Summary
In this post, I share my data-driven, gamified approach to gauging success in fluid removal during renal replacement therapy (RRT). I dive into the importance of precision in achieving net fluid balance goals, while tackling real-world challenges like inherited deviations, partial treatments, and unexpected interruptions. By introducing success tiers—Optimal, Acceptable, Marginal, and Failure—and adjusting goals proportionally for special circumstances, I’ve created a system that ensures fair and meaningful evaluations. My motivation for this approach stems from a desire to track data and identify areas for improvement in managing renal replacement therapy. By analyzing performance metrics and success tiers, I can pinpoint where adjustments are needed to enhance precision and outcomes.
Introduction
The idea to “gamify” my performance in achieving Continuous Renal Replacement Therapy (CRRT) net fluid balance goals was initially suggested by my coworker. At first glance, the concept seemed straightforward: Hit the goal and I “win”; miss it and I “lose.” However, as I explored the idea further, I realized that achieving the net fluid removal goal in CRRT isn't always straightforward. Fluid removal targets often span a wide range to account for patient-specific factors, and simply falling within that range doesn’t always reflect how well I’m meeting the clinical intent.
Disclaimer: Before diving into the tiered framework for evaluating net fluid removal success, it’s important to clarify how I’m speaking about these values. When I refer to fluid balance targets, I am using integers in the context of negative values, not absolute numbers. For instance, if the goal is to achieve a net fluid balance less than -2 L, this refers to values such as -3 L, -4 L, or lower, not values like -1 L, 0 L, or 1 L.
This distinction is critical because the terminology can easily be misunderstood without this context. In this discussion, a “less than” relationship is always relative to increasingly negative numbers (e.g., moving further into the negatives). Conversely, if a fluid balance is greater than -2 L, it refers to values like -1 L, 0 L, or higher, meaning the fluid removal is less aggressive or even positive. The maximum prescribed range is the most negative number while the minimum prescribed range is generally zero.
This framing ensures that the numerical references are consistent and avoids confusion about the directionality of the target values.
Also, the net fluid removal goal refers to the volume removed by the dialysis machine, while the net fluid balance goal reflects the patient’s overall fluid status, accounting for all inputs and outputs. The removal goal focuses on machine performance, whereas the balance goal provides a broader measure of the patient’s clinical fluid management. Distinguishing these terms ensures clarity in evaluating outcomes.
That being said, let’s talk about what defines success.
Tiers of Success
Categorizing success into tiers rather than relying on a simple met/not met framework was the best approach because it captures the nuances of fluid management in renal replacement therapy. A binary evaluation doesn’t account for degrees of precision or the context behind achieving—or falling short of—the goal. For instance, achieving the lower end of a range might technically “meet” the target but fail to align with the clinical intent, while a slight deviation from the range due to unavoidable circumstances may still reflect a well-executed effort. By using tiers such as Optimal, Acceptable, Marginal, and Failure, I can better assess not just whether the goal was reached but how closely performance aligned with the intended outcomes, providing a more actionable and realistic evaluation. This stratification fosters accountability, highlights areas for improvement, and ensures that patient care remains the central focus.
For example, a net fluid balance of 0 L in a 0 to -2 L range is technically a “win,” but it might fall short of the clinical intent if the goal was aggressive fluid removal closer to -2 L. This led me to stratify success into four tiers—optimal, acceptable, marginal, and failure—to better account for precision, intent, and context.
For a net fluid balance goal ranging from 0 to -2 L, success is classified into four tiers—Optimal, Acceptable, Marginal, and Failure. Optimal success is achieved when the actual net fluid balance is within ±10% of the maximum prescribed range, or between -1.8 L and -2.2 L. Acceptable success occurs when the balance falls outside the Optimal range but remains within the prescribed range, specifically from 0 to -1.8 L. Marginal success includes balances that are either 11–20% below the maximum range, or slightly above the minimum range (up to 10%). For this example, this means a balance between -2.2 L and -2.4 L, or from 0 to 200 mL. Finally, Failure is defined as any balance that falls outside the Marginal limits, such as greater than 200 mL or less than -2.4 L. This tiered system ensures a structured and clinically relevant assessment of success in achieving fluid removal goals.
The variance percentages I use for categorizing performance are similar to the benchmarks we used in my Chem51 lab (UC Irvine) to evaluate reaction yields. Just like in the lab, these thresholds are somewhat arbitrary but serve a practical purpose: providing clear, measurable benchmarks to guide performance and determine success. In the lab, we often needed to set acceptable ranges for reaction yields to account for variability in methods, equipment, and conditions, even though the specific thresholds didn’t always have a scientific basis. They were there to ensure consistency and fairness in evaluation.
