was 96% with 4% ending early due to alarms. The figure above shows total treatment by time; 0-6 hrs, >6-12, >12-24 hrs with success rates. Total time off therapy compared to a Non-Tablo continuous model was 2299 hrs equating to approximately 1.2 FTE ($100k) in labor productivity.
CONCLUSION
At Covenant HealthCare, conversion to Tablo adaptive therapy model successfully delivered treatments up to 24 hrs to critically ill patients who would otherwise be on CRRT. Adaptive therapy improved nurse staffing efficiency while reducing cost and patient time off dialysis. Application of this model allows a more individualized approach to ICU patient care without increasing the burden on the ICU or acute hospitals.
Comment from the study co-authors:
“It was an amazing experience to compile our data and see how successful we have been with our Tablo program. We are seeing the positive effects that it has on our staffing, finances and most importantly our patients. We continue to extract the data to see the immense benefits that Tablo provides us. Being able to present the data at the 2022 ASN conference was an incredible opportunity to share our successes. We look forward to the future and what Tablo can provide for us. We are very proud of how far we have come in just the first year of our Tablo program, and can’t wait to see what the future holds.” – Tara Greenleaf-Nichols, MSN, RN, and team, November 30, 2022
“We really needed something like Tablo to come in and shake things up. It’s plug-and-play dialysis. Our Tablo program has led to an efficient use of resources in our ICU,” says Dr. Ramaiyah. “Everybody is very pleased with how the machines work and how things are going, and we all appreciate the phenomenal support we have received from Outset. And we are seeing better outcomes.”
Staffing Shortages Alleviated
In Toni’s view, the versatility of Tablo has had a positive impact on staffing. “The ability to run shorter [<24-hour] treatments allows us to achieve the same clearance results and alleviates some staffing concerns. We can run those 1:1 treatments on day shift if that’s where our staffing is, or move treatments to the night shift if needed. That has been very accommodating.”
“With our previous machines, we would be having to constantly take patients off to go do a test, a treatment, a surgery, work on their mobility or whatever is needed, so having the flexibility to do shorter-duration treatments really benefits patients and our efficiency,” adds Tara.
Toni describes that it was very easy to transition their nurses to Tablo, and that there have been zero complaints. “In the ICU, none of them had experience with dialysis, but they were easily trained to use Tablo. I think the biggest message I would say about our experience is that you don’t have to be a dialysis nurse to use this machine and see the impact on your patient care.”
About Covenant HealthCare
From moms-to-be to babies to great-grandfathers, Covenant HealthCare delivers extraordinary care across generations and across specialties in Michigan’s Great Lakes Bay Region. Patients can trust Covenant HealthCare with the health needs of the entire family. With 4,800 employees and a medical staff of more than 500 physicians, the Saginaw-based health system offers a broad spectrum of programs and services including high-risk obstetrics, neonatal and pediatric intensive care, acute care, a Level II Adult and Pediatric Trauma Center, cardiology, oncology, orthopaedics, robotic surgery, stroke, rehabilitation and more.
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