Table 1.

Summary of Challenges and Solutions Encountered During Startup of Urgent PD Program

Situation	Challenge	Solution
Surge of patients with AKI requiring KRT	Limited resources (including machines and dialysate bags) for iHD and CKRT	Reduce iHD and CKRT duration to maximize no. of treatments; temporarily use 1.5% dextrose PD fluid as CKRT dialysate when no CKRT dialysate was available; add urgent PD to increase KRT capacity
Obtaining supplies	Identifying the quantity estimated for the surge of patients	1 experienced nephrologist and 2 nurses with extensive PD experience placed order with supplier for predicted number of 25 patients to be started on PD over the following 2 wks
Access needed to start PD	Limited/no OR time meant patients needing a PD catheter were waitlisted or unable to receive a catheter	Transplant surgeons performed bedside laparoscopically assisted flexible PD catheter placement for intubated and ICU patients; interventional radiologists performed fluoroscopy-guided flexible PD catheter placement for nonintubated non-ICU patients
Limited staff	Limited nursing staff (due to illness or higher patient to nursing ratio than usual) available to perform iHD, CKRT, or PD	For ICUs in which there were no PD-trained nurses available, a clinical educator provided a PD training session for nurses interested in/who had the time to learn PD; the urgent PD service conducted patient rounds and performed 1-2 manual exchanges per day per patient in addition to providing training to nurses and house staff residents during the daytime
More patients started on PD	As the program grew rapidly, the urgent PD service was becoming overwhelmed as demand increased	Urgent PD service increased in staff and more time was spent educating nurses and residents caring for PD patients on how to perform manual exchanges of PD; availability of cyclers helped with the work load of the urgent PD service nephrologists and the patients’ nurses because interaction with machine was limited when the nephrologists set up the machine for each patient
Prone positioning	Limited the use of PD to when patients were supine to avoid increased intra-abdominal pressure during prone positioning, which may cause dyssynchrony with the