Renal Replacement Therapy in Critical Care

Aim: To provide guidance on the choice of modality and delivery of renal replacement therapy (RRT) on the ICU.
Scope: All adult patients on the Intensive Care Unit who need renal replacement therapy

Version: 2 Ratified by: Critical Care Governance Group Author: Dr S Blakeley

Date: 06 Sep 13 Revision due: 06 Sep 15 Produced by: Critical Care Governance Group
An equality impact assessment has been applied to this policy (Appendix D). This guideline is subject to professional judgment and accountability.

Choice of mode

• First choice for most • Recovering multi • Failure of CVVH • Fluid removal only
ICU admissions with organ failure but • Limited period of
multi organ failure ongoing need for RRT time for therapy
Critical Care Clinical Guideline

• Septic shock/severe • AKI with high urea

sepsis (initial setting)

CVVH CVVH CVVHDF

35mls/kg/hour SCUF
35mls/kg/hour 25mls/kg/hour

Delivery of therapy

Prescription Re-Assess Daily

Effluent production: use mls/kg/hour effluent as above • Need for RRT/mode of RRT
Replacement fluid: CVVH: effluent rate = replacement fluid rate. • Fluid balance
CVVHDF: effluent rate = 50% dialysate / 50% replacement.
• Electrolytes including phosphate &
Pre/post dilution ratio: initially use 30% pre- / 70% post-dilution.
Blood flow rates: set according to Table A below magnesium (usually need daily
Anticoagulation: according to guideline below replacement)
Patient fluid removal rate: titrate to volume status • Drug dose adjustment based on renal
Check biochemistry after 6-8 hours on therapy; thereafter check handbook & pharmacist
daily (including phosphate) or as clinical need dictates. • DVT prophylaxis
If starting Urea >30 mmoll-1, do not let Urea fall by more than • Vascath for signs of infection
1/3 during first 24 hours (NB still beware if Urea 25-30 mmoll-1) • Remember RRT may mask a fever

Termination of therapy

• Consider break/termination of therapy if patient has good solute clearance, normal pH, normal potassium and
is euvolaemic/persistently passing good urine volumes.
• Filters should be electively taken down where possible rather allowed to clot (to minimise blood loss)
• All filters should be electively taken down after 72 hours and a fresh circuit built.
• If therapy is terminated for 3 hours or more and the vascath remains in situ it should be locked with Taurolock.
• The vascath should be removed as soon as it is no longer needed for ongoing therapy.
 Anticoagulation for Renal Replacement Therapy

Low risk Moderate risk High risk

of bleeding of bleeding * of bleeding *
Normal clotting INR 1.3-1.4 INR ≥ 1.5
INR ≤ 1.2 APTR 1.3-1.4 APTR ≥ 1.5
APTR ≤ 1.2 Platelets 60-99 Platelets ≤ 60
Platelets ≥ 100 < 48 hours post surgery < 24 hours post surgery
Intracerebral / GI bleed
Therapeutic anticoagulation

Prime circuit with heparinised saline (1000mls 0.9% sodium chloride with 5000 units heparin sodium) #
Critical Care Clinical Guideline

Heparin Anticoagulation No Anticoagulation

20mls heparin sodium 1000 IU/ml in 20ml syringe 20 ml 0.9% saline in
20 ml syringe

Standard Heparin Low Dose Heparin No Heparin

10 IU/kg/hr 5 IU/kg/hr
Check APTR 4 hours after Check APTR 4 hours after
starting heparin starting heparin

APTR Bleeding$ Action Monitoring

Standard Heparin Low Dose Heparin

1.4 Check APTR 12 hourly unless
None Continue 10 IU/kg/hr Continue 5 IU/kg/hr
or less otherwise indicated
1.5 Recheck APTR 4 hrs after
None Reduce to 5 IU/kg/hr Stop heparin
or more heparin dose change
Reduce to 5 IU/kg/hr Check APTR immediately on
or run heparin free identifying new bleeding
ANY Yes Stop heparin
depending on Recheck APTR 4 hrs after
significance of bleeding reducing or stopping heparin

* If individual patient felt to be at risk of bleeding for other reasons use low dose or no heparin
# Prime with saline ONLY if suspicion/diagnosis of heparin induced thrombocytopenia (HIT)
$ Bleeding should be assessed to determine clinical significance

