How Tablo Transformed Critical Care in One Hospital’s ICU
Summary
Kara Robinson, BSN, RN, is the Nurse Education Coordinator at Trinity Health Oakland and the driving force behind the hospital’s ICU switch from a conventional dialysis program to a PIRRT and sequential therapy program using the Tablo® Hemodialysis System. Recently, our Clinical Sales Manager Amanda Torney, BSN, RN, met with Kara to learn more about how the transition to Tablo transformed the ICU experience for both patients and providers.
Watch or listen to the full webinar here:
The following responses from Kara have been edited for length and readability.
For starters, can you give us some background on Trinity Health Oakland and your ICU?
Trinity Health Oakland is a Level II Trauma Center. It has 497 beds, a comprehensive stroke center, cardiac unit, OB/GYN, and multiple other service lines for our wide diversity of patient populations. I’m the Education Coordinator for the ICU and the hemodialysis unit. We have two separate ICUs. One is a general ICU, and the other is a cardiac ICU. Altogether, there are 44 ICU beds and about 120 nurses.
What were your dialysis services like before you made the switch to Tablo?
Prior to Tablo, we used an outsourced provider for dialysis, and our ICU dialysis was utilizing the NxStage System. Their staffing limited our options and often delayed our treatments because of the other needs throughout the hospital. We identified that there were some operational inefficiencies, and we saw that Tablo could meet those needs and even fill in the additional gaps that we found. So that’s why we decided to go with Tablo
When you were considering making a change in your dialysis technology, what was most important to you and your team?
Patient needs are the main priority. You have critical patients in the ICU, so meeting the needs of these patients was a top priority. But we also wanted to look at functionality. Is it easy to use? Is it reliable? And Tablo seemed to provide that. We were able to do a cost analysis that showed that this change would be beneficial; and while that was not the priority, it was definitely a benefit. And then, though we didn’t fully realize it at the time, the flexibility that Tablo offered would potentially lead to our decreased workload and even improved patient outcomes and decreased length of stay. That was a huge bonus that we found.
How did your team react to making this technology switch during peak COVID in 2020?
The nurses were hesitant. Tablo was a completely foreign concept to them. They were used to the CRRT-type philosophy. So, Tablo – they didn’t understand it. They didn’t understand the functionality or even the ability that it had. They were really worried. ‘Is this going to be safe for our patients? Is it going to meet the needs of the critically ill patients, especially during COVID?’ At the time, we had really high acuity, so there were hesitations and concerns.
How long did it take your team to become comfortable with Tablo in the ICU?
We launched in May of 2020, which was the peak of COVID, and so our training was expedited. Because of the high number of high acuity patients and all the treatments that were needed, we were training all of our ICU nurses. And we were dealing with nursing shortages too. It took several months for us to get our training finished, but we were able to do that with a combination of different training options.
How were you able to achieve a successful new dialysis program in those circumstances?
COVID forced our hand. We had a high spike in patient numbers, so we had to train quickly, and we also learned quickly because of that. We had about 100 nurses, and we went live within 60 days of our launch. We were moving pretty fast, but with all of that, we recognized early on that we needed to actually develop some sort of Tablo leadership or ownership. That also included having a physician champion. After about six months of getting experience and doing a lot of those different things in the advanced training, we were able to use that philosophy to provide some additional support for the nurses internally. We identified learning gaps and different needs, and by that point we could really take our time and attention to accelerate that learning and help with that RN experience.
How did you train nurses to complete cannulation?
When we developed our program, we met with the nephrologist and really asked, “What do you want out of this Tablo program?” And same thing, they asked us, “What do the nurses want out of this Tablo program?” After going back and forth, we realized that the safest for both the nurses and the patients was that our nurses were only going to provide treatments to the ICU patients that had temporary or permanent catheters. So, our nurses do not provide treatments for those that have fistulas. I can see where the concern is with that, because there are the chronic dialysis patients that come into the ICU, but often when those patients are coming into the ICU, they are so hemodynamically unstable that they end up getting a catheter anyways. Our treatments are provided by our nurses in the ICU through that access, so they don’t cannulate, but they do provide treatments through the catheters.
What were the physicians’ biggest concerns, and how did you manage their expectations and objections?
The physicians had similar concerns to the nurses. They were worried that those critically ill patients wouldn’t be able to tolerate the Tablo, since it wasn’t a CRRT type treatment. And then on the opposite end of that, they were resistant to the different settings within Tablo, and whether or not a patient could potentially tolerate those settings. But actually, they identified over time that based on the patient’s needs, being able to adjust those [settings] was actually more efficient, and patient outcomes and labs were showing that [our] 12 hour treatments were just as beneficial for the progress of the patient.
How has the switch to Tablo benefitted your patients and the unit as a whole?
We saw a lot of benefits. Looking at patient benefits; previously with the CRRT, you had delayed procedures, delayed imaging, different tests. You couldn’t progress the patient care. Early mobility is a really big thing in the ICU, so we weren’t able to do that with the previous system. But with Tablo, with those 12 hour treatments or even shorter, we could actually have those things included throughout the day for the patient. So not only could we do the Tablo treatment, but we could also include the testing, the imaging, the therapy, the mobility. We were seeing progression in the patient care a lot better than we were previously.
