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Paper text:
the role of critical care nurses in the management of continuous renal replacement therapies ( crrt ) in intensive care units ( icu ) is currently a matter of debate .
many centres have applied a collaborative approach , where nurses from the dialysis unit ( du ) intervene during a crrt session , generally to take care of the technical aspects of the dialytic treatment .
although some controversial literature was published on the subject , it must be acknowledged that the intervention of nurses from the du allows for a high level of specific expertise as far as the technical and clinical aspects of dialysis are concerned .
furthermore , when organized this way , the increased workload on the critically ill patient undergoing continuous dialysis is shared by two bedside healthcare providers . however , an adequately trained icu employee might begin the treatment in a more timely manner and proceed to the dialysis machines without any delay ( hypothetically , that is , due to the  on call  nature of the schedule )
this may have a positive effect on dialysis timings and costs , as well as increasing the responsibilities and duties of critical care nurses at the bedside .
the problem currently dividing italian hospital administrators and nurse coordinators is that no general rule has ever been recommended for crrt in the icu .
it is unclear whether different approaches should be applied at different levels of care , or if a standardized method might be suggested in the future , or if each centre should be able to take decisions based on local resources .
the aim of this study wasto better clarify the issue of nursing organization for crrt in the icu : in order to address this issue , a national - level survey was conducted .
a survey was carried out of people attending a course on nursing practices during crrt .
a questionnaire was made freely and widely available , and participants were invited to complete it .
they focussed on specific issues regarding practice patterns in the field of critical care nephrology and consisted of six demographic inquiries and 15 multiple choice questions , divided into four sections as follows : information about the participants background and working environment;specific questions regarding several aspects of nursing organization;specific aspects of crrt management , such as the hypothetical presence of another device ( i.e. extracorporeal membrane oxygenation ( ecmo ) ) or crrt delivered to children;an open - answer question about the most frequent problems encountered during crrt .
information about the participants background and working environment ; specific questions regarding several aspects of nursing organization ; specific aspects of crrt management , such as the hypothetical presence of another device ( i.e. extracorporeal membrane oxygenation ( ecmo ) ) or crrt delivered to children ; an open - answer question about the most frequent problems encountered during crrt . statistical analysis .
all documents were analysed using a microsoft excel database , where the working group entered the information received .
of the 130 participants attending the meeting , 120 filled out the questionnaire ( 92% ) . in one case ,
consequently , 119 questionnaires were analysed ( 114 nurses , 2 medical doctors , and 3 dialysis technicians ) .
sixty - nine responders ( 58% ) were healthcare providers working in dus , and the remaining 50 ( 42% ) were nurses operating in icus .
most of the participants worked in an adult setting , but 47 ( 39% ) stated that they had paediatric expertise .
more than half ( 66 ; 56% ) had over ten years experience , and only 22 ( 19% ) were  young  workers with less than 5 years experience .
ninety - one ( 77% ) of the participants stated that in their hospital the average number of acute dialytic treatments was below 10 per month .
of these , about one third came from low - volume centres delivering less than one treatment per month .
the second part of the questionnaire concerned nursing organization . to the question  who is in charge of crrt management in your institution ?  27 ( 23% ) answered  the dialysis staff  , 46 ( 39% )  the critical care nurse  , and 45 ( 38% )  a shared organization  ( figure 1 ) .
crrt management : the answer to the question  who is in charge , in your institution , for crrt management 
, was in 27 ( 23% ) cases  the dialysis staff  , in 46 ( 39% ) cases  the critical care nurse  and in 45 ( 38% ) cases  a shared organization  .
however , 25% did not consider their shifts to be made more demanding by crrt ( 71% of this subgroup came from high - volume institutions ) .
the remaining 12% ( all coming from nephrology units ) stated that collaboration between critical care nurses and dialysis nurses implies a correct balance in the healthcare workload .
only 50% of the participants stated that specific training was provided for crrt management , while 45% stated that they had never attended any dedicated training and had gained their expertise in the course of their work .
an analysis of theoretical and technical crrt training by specialty area revealed that 62% of operators working in nephrology and dialysis departments had received training , whereas only 34% of critical care nurses had attended a crrt training program .