The Four Goals
As I developed this framework, I realized there were two key areas that required assessment to truly evaluate performance. The first is the overarching 24-hour net fluid balance goal, which must be achieved collaboratively across shifts. For instance, if the 24-hour goal is 0 to -2 L, seamless coordination between day and night shifts is essential to keep the patient within that range. The second area is my 12-hour shift, which carries a proportional responsibility for the 24-hour goal—typically half. For example, if I start my shift with the patient already at -300 mL, my adjusted target would be -1700 mL to stay on track for the 24-hour goal. Addressing this dual responsibility also requires considering the previous shift’s impact, which I refer to as “Inherited Deviations” or “Inherited Conditions.” These represent the starting net fluid balance handed over to me, which may align with or deviate from the expected trajectory of the 24-hour goal. Balancing my 12-hour responsibility with these inherited deviations often requires flexibility and critical thinking to adjust for any over- or under-removal by the previous shift. To guide this process, I also incorporate a theoretical 12-hour goal, which assumes an even distribution of the 24-hour target across shifts. By comparing this idealized goal to the realities of my shift, I can better balance expectations with practical adjustments.
It’s important to keep in mind both the theoretical 12-hour goal and the actual net fluid balance goal during my shift because they serve complementary purposes. The theoretical goal provides a baseline for what I should aim to achieve under ideal conditions, ensuring I contribute my share toward the 24-hour target. The actual goal, however, reflects the reality of what I inherit from the prior shift, including any deviations from their target and adjustments needed to compensate. By balancing these two perspectives, I can stay on track for the 24-hour goal while adapting appropriately to patient-specific needs and the performance of the prior shift. Ignoring either one risks overcompensating or falling short, which could impact patient outcomes or complicate care for the following shift.
For clarity, I will include a fourth, overarching goal: Met/Not met. This goal evaluates whether the patient achieves the 24-hour fluid balance goal by the end of my shift. This overarching goal provides a straightforward assessment of whether the treatment is aligned with the intended outcomes, regardless of inherited deviations, interruptions, or proportional adjustments.
Information related to tier success will help track Shift Success Rate, which measures the percentage of shifts classified as optimal, acceptable, or marginal success based on the defined tiers. This metric will help me gauge how consistently I meet goals, offering insights into my overall performance.
Special Circumstances
Special circumstances may arise involving PIRRT (Prolonged Intermittent Renal Replacement Therapy) or situations where CRRT runs only for a portion of the shift because the treatment was just initiated. In these cases, adjustments to the net fluid balance goals are necessary to ensure accurate assessment.
For PIRRT, the goal will be proportional to the time I was managing the machine and will include any inherited deviations, calculated as:
(number of hours managing machine / total number proposed hours machine is intended to run) x net fluid balance goal minus the previous shift’s fluid balance
For example, if a patient is to be on RRT between the hours of 2000 to 0800 with a net fluid balance goal of -2L, the fluid balance at the start of the shit was -700 mL, and I am only managing the treatment for 12-hours (1900-0700), the adjusted net fluid balance goal is (11 hours / 12 hours) x -2 L minus -700 mL, or -1.13 L.
For CRRT scenarios where the treatment is initiated shortly before or during my shift, the net fluid balance goal will account for both the hours it is running under my care and the inherited fluid balance from the previous shift. This is calculated as:
(hours machine ran / 24 hours) x net fluid balance goal minus the previous shift’s fluid balance
For example, treatment first started at 1400. I am on shift for 12-hours. Net fluid balance goal is -2 L; however, the patient is approximately 500 mL positive. The adjusted net fluid balance goal is (12 hours / 24 hours) x -2 L minus 500 mL, or -1.5 L.
This adjustment applies exclusively to new starts or initiations of CRRT. In contrast, for treatments that have already been running for at least 24 hours but were interrupted due to issues like circuit clotting or procedures, the net fluid balance goal will not be proportioned. Instead, inherited deviations resulting from these interruptions will be documented and factored into the overall assessment.
Additionally, in special circumstances where treatment abruptly ends and therapy cannot be restarted, such as when HD access becomes unusable or care is withdrawn, success will transition from the conventional audit to the Dynamic criteria.
Under the Dynamic criteria:
The net fluid balance goal will still include inherited deviations and be proportional to the time the machine was active during my shift.
Success will be evaluated solely for the time the machine was running, ensuring fairness and accountability.
By including inherited deviations in these calculations, the system ensures that every shift’s contribution is accurately assessed within the context of collaborative patient care.
In special circumstances, two goals are evaluated to ensure fairness and simplicity. The first is the proportional goal, which adjusts the net fluid balance target based on the time the machine was under my care. The second is the simple met/not met goal, which determines whether the 24-hour net fluid balance goal was achieved by the end of my shift.
Conclusion
By combining all these metrics and gamifying my goals, I’ve created a process that is both engaging and motivating. Treating net fluid balance targets as a challenge not only keeps me focused but also transforms a routine task into an opportunity for growth and improvement. At the end of next year, this project will give me a detailed view of my performance—highlighting strengths and pinpointing areas of improvement.