Design of Breakdown and Checklist for Continuous Renal Replacement Therapy

Objective.-is study aimed to improve the quality of continuous renal replacement therapy (CRRT).Methods. A pool of candidate indicators was established using literature retrieval, panel discussion, and experience summary. -e first round of consultation was performed with the selected 18 experts by the Delphi method. -en, the checklist was modified according to the experts’ opinions for the second round of consultation to prepare the final checklist. Results.-e positivity coefficients of experts in the two rounds of consultation were 100% and 88.9%, respectively, with the authority coefficient of 0.88. -e Kendall coordination coefficients of the primary and secondary indicators were 0.296 and 0.303, respectively (P< 0.05). Finally, the breakdown and checklist were prepared, which involved 16 primary indicators and 56 secondary indicators. Conclusion. -e scientific and reasonable breakdown and checklist prepared based on a consultation can provide scientific guidance for nursing during CRRT, reduce the incidence of adverse events, and improve work efficiency and satisfaction of medical care.


Introduction
Continuous renal replacement therapy (CRRT), a continuous therapy for blood purification for around 24 hours a day to replace the damaged kidney, is the general term for continuously and slowly removing water and solutes [1]. Given the promising therapeutic effect and prognosis of CRRT, it has been widely used to treat critically ill patients. However, the multiple treatment modes have complicated the preparation and operation, bringing difficulties to homogeneous management in clinical work [2,3]. In 2010, a total of 2.618 million people received renal replacement therapy (RRT) worldwide. It is estimated that by 2030, the number of people using RRT will be more than double to 5.439 million, with the highest growth rate in Asia (by 968,000 increased to 2.162 million) [4]. CRRT is the main approach for patients to maintain life, which can prolong the survival time and improve the quality of life. Meanwhile, CRRT has the characteristics of high technical content, substantial expertise, and high risk. erefore, actively exploring intervention methods to improve the quality of CRRT care and developing a scientific and reasonable management plan are of practical significance to prolong the survival period of hemodialysis patients and improve the quality of life of patients. erefore, we prepared the Breakdown and Checklist for CRRT to better cooperate with clinical work, improve the work efficiency, realize homogeneous management, and reduce the incidence of adverse events [5]. eir clinical application has obtained promising therapeutic effects, which are reported as follows.

Preliminary Design.
A CRRT team was established to select the relevant literature articles about CRRT checklist from Chinese and English databases according to the research objectives and prepare an item pool for the breakdown and checklist according to the high-risk steps during operation and in combination with the clinical experience based on the adverse events of CRRT [6][7][8][9]. Four experts (two directors and associate chief physicians of the nephrology, one chief nurse, and one supervisor nurse) evaluated the rationality of the sorted pool, gave reasons for adding or removing items, and prepared the initial lists, including the breakdown and checklist [10][11][12][13].

Preparation of Consultation
Questionnaire. e consultation questionnaire was prepared according to the first draft of the revised breakdown and checklist (three parts): (1) letter to experts, in which the research objective, content, and significance were briefly introduced; (2) CRRT breakdown and checklist evaluation form, which was used to solicit expert opinions and suggestions on the setting and importance of the breakdown and checklist; (3) expert situation questionnaire, which was used to collect experts' general information, judgment basis, and familiarity with the research content.

Selection of Experts.
e number of consultant experts should be determined based on the amount of research. It was reported [14] that the number of experts was generally set as 15-30 to ensure the reliability of the inquiry results. Inclusion criteria of consultant experts in this study: (1) the clinicians and nurses in grade A class three hospitals, with over 10 years of experience in the field of renal replacement therapy; (2) with the bachelor degree or above, intermediate title or above; (3) with sufficient understanding of the study and can actively complete the expert consultation; and (4) with a willingness to participate in this study, were included. After screening, 18 experts from 5 provinces and municipalities were selected.

Expert Consultation.
e consultation questionnaire was prepared according to the initial breakdown and checklist and sent to 12 experts by e-mail or field distribution from January to May 2018 for two rounds of an expert consultation. e questionnaires of the first round were collected and analyzed based on the summarized expert opinions and suggestions. en, the contents were adjusted and distributed for the second round of consultation to make the breakdown and checklist more scientific, reasonable, and consistent.

Statistical Methods.
Excel 2016 and SPSS 19.0 were used for data analysis and calculation of expert positivity coefficient, authority, arithmetic mean of various indicators, coefficient of variation, and coordination coefficient of opinions. e coordination of opinions was expressed by the Kendall coordination coefficient. P < 0.05 was considered statistically significant. e indicators with the average score of importance and reliability >3 points, coefficient of variation <25%, and the full-score rate >20% were retained and then modified and selected through panel discussion based on expert opinions and comprehensive consideration of all scientific indicators.

Basic Data of Experts.
Basic data of the selected 18 experts are shown in Table 1.

Expert Positivity Coefficient.
e response rate of consultation questionnaire was used to calculate the expert positivity coefficient. As reported previously [15], the experts were considered highly positive when the expert positivity coefficient was higher than 70%. 18 questionnaires were released for either round of expert consultation, and 18 and 16 were collected in the first and second rounds, with the response rate of 100% and 88.9%, respectively, indicating high positivity of experts.

Expert's Authority.
e expert's authority coefficient (Cr) was calculated based on the reason of judgment (Ca) and degree of familiarity (Cs). Generally, it is believed that the authority coefficient not lower than 0.7 can be acceptable [16][17][18]. e expert's authority coefficient in the first round of consultation was 0.85 (Ca � 0.89, Cs � 0.82), while Ca in the second round of consultation was 0.91 (Cs � 0.85, Cr � 0.88). e authority coefficients in both rounds were >0.7, indicating the high authority of the experts.