If recurrent filter clotting do not increase heparin – Refer to guidance below

 Stop Heparin Anticoagulation if:
• APTR is ≥ 1.5 despite low dose heparin (can • INR rises to ≥ 1.5 or platelets fall < 60
be continued at the discretion of the • Concern regarding heparin induced
consultant in exceptional circumstances) thrombocytopenia (note: circuit will need to be
• Significant bleeding is seen rebuilt with NO heparin in the priming solution)
• Patient is due for theatre/invasive
procedure

If the Filter Clots Repeatedly:

• Ensure good vascular access: blood should A 70:30 pre/post dilution split can be used at the
flow freely from both lumens of the discretion of the consultant, remembering there
Vascath. If not, reposition or re-site line. will be a significant reduction in solute clearance
• Ensure patient has adequate intravascular unless there is a compensatory increase in
effluent production.
Critical Care Clinical Guideline

volume.
• Ensure appropriate blood speeds are • Filters do not clot due to lack of heparin. In
achieved right from the start of therapy. septic patients there is often fouling of the filter
membrane due to inflammatory proteins leading
• Change pre/post dilution split to 50:50 to to a shortened filter survival time.
increase haemodilution within the filter.

Table A: Exchange volume, pre/post dilution split and minimum blood pump speed for RRT

Note: If the minimum blood flow cannot be achieved, reasons should be sought such as access problems
or severe haemodynamic instability. Remember good blood flow leads to better filter function and
solute clearance.
TABLE OF CONTENTS

1. Introduction
2. Purpose
3. Scope
4. Definitions
5. Duties and Responsibilities
6. Process
7. Training Requirements
8. Monitoring Compliance with, and the Effectiveness of Procedural Documents
9. References and Associated Documents
Appendix A. Checklist for the Review and Ratification of Procedural Documents and Consultation
and Proposed Implementation Plan
Appendix B. Equality Impact Assessment

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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1. INTRODUCTION

8% of admissions to the Department of Critical Care require renal replacement therapy (RRT). Our
haemofiltration machines offer the full range of continuous renal replacement therapies: continuous
veno-venous haemofiltration (CVVH), continuous veno-venous haemodialysis (CVVHD),
continuous veno-venous haemodiafiltration (CVVHDF) as well as slow continuous ultrafiltration
(SCUF). Therapeutic plasma exchange (TPE) is performed using the same machine but will not
be discussed in this guideline.

Evidence shows that the method of renal replacement therapy should be tailored to the individual,
and in particular it should be ‘dosed’ according to the patient’s body weight and to the clinical
situation. Studies have shown there is no difference in outcome between 20-25mls/kg/hour
compared with 35mls/kg/hour of effluent production. This guideline however recommends that the
higher dose of 35mls/kg/hour is still used in certain clinical situations, most notably in septic
patients who have multi organ failure when they first present. This is to compensate for periods of
intentional or unintentional down time that may lead to delivered dose falling short of prescribed
dose. When the patient is acutely unwell it is very important to ensure that the patient receives
effective therapy.

Key points in selecting the mode of RRT include:

a. Blood flow rates should be optimised to reduce filter clotting and improve efficiency.

b. The rate of effluent production should be ‘dosed’ according to patient body weight at either
25mls/kg/hour or 35mls/kg/hour of effluent production depending on the clinical scenario.
The patient weight is taken to be the ‘working weight’ of the patient, i.e. the weight used for
drug/infusion calculations.

c. Replacement fluid should be infused as a pre and post dilution split to maximise both filter life
(pre dilution) and solute clearance (post dilution).

d. Septic patients should have a predominantly convective mode of therapy (CVVH). Recent
studies have not shown any survival benefit with high volume haemofiltration (effluent flow
rates in excess of 35mls/kg/hour) in the management of severe septic shock. The use of
flow rates above 35mls/kg/hour in these patients is at the discretion of the duty ICU
consultant.

e. Patients with high solutes should not have a rapid reduction in their solute levels in the first
24-48 hours.

f. If fluid removal only is the goal of therapy use slow continuous ultrafiltration (SCUF).

g. In patients with profound hyper/hyponatraemia then the delivery of therapy should be

modified to minimize rapid correction of sodium. Further guidance in this situation can be
found on the departmental intranet.

The very nature of continuous renal replacement therapy (CRRT) means that blood is continually
in contact with the tubing of the circuit and the membrane of the filter. This can lead to activation of
the coagulation cascade resulting in low levels of clotting within the filter reducing efficiency and
ultimately leading to complete clotting and loss of the circuit. Recurrent clotting of the circuit leads
to inadequate treatment and loss of circuit blood. Continual rebuilding of the circuit is a drain on
resources, both nursing staff and financial.