With being able to do all of those things, we saw nurse benefits out of that. The nurses were able to provide those things, prioritize schedules appropriately, and get those things so there weren’t delays, and it wasn’t adding to the frustration in the nursing workflow. Being able to meet those needs and provide all those things for the patients was definitely a success.
We’re also seeing that the workflow — just in general — of the unit and the ICU was benefiting because we were able to plan staffing better with it; meet the needs of not only the staffing and the patient flow, but we were able to better plan for the bedflow of the unit and what the plan and outcome would be day to day, instead of worrying how or when — if ever — the CRRT was going to be done.
How did you manage the change to Tablo with your team?
We wanted to be as safe and as efficient as possible, so the nurses and the physicians looked at the build of Tablo and looked at our medical record system. We were using Epic (EMR) and actually built flow sheets to match not only the functionality, but the wording and the steps that are built into the Tablo system. It definitely helped; with the nurses being able to flow more efficiently with their workflow, it just made it that much easier. We also worked with our pharmacy team to build order sets that matched the information that was in Tablo — how the prescription would be written — and it met the needs of how to program that. So the nurses just used the order and went straight from the order to Tablo, and were able to go straight down the line and follow the order and program the treatment as ordered. So definitely a benefit there.
How have you creatively handled staffing to make ICU workloads more efficient?
All of our ICU RNs are trained to provide treatments. So if we need to flex staffing, we can. They are 1:1 for the duration of the treatment. A lot of times our treatments aren’t necessarily 12 hours, so for the shorter treatments, we’re able to flex staffing so that we can free up a nurse. We also have an alternate shift, an 11 to 11, so they can come in, they can cover those treatments, because we usually know by morning what treatments we have and how many. A lot of those staffing flexes that we’ve done have helped to decrease the delay in treatments and also allows the nurses to accommodate the needs of the patient. That’s been a huge, huge benefit in helping timely with those treatments, decreasing length of stay and just benefit the patient.
We also offer the nurses the opportunity, if we’re short, to come in and pick up just for a Tablo treatment. So they can come in, they do the Tablo treatment and they leave. That’s a big opportunity for nurse satisfaction, because they can pick up extra time and extra pay without actually being committed to a full 12 hour shift.
We also created a Tablo Tech — or an Equipment Tech — role, who is responsible for the routine maintenance of the machines, the ordering, the supplies. We were also able to justify that by saying, we’re going to make this role responsible for all of our equipment in the ICU and supplies, ordering, work orders and that type of thing. So having just a little additional piece where they could dedicate part of their time to the daily maintenance of the Tablo devices has really helped make us more efficient with our treatments and prolong the life of the machines. It helps decrease delays in that aspect, too.
How has Tablo changed the length of stay for patients in the ICU?
We didn’t track it previously, but just seeing that we have a Tablo patient who we can provide with early mobility, it’s obvious that we’re already ahead of the game because we’re not delaying it like we would with CRRT. So we’re providing those treatments early on, which means that we’re progressing their care and eventually decreasing their length of stay.
One of the biggest populations we see that in is our cardiac surgery patients, with a goal to ambulate three times a day. With shorter treatments, if they’re needed, we can actually meet those needs, and it’s been a huge success in progressing the care of those patients. Even our staffing costs have decreased because having those shorter treatments, we don’t need the continuous treatments. So our 1:1 time related to providing dialysis has significantly decreased. Even though it wasn’t tracked previously, we know that it has definitely helped in the cost savings there with the unit and even the staffing experience overall. And then just the cost savings that we have with the Tablo system. I know that we’ve saved significantly on that.
What are the best practices that made your program a success?
When you’re creating something, you want to be able to dedicate the time and attention that it needs to make it, create it, help it grow and be successful. So having someone who owns the program is essential. Having someone who owns the program, can be the device expert, help with training, organizing, day to day flow, that type of thing, is really important. And then having dedicated team members who can dedicate their time to the supplies, the maintenance, those ordering pieces to help your program stay up and running, is really important, too.
A physician champion is a huge piece, because you need a physician who knows and understands Tablo, but can also help with their colleagues — the other physicians — and can speak to the Tablo capabilities. Just like any program, you have ongoing learning, continuous training, advanced training, following up, learning and evaluating things, making adjustments. Doing that is important, but having a group of super users who can help with that, help continue to teach, provide those real time learnings when needed at the bedside, is really important. And then for evaluating your program, having huddles and lunches so that you can review needs, learning opportunities, and even share updates from Outset. That’s very valuable, and not having access to that before and having it now, we’ve seen our program be a lot more successful because of that.
It’s really important to have those things, but then also know that change is going to come, and be prepared for change, because after you go live, you’re going to see what works and what doesn’t. So just know that you want to continuously monitor your program and make adjustments as needed, because that’s what’s going to build your program. And then when it comes to having a successful Tablo treatment program, you need the machines to be able to be functioning. Having a service program in place and maintaining the life of the machines is also essential. Those would be my big pieces that would make a successful program.