Providence St. Joseph Hospital: Tablo as a Pandemic-Proven Game Changer
Tablo helped to solve critical dialysis supply, nursing workflow, and prolonged therapy issues—and saved many lives—at one of the busiest COVID-impacted hospitals in Southern California.
In a scene played out similarly around the world, COVID-19 patient surges spread across Southern California in several waves last year, leading to capacity-exceeding hospital caseloads and restrictive stay-at-home orders. For Karlo Pajaro, BSN, RN, Clinical Nurse Manager of the Renal Center at Providence St. Joseph Hospital in Orange, CA—one of the busiest hospitals in the region—unprecedented admissions of COVID-19 patients with ESRD and acute kidney injury stretched he and his nursing staff to their limits as they worked to save lives. Challenges created by the sheer volume of critically ill patients requiring resource-intensive continuous renal replacement therapy (CRRT) led to the need for a novel alternative.
The first-of-its-kind Tablo Hemodialysis System became a game-changer for Pajaro’s acute dialysis team, nephrologists, and MedSurg, ICU, and ER nursing staff at Providence St. Joseph during this crucial time. Tablo’s ease of training and use throughout the hospital and its clinical versatility—in particular the Extended Therapy (XT) modality option in place of CRRT—led to many patient lives being saved and a cost-effective impact on the hospital’s nursing workflow. And, lessons learned during the pandemic continue to resonate with a team that pivoted quickly to deliver dialysis under extraordinary circumstances.
Providence St. Joseph Team Addresses a Crisis
Prior to the pandemic, the dialysis team at Providence St. Joseph provided intermittent hemodialysis (IHD) treatments with a fleet of Fresenius systems, and CRRT with a smaller number of NxStage machines. However, after the COVID-19 pandemic took hold last March, traditional CRRT at the hospital was thrown into the spotlight, both for its life-sustaining properties but also because of its inefficiencies—one of those being the consumables required. “Several weeks into the pandemic, NxStage notified us that they were running critically low on bagged dialysate solution due to enormous demand for COVID-related CRRT, and were having to institute a supply allocation program,” says Pajaro. Pajaro (pictured at right with a Tablo console), a nurse for 18 years, manages Providence St. Joseph’s acute, outpatient/chronic and home dialysis programs.
He and his Renal Services team met with hospital directors to address this critical situation, as their dialysis procedure volumes were skyrocketing. The decision was made to bring on Tablo, as it addressed many of their needs with its on-demand dialysate production, easy training, portability, lower cartridge cost, and integrated water purification. The initial plan was for the consoles to supplement the hospital’s existing traditional dialysis machines and IHD treatments, and they made their debut in August.
Cross-Training Boosts Surge Capacity
Pajaro and his team, along with nurses from the ICU and MedSurg units—many of whom had no prior dialysis experience—were trained on Tablo by the Outset Medical support team in just a few hours, aided by the system’s touchscreen guidance and step-by-step animated instructions. Some dialysis nurses were hesitant of the new technology at first, Pajaro notes, but after a couple of weeks of treating on Tablo they began to prefer it over the traditional machines.
Providence St. Joseph’s emergency room nurses were also trained on Tablo, as a back-up plan in case of future surges. Pajaro commented that it was easier to train the ER team to provide dialysis on Tablo, rather than sending a dialysis nurse to the emergency department to perform mostly IHD treatments there. “Our ER nurses were really excited to learn Tablo and said that it was very easy to use. Although we didn’t end up having another big COVID surge, they are using the system for emergency treatments,” he says. “I am confident in delegating Tablo treatments to any of our nurses, because of how easy it is to use. In my experience with many other machines, Tablo’s user-friendly graphic user interface is a game-changer. And, with the consoles being compact and self-contained, we are able to provide dialysis care in any area of the hospital where it is needed,” he continued.
The team also gained additional technical expertise from participating in Outset Medical’s enhanced 8-hour Bio-Med training course. “The technical training helped me, my renal services team and our bio-med technicians to really understand the machine’s disinfection, maintenance, and other advanced safety functionality, especially in light of COVID. After the trainings, our usage of the machines increased, and we even added another Tablo console to our fleet,” he says. Nurses from Providence Mission Hospital in Mission Viejo, CA, participated in the initial and Bio-Med trainings as well, as they had just introduced Tablo consoles in their acute dialysis unit.
Extended Therapy: A Pandemic-Proven Game-Changer
Following a slowdown in COVID-19 cases in September and October, Providence St. Joseph experienced a sharp, deadly rise in the number of patients requiring dialysis in November and early December.
“That’s when it really hit us hard, we saw huge numbers of patients with renal failure due to COVID coming into our hospital,” says Pajaro. “We got to the point where we had more patients needing dialysis than we could handle with the staff and machines that we had, especially NxStage.”
Exhausted at his desk one day, Pajaro examined his options and decided that Tablo’s Extended Therapy (XT; allows up to 24 hours of slow, continuous therapy at a minimum Qd of 50 mL/min) modality could potentially help his team get a handle on the large influx of patients needing long-duration dialysis. He discussed the option with his Renal Services team and nephrologists, who were impressed with the results seen with IHD treatments on Tablo to date, and they agreed.
At first there was concern that the consoles wouldn’t be able to treat patients continuously, as they were used to doing with the NxStage machines. Pajaro gained their confidence about XT as an alternative to CRRT, by educating them about the clinically versatile advantages that Tablo XT has over their traditional machines. XT allows safe and effective treatment of their long-duration patients, with features designed to address the complications and risks associated with traditional CRRT. These include quick and easy priming, automated or manual saline bolus with volume tracking to minimize clotting, tight regulation of dialysate temperature, and on-demand dialysate production and rapid adjustment to dialysate sodium and buffer, among other capabilities.
“We’re really thankful for Tablo because it saved a lot of lives.”
Pajaro and his team then developed an efficient plan to treat patients with prolonged intermittent renal replacement therapy (PIRRT) or sustained low efficiency dialysis (SLED), using Tablo machines. They designated one dialysis nurse a day to the ICU, to prime and set up all the consoles and start each patient on their treatment. The ICU nurses would then monitor patients during their 6 to 8-hour dialysis. The dialysis nurse would then conclude the treatments and disinfect and prime the machines for the next set of patients.
This strategy had an immediate positive impact on the team’s workflow. Prior to Tablo XT being implemented, if Pajaro had 10 patients needing CRRT with a NxStage machine, he would need to send 10 RNs to the ICU to accommodate those treatments. “When we started using Tablo XT for long-duration therapy, I only had to send one nurse to the ICU to set up and finish treatment for all 10 patients. So, I saved 9 RNs. Tablo has really been a game-changer for us. It really solved our staffing issue, and the machine and treatment issues we were having,” says Pajaro.
“Our team started to feel a sense of relief from that patient surge,” he continues. “We’re really thankful for Tablo because it saved a lot of lives. And now that we’re coming out of COVID, we are reassured knowing that Tablo is there for us.”
About Providence St. Joseph Hospital
Providence St. Joseph Hospital in Orange, California is a nationally recognized, 463-bed Catholic hospital founded in 1929 by the Sisters of St. Joseph of Orange. Fully accredited by The Joint Commission and designated four consecutive times as a Magnet® hospital for nursing excellence, Providence St. Joseph Hospital’s reputation for clinical excellence and compassionate, family-centered care draws patients from all over the United States.
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