Some form of anticoagulation is generally used to maintain filter patency. The commonest form of
anticoagulation on Intensive Care Units is unfractionated heparin, but other alternatives include
regional citrate anticoagulation, low molecular weight heparin and prostacyclin.

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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Balanced against this is the risk to the patient of bleeding and adverse effects of the
anticoagulation itself. Many critically ill patients may already have a degree of auto-
anticoagulation, may be at high risk of bleeding (e.g. post op, recent gastrointestinal bleed) or have
a condition where bleeding may be catastrophic (e.g. post intracerebral bleed). In these patients it
may be safer to attempt to run therapy without any form of anticoagulation, remembering it is better
to lose the filter than to lose the patient.

On our Intensive Care Unit the two most commonly used methods are heparin anticoagulation and
‘heparin free anticoagulation’ although this guideline also outlines the use of prostacyclin.

The first stage is to determine whether the patient is suitable for heparin or not. This is based on
the presence and degree of existing auto-anticoagulation, and the risk of bleeding due to
underlying medical or surgical conditions. If heparin is to be used, the goal is for anticoagulation of
the filter, not for full systemic heparinisation. There is no relationship between APTR and filter
survival time and the aim of heparin anticoagulation on CRRT is to have a well running filter, with a
normal or near normal APTR and no evidence of bleeding.

This guideline is in accordance with guidelines published by the Intensive Care Society (2008) and
should be read in conjunction with the Critical Care Standard Operating Procedure on Central
Venous Catheters.

2. PURPOSE
To provide guidance on the mode and delivery of renal replacement therapy (including
anticoagulation) for critically ill patients on the Intensive Care Unit.

3. SCOPE
This guideline is for use on the Intensive Care Unit using the Gambro Prismaflex haemofiltration
machine. This guideline is subject to professional judgement and accountability. The ability to
comply with this guideline may be affected by infection outbreak, flu pandemic or any major
incident due to resource constraints.

4. DEFINITIONS
AKI Acute kidney injury.
APTR Activated partial thromboplastin time (normal range 0.8-1.2)
(C)RRT (Continuous) renal replacement therapy
CVVH Continuous veno-venous haemofiltration
CVVHDF Continuous veno-venous haemodiafiltration
SCUF Slow continuous ultrafiltration

5. DUTIES AND RESPONSIBILITIES

The decision to implement this guideline is at the discretion of the on-call critical care consultant.
Implementation of this guideline is the joint responsibility of appropriate critical care medical/
nursing staff. This guideline is subject to professional judgment and accountability.

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6. PROCESS (Recommendations & Justification)

A: Indications for starting renal replacement therapy

Recommendation (Action) Justification (Rationale)

Classical indications for RRT: 1. There are no set levels of urea/ creatinine/ potassium/
 Rapidly rising urea and pH at which to start RRT: the overall clinical state of
creatinine 1 the patient should be considered. Therapy should be
started sooner rather than later, as a guide, before the
 Hyperkalaemia unresponsive to
urea rises above 20-25 mmol/l in critically ill patients
medical therapy 2
 Severe metabolic acidosis 1
2. RRT removes potassium rapidly, however as it takes
 Fluid over load time to set up the circuit, hyperkalaemia should always
 Oliguria or anuria 3 be treated by medical means first. There is no set level
of potassium at which to start RRT. The rate of change
Other uses of extracorporeal and overall clinical state of the patient should be taken
therapy: into consideration.
 Drug removal 4
 Adjunct in the management of 3. There is no set level of minimum urine output at which
severe sepsis 5 RRT should be started. The overall clinical state of the
patient should be considered.

4. Specialist advice should be sought regarding use of

RRT in the removal of ingested toxins.

5. Convective therapy can remove septic mediators and

therefore has the potential to be used as an adjunct in
the treatment of severe sepsis. Currently CRRT
should not be used in patients with severe sepsis who
do not have AKI without direction from the consultant.