regarding professional requirements for managing crrt patients , 22% answered that only trained personnel could handle critically ill patients .
contrastingly , only 2% of critical care nurses believed this requirement to be essential for their unit . in 49% of cases , both trained and untrained nurses were allowed to manage crrt , whereas 30% stated that trained personnel were required to supervise those who had not received any training . to the question of whether a professional operator was required to set up the crrt machine after prescription was made on the clinical chart , 75% confirmed that this was done by the medical staff ( 30% by an intensivist , 45% by a nephrologist ) . interestingly , 21% stated that the dialysis nurse was allowed to set up the machine following medical prescription on the clinical chart .
regarding who was in charge of patients connection to crrt , 71% stated that this was the dialysis nurse , in 13% of cases the duty fell to the critical care nurse , and in 16% it was the intensivist .
analysis of the subgroup of critical care nurses revealed that the intensivist was in charge of patient connection in 40% of cases . there were no instances of the nephrologist connecting crrt at the start of the session .
to the question of who was responsible for managing and overriding crrt alarms , 50% answered that the role was shared between dialysis and icu staff .
however , 35% answered that the critical care nurse was independently responsible for alarm management and troubleshooting .
when dialysis and critical care subgroups were analysed individually , it was revealed that 65% and 66% , respectively , were assigned to alarm management .
when the nurses roles were analysed in detail , 69% answered that the nurse in charge of the crrt patient was responsible for circuit management and should be able to understand all technical aspects of crrt sessions ( figure 2 ) and 25% of respondents claimed that nurses should only be in charge of basic functions ( bag changes , alarms silencing and overriding ) ( figure 2 ) .
nurses roles on technical aspects of dialysis machines : 69% of people answered that the nurse in charge with the crrt patient is responsible for circuit management and should be able to understand all technical aspects of crrt sessions .
however 26% of responders claimed that nurses should be involved only in basic functions management ( bag changes , alarms silencing and overriding ) and 5% of respondents surprisingly claimed that no role is due to nurses during a crrt session .
the third part of the survey was dedicated to particular crrt set ups and settings .
participants were asked if ecmo treatments were performed in their unit , and 60% of participants ( 86% of critical nurses ) claimed to have experience in ecmo .
overall , 50% of respondents had connected a crrt patient to an ecmo machine ( 87% of critical nurses and 17% of dialysis nurses ) .
a perfusion nurse was present and shared patient workload in 50% of cases when a crrt patient was connected to an ecmo machine .
interestingly , regarding the question of who should be in charge of such a complex procedure ( ecmo+crrt ) , 26% answered , 
i do not know  , and 43% answered that the critical care nurse should be in charge ( this increased to 77% in the subgroup of critical care nurses ) .
the remaining 21% answered that the dialysis nurse should be responsible for managing crrt under these circumstances ( figure 3 ) .
i do not know  , 43% answered that the critical care nurse should be managing such a case and the remaining 21% answered that the dialysis nurse should be responsible for crrt managing also in this kind of patients .
the last part of the questionnaire concerned the most frequent problems encountered by participants during their everyday practice involving crrt .
a need for greater collaboration among operators during a crrt session was cited by 24% .
the remainder made negative mention of workloads or frequent technical problems encountered during the majority of crrt sessions .
the main finding of this study was that in italy no standardized protocol exists on crrt nursing management in the icu : one third of centers apply a collaborative approach , where nurses from du and from icu share the crrt workload , in one third of cases the critical care nurses are fully in charge for crrt management and in the remaining centers only du staff manages crrt in the icu . in spite of the great developments in critical care nephrology , and an increase in dialytic indications in icus worldwide , several issues remain controversial .
these include the fact that no recommendation is currently in place regarding who should indicate , prescribe , start , deliver and manage crrt . in the last decade ,
however , it is only recently that they have started to develop a common language , and the multidisciplinary approaches of clinicians involved in the care of severe acute kidney injury may vary significantly from institution to institution .
what clearly emerges from our survey is that nursing management and coordination in italy requires significant optimization .