Coordination Degree of Opinions.
e coefficient of variation and Kendall coordination coefficient were used to test the coordination of experts. e coefficients of variation were 0.03-0.36 and 0.00-0.23 in the first and second rounds of expert consultation, respectively, while the Kendall coordination coefficients were 0.296 and 0.303, respectively, showing statistical significance (P < 0.05).
e experts were asked to score according to the degree of importance and gave the corresponding opinions in the columns of "suggestions on revision" and "items 2 Scientific Programming suggested to be added." e indicators with the mean score >3 points, coefficient of variation <25%, and full-score rate >20% were retained, then deleted, and modified based on expert opinions. In the first round of consultation, the primary indicators had the mean value of importance of 3.28-5.00 points, the coefficient of variation of 0.082-0.181, and full-score rate of 10%-100%, which were 4.02-5.00, 0.000-0.284, and 30%-100% points, respectively, as for the secondary indicators. According to the screening conditions and expert opinions, the primary indicator "evaluation of hemofiltration tube" was merged into the primary indicator "preparation prior to operation." According to the screening conditions, and in accordance with the experts' opinions and panel discussion, the primary indicator "evaluation of hemofiltration tube" was merged into "preparation prior to operation." e item "following the doctor's advice" under the secondary indicator "termination" was removed, and the secondary indicator "doctor's advice after termination" was added. e secondary indicators "date" and "wearing gloves" were removed. Moreover, "final treatment" and "evaluating patients' tolerance, and whether sedation or restraint is required" were added. As suggested by the experts, the warning signs "Caution: Use with caution in the case of liver dysfunction!" and "Note: Total calcium/free calcium >2.5 ⟶ citrate accumulation" was added.
In the second round of consultation, the average value of importance of the primary indicators was 4.12-5.00, the coefficient of variation was 0.000-0.208, and the full-score rate was 33.63%-100%, which were 3.85-5.00, 0.000-0.227, and 30%-100%, respectively, for secondary indicators. As suggested by the experts, the warnings were bolded in red. e item "evaluate the bleeding and coagulation of the patients" was changed to "check whether there are bleeding spots on the skin and mucosa and evaluate the bleeding and coagulation of the patients." Finally, the breakdown and checklist were prepared, which involved 16 primary indicators and 56 secondary indicators, respectively, whose consultation results are shown in Table 2.

Reliability of Consultation Results.
We performed two rounds of expert consultation based on document retrieval, clinical needs, and brainstorming of the CRRT team to ensure the scientificity and practicability of the breakdown and checklist. All the selected experts were familiar with the knowledge of CRRT and can provide clinical opinions combining theoretical and practical experience. e response rate of either round of consultation was 100%, and the suggestions on modification were given, indicating that the experts highly supported this study. In the first round of consultation, the expert's authority coefficients were 0.85 and 0.88 in the first round, both of which were larger than 0.7, indicating the high authority. After two rounds of consultation, the Kendall coordination coefficient of the secondary indicators was 0.303 (P < 0.05), indicating that the experts had high consistency on the contents of the breakdown and checklist, with only small divergences. erefore, the consultation results of this study had a certain degree of reliability [16].

Scientificity of Consultation Results.
In this study, the breakdown (involving 11 items of patient information, evaluation prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, test indicators, and others) and checklist (involving 5 items of preparation prior to operation, preparation of pipeline, operation process, treatment process, and termination of operation) were prepared according to the mature domestic practice [6,7], studies of domestic scholars [8], and the related documents [9]. Given the multiple CRRT treatment parameters and modes, there would be errors in communication between doctors and nurses, doctors shifting, and operation preparation [3]. e checklist can be used to check patient information, examination prior to operation, treatment mode, pipeline preflushing, anticoagulation method, replacement fluid, plasma exchange, blood flow rate, fluid balance, and detection indicators, which the doctors and nurses should confirm to reduce the incidence of information transmission errors to "zero." e complicated CRRT treatment procedures, as well as their unskilled and irregular operations, can delay the treatment. e breakdown can be used to guide the whole operation process and enable the nurses of different levels, especially junior nurses, to operate in accordance with the standard and norms, and gradually complete the preparation prior to operation, pipeline preparation, operation, treatment, and termination to ensure that the nurses can efficiently complete the preparation prior to operation, thus avoiding omissions due to the complicated process and numerous steps.

Significance of the Preparation of Breakdown and Checklist for Continuous Renal Replacement erapy (CRRT)
. CRRT, with professional theory and skills and high operational risks, has proposed higher requirements for the overall quality of nurses; however, in the application of CRRT technology, nursing is the key to successful treatment [19]. Firstly, the breakdown and checklist can realize the homogeneous management of the whole process from the doctor's advice to the end of treatment, examine and monitor the nurse operation procedures, and guide the junior nurses. e incidence of adverse events has been reduced from 9.1% to 1.4% (X 2 � 4.955, P � 0.026). Secondly, the checklist can improve the work efficiency, and the breakdown can make the doctor's advice clearer, thus effectively avoiding time delays due to doctor's advice, while the checklist can ensure the preparation of items at one time and the orderly advancement of the treatment process, thus avoiding the waste of time due to omissions in the complicated process. In terms of handover, the breakdown and checklist should be used to show the entire process to the Scientific Programming

Conclusion
is study constructs a CRRT nursing management plan; that is, a table, including 16 main indicators and 56 secondary indicators, and the indicators have good internal quality. rough clinical exploration, it has provided scientific basis for the nursing management of CRRT patients and has improved the job satisfaction of medical staff.
Data Availability e datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
e authors declare that they have no conflicts of interest.