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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 B: Basic set up for renal replacement therapy: CVVH (‘Haemofiltration’)

Recommendation (Action) Justification (Rationale)

 Prime the Prismaflex in CVVH mode 1 1. Convective therapies have been shown to be
beneficial as an adjunctive treatment in
 Calculate total exchange volume of severe sepsis. CVVH will clear solutes and
35mls/kg/hour2 or 25mls/kg/hour3 based correct acidosis and for most patients is
on the working weight of the patient (i.e. adequate therapy – a few will need CVVHDF
weight used for drug calculations) (see variations) but for most CVVH is the
default starting mode.
 Calculate blood flow rate from Table A
according to replacement volume 4 2. 35mls/kg/hour is appropriate for patients with
severe sepsis and/or multi organ failure, and
 Calculate the pre and post dilution split also takes into consideration periods of ‘filter
from Table A 5 down time’.

 Set fluid removal rate according to clinical 3. 25mls/kg/hour is appropriate for patients who
state of patient need ongoing therapy, who are not acutely
septic and who have good solute clearance
 Set anticoagulation as per DCCQ clinical already.
guideline
4. An appropriate blood flow rate helps to
improve solute clearance and prevent
sluggish blood flow within the haemofilter,
helping to prevent premature clotting.

5. Pre dilution helps to reduce the need for

anticoagulation but post dilution improves
solute removal. Pre and post dilution are
therefore used simultaneously to maximise
the benefits of both.

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 C: Variations

i. Failure of CVVH to clear acidosis or solute load: CVVHDF (‘diafiltration’)

In some profoundly acidotic patients or patients who are usually on long term renal
replacement therapy1, CVVH may not clear the acidosis in the time frame required, therefore
a change to haemodiafiltration may be required
Recommendation (Action) Justification (Rationale)
 Prime the Prismaflex in CVVHDF mode 1 1. Patients with end stage renal failure,
 Calculate total exchange volume of who have a high serum urea but who are
35mls/kg/hour based on the working weight of not yet fully established on haemodialysis
the patient (i.e. weight used for drug should be treated as per variation iii
calculations)
 Provide 50% of exchange volume as
replacement fluid and 50% as dialysate (50:50
split)
 Calculate blood flow rate from Table A
according to replacement volume
 Calculate pre/ post dilution split from Table A
 Set fluid removal rate according to clinical state
of patient
 Set anticoagulation as per DCCQ clinical
guideline

ii. Patient with fluid overload only

Recommendation (Action) Justification (Rationale)

 Prime in SCUF mode 1 1. If the machine is already primed in
 Set blood flow rate at 180ml/min2 CVVH or CVVHDF then turn the
 Set fluid removal rate according to clinical state replacement/dialysate rate down to 0 and
of patient this delivers SCUF
 Set anticoagulation as per DCCQ clinical
guideline 2. Blood flow rates of 150-180mls/min
are acceptable

iii. Patients presenting with a high urea E.g. urea > 30 mmol/l

Recommendation (Action) Justification (Rationale)

 Prime in the Prismaflex in CVVH mode 1. A rapid reduction of serum urea leads
 Calculate total exchange volume of to rapid changes in plasma osmolality and
25mls/kg/hour based on the working weight of the risk of dysequlibrium syndrome – urea
the patient (weight used for drug calculations) should not be allowed to fall by more
 Calculate blood flow rate from Table A than 1/3 in the first 24 hours
according to replacement volume
 Calculate pre and post dilution split from Table A 2. Note, as mentioned above, this also
 Set fluid removal rate according to clinical state includes dialysis naive end stage renal
 Set anticoagulation as per DCCQ guideline. failure patients
 Check urea after 12 hours of being on the filter,
adjust flow rates accordingly aiming to drop the
urea no more than 1/3 in the first 24 hour period1

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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 D: Termination of therapy

Recommendation (Action) Justification (Rationale)

 After 72 hours the circuit should be electively taken 1. To avoid unnecessary blood loss for
down and a fresh circuit built if the patient needs to the patient, the decision to
continue on therapy1 terminate therapy should be an
 Consider termination of therapy if the patient is active one rather than waiting for
persistently passing over 0.3-0.5 mls/kg/hour of the filter to clot
urine (or more than 500 mls of urine/day)2 2. There is no test or indicator that will
 determine whether a patient will be
Urea and creatinine are a poor guide to termination
of therapy once the patient is on CRRT – they able to manage without RRT, the
indicate degree of solute removal by the filter clinical situation as a whole should
and are not a reflection of intrinsic renal be taken into consideration
function 2 3. Taurolock is used to prevent the
 Filter breaks can be considered if the patient has development of thrombosis and
good solute clearance, a normal pH, normal infection within the vascath when it
potassium and is euvolaemic is not in use. Any vascath that is
 If therapy is terminated and the vascath remains in not to be used for 3 hours or more
situ it should be locked with Taurolock as per should be locked with Taurolock
protocol 3