one of the most important lessons learned from this questionnaire is that the responsibility for crrt in the icu differs significantly according to the institution .
another interesting observation concerns the substantial lack of standardized training for clinical staff involved with crrt patients .
it appears that half of employees handling crrt machines have never received any specific training .
it might be argued that in a high - intensity setting such as this , nurses can not necessarily receive training for every device that they use . in our opinion , however , crrt machines have become part of routine icu equipment , and as such merit specialist knowledge for their use .
this would improve critical care and dialysis nurse coordination , and optimize the organization of crrt management .
with the exception of alarms management , it is clear that a well - trained nurse would be able to handle every aspect of a crrt session ( priming , connection , troubleshooting , circuit maintenance and , probably , modification of settings based on prescribed dose ) .
it has been recently shown that specific training also improves circuits patency and reduces avoidable errors during crrt troubleshooting . finally , it is a fact that extracorporeal treatments are becoming more and more complex , and that ecmo treatments are less infrequent , especially in high - volume centres . in light of this ,
multiple skills involving different healthcare professionals - including the perfusionist , who is often in charge of the ecmo device - are required for treating crrt patients .
the application of a crrt machine to an ecmo patient ( including the potential connection of crrt to ecmo ) requires specific protocols , knowledge , training and collaboration . as such
in partial confirmation of this observation , the vast majority of nurses complained about the lack of coordination , regardless of the type of organization employed by their hospital . in our opinion , this relates to every part of crrt management , including knowledge of the basics , troubleshooting simulation , and manual training in the management of machines operating at the bedside .
a plausible solution to the issue of crrt handling might be the provision of similar basic training to all healthcare professionals including advanced programs with simulation .
if critical care and dialysis nurses were all able to provide the same assistance to crrt patients , their cooperation might be significantly easier and the distribution of responsibilities less strict [ 11 , 12 ] .
finally , an optimized application of competences acquired by healthcare professionals would significantly reduce the cost of increased staffing for patients undergoing crrt and likely improve technical management , reduce errors and optimize average circuit lifespan .
as participants in the same course , the respondents may represent a self - selected population , causing a significant bias to the overall results and their interpretation .
furthermore , the sample size was not particularly large . however , based on the authors experience , the results confirmed existing ( if unverified ) knowledge about crrt practice in italy . furthermore , while the participants came from a large number of centres , an uncertain number of italian centres was unrepresented by the respondents .
however it is unlikely , in these authors opinion , that the inclusion of some unrepresented institution would have significantly changed our findings .
according to the results of this small survey , the role of italian nurses in the treatment of crrt patients is not standardized and requires significant modification . at present , established duties for critical care and dialysis nurses vary significantly across the country .
it is possible that intensive standardized training and educational programs may help resolve this issue .
introductionthe current role of nurses in the management of critically ill patients needing continuous renal replacement therapies is clearly fundamental . 
 the care of these complex patients is typically shared by critical care and dialysis nurses : their precise duties may vary from country to country.methodsto clarify this issue we conducted a national - level survey at a recent italian course on nursing practices during continuous renal replacement therapies.resultsa total of 119 questionnaires were analysed . 
 the participants , who were equally divided between critical care and dialysis nurses , came from 44 different hospitals and 35 italian cities . 
 overall , 23% of participants answered that  the dialysis staff  were responsible for continuous renal replacement therapies in the intensive care unit , while 39% answered  the critical care nurse  , and 38%  a shared organization  . 
 interestingly , less than the half of participants claimed specific continuous renal replacement therapies training was provided to employees before handling an acute dialysis machine . 
 finally , about 60% of participants had experience of extra - corporeal membrane oxygenation machines used in conjunction with continuous renal replacement therapies.conclusionsworkload coordination and management of critically ill patients undergoing continuous renal replacement therapies in italy is not standardized . at present , the duties of critical care and dialysis nurses vary significantly across the country . 
 they frequently overlap or leave gaps in the assistance received by patients . the role of nurses involved in the care of continuous renal replacement therapies patients in italy currently requires better organization , possibly starting with intensive standardized training and educational programs .