E: Heparin Regimes

Recommendation (Action) Justification (Rationale)

The Prismaflex circuit should be primed with This leads to some heparin ‘sticking’ to
heparinised sodium chloride 0.9% (5000units heparin the haemofilter and tubing so helping to
sodium in 1L sodium chloride 0.9%) prolong the circuit life

Fill the a 20ml syringe with 20mls of heparin sodium

1000unit/ml

Start the heparin infusion at: Based on working weight of the patient

 10 IU/kg/hour (standard heparin)

 5 IU/kg/hour (low dose heparin)

Check the APTR after 4 hours To ensure over-anticoagulation has not

occurred
Target is APTR < 1.4 with NO bleeding

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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 E: Heparin-Free Regimes

Recommendation (Action) Justification (Rationale)

The Prismaflex circuit should be primed with This leads to some heparin ‘sticking’ to
heparinised sodium chloride 0.9% (5000units heparin the haemofilter and tubing so helping to
sodium in 1L sodium chloride 0.9%) prolong the circuit life

Note: Do not prime filter with heparinised saline if there

is concern regarding heparin induced
thrombocytopenia.

Fill a 20ml syringe with 20mls of 0.9% sodium chloride

Set the anticoagulation rate to 0mls/hour No anticoagulation will be delivered but

the Prismaflex still requires that the
syringe be filled and loaded correctly

E: Epoprostanol Anticoagulation

Recommendation (Action) Justification (Rationale)

The Prismaflex circuit should be primed with This leads to some heparin ‘sticking’ to
heparinised sodium chloride 0.9% (5000units heparin the haemofilter and tubing so helping to
sodium in 1L sodium chloride 0.9%) prolong the circuit life

NOTE: Do not prime filter with heparinised saline if

there is concern regarding heparin induced
thrombocytopenia.

Please refer to electronic prescription

Fill a 20 ml syringe with 20mls epoprostenol [Flolan®] and product insert with regards to
dilution of drug

Run at 2.5nanogram/kg/minute A low dose is used as epoprostenol can

cause marked reduction in blood
pressure and cardiac output

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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7. TRAINING REQUIREMENTS

This guideline should be read in conjunction with the ICU Renal Handbook. All Critical Care staff
will be informed of the content of this guideline and how to access it via the Critical Care
Guidelines and SOPs intranet page. All staff involved in prescribing and delivering RRT will be
given appropriate training, managed by the Critical Care Education Team and Renal Team. A
laminated summary of this guideline will be attached to all haemofiltration machines.

8. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,

PROCEDURAL DOCUMENTS

This guideline will be reviewed initially at 6 months and thereafter 2 yearly by the Critical Care
Governance Group. Measurement of compliance will be achieved by unit-based audit. Results
reviewed will be fed back to members of the senior medical /nursing team and the Critical Care
Governance Group.

9. REFERENCES AND ASSOCIATED DOCUMENTATION

Palevsky PM et al. Intensity of renal support in critically ill patients with

acute kidney injury. N Engl J Med 2008; 359:7-20 [ATN study]

Bellomo R et al. Intensity of continuous renal replacement therapy in critically ill patients. N Engl J
Med 2009; 361:1627-1638 [RENAL study]

Jun M et al. Intensities of renal replacement therapy in acute kidney injury: A systematic review
and meta-analysis. Clin J Am Soc Nephrol 2010; 5: 956-963 [Meta-analysis 1]

Van Wert R et al. High-dose renal replacement therapy for acute kidney injury: Systematic review
and meta-analysis. Crit Care Med 2010; 38 (5): 1360-9 [Meta-analysis 2]

Uchino S, Fealy N, Baldwin I et al. Continuous venovenous haemofiltration without anticoagulation.

ASAIO J 2004; 50:76-80

Oudemans-van Straaten HM, Wester JPJ, de Pont ACJM et al. Anticoagulation strategies in
continuous renal replacement therapy: can the choice be evidence based? Intensive Care Med
2006; 32:188-202

Baldwin I, Bellomo R, Koch W. Blood flow reductions during continuous renal replacement therapy
and circuit life. Intensive Care Med 2004; 30: 2074-2079

Oudemans-van Straaten HM, Kellum JA, Bellomo R. Clinical review: Anticoagulation for
continuous renal replacement therapy – heparin or citrate

Intensive Care Society Standards for Renal Replacement therapy

http://www.ics.ac.uk/icmprof/standards.asp?menuid=7

Renal association guidelines for management of AKI

http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx#downloads

Please refer to Renal Handbook available via DCCQ website for a comprehensive list of
references and further reading.

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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Appendix A

Checklist for the Review and Ratification of Procedural Documents and

Consultation and Proposed Implementation Plan

To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies -> Templates

CHECKLIST FOR REVIEW AND RATIFICATION

YES/NO
TITLE OF DOCUMENT BEING REVIEWED: COMMENTS
N/A
1 Title
Is the title clear and unambiguous? Yes
Will it enable easy searching/access/retrieval?? Yes
Is it clear whether the document is a policy, guideline, procedure,
Yes
protocol or ICP?
2 Introduction
Are reasons for the development of the document clearly stated? Yes
3 Content
Is there a standard front cover? Yes
Is the document in the correct format? Yes
Is the purpose of the document clear? Yes
Is the scope clearly stated? Yes
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major Yes
incident?
Are the definitions clearly explained? Yes
Are the roles and responsibilities clearly explained? Yes
Does it fulfill the requirements of the relevant Risk Management
Yes
Standard? (see attached compliance statement)
Is it written in clear, unambiguous language? Yes
4 Evidence Base
Is the type of evidence to support the document explicitly identified? Yes
Are key references cited? Yes
Are the references cited in full? Yes
Are associated documents referenced? Yes
5 Approval Route
Critical Care
Does the document identify which committee/group will approve it? Yes
Governance Group
6 Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring
Yes
of compliance with the effectiveness of the document?
7 Review Date
Is the review date identified? Yes
6 Dissemination and Implementation
Is a completed proposed implementation plan attached? Yes
7 Equality and Diversity
Is a completed Equality Impact Assessment attached? Yes

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

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Appendix A
continued

CONSULTATION AND PROPOSED IMPLEMENTATION PLAN

Date to ratification committee
Groups /committees / individuals involved in the Critical Care Renal Team
development and consultation process Critical Care Governance Group
Multidisciplinary staff working in DCCQ

Is training required to support implementation? Yes

If yes, outline plan to deliver training 1. Distribution of revised guideline via email, and
uploading to intranet site.
2. Coverage at identified Friday multidisciplinary
teaching session.
3. Targeted training via Renal Team and
Education Team where appropriate
Outline any additional activities to support As above
implementation

Individual Approval

If, as the author, you are happy that the document complies with Trust policy, please sign below and send the document,
with this paper, the Equality Impact Assessment and NHSLA checklist (if required) to the chair of the committee/group
where it will be ratified. To aid distribution all documentation should be sent electronically wherever possible.

Name Dr S Blakeley Date 06 Sep 13

Signature signed electronically

Committee / Group Approval

If the committee/group is happy to ratify this document, would the chair please sign below and send the policy together with
this document, the Equality Impact Assessment, and NHSLA checklist (if required) and the relevant section of the minutes
to the Trust Policies Officer. To aid distribution all documentation should be sent electronically wherever possible.

Name Dr N Tarmey, Critical Care Governance Group Date 06 Sep 13

Signature signed electronically

If answers to any of the above questions is ‘no’, then please do not send it for ratification.

Renal Replacement Therapy in Critical Care (2013) dated 06 Sep 13

14
 Appendix B

Equality Impact Assessment

To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies ->
Templates

Title of document for assessment Renal Replacement Therapy in Critical Care

Date of assessment 18 June 2013
Job title of person responsible for assessment Dr S Blakeley
Division/Service DCCQ / CHAT CSC

Yes/No Comments
Does the document affect one group less or more favorably than another on the basis of:
No
 Race
No
 Gender (including transgender)
No
 Religion or belief
No
 Sexual orientation, including lesbian, gay and
bisexual people
No
 Age (for HR policies only)
No
 Disability – learning disabilities, physical disabilities,
sensory impairment and mental health problems
Does this document affect an individual’s human No
rights?
If you have identified potential discrimination,
are the exceptions valid, legal and/or justified?

If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality
Impact Assessment (available from the Equality and Diversity website) or amend the policy such
that only an disadvantage than can be justified is included. If you require any general advice
please contact staff in the Equality and Diversity Department on 02392 288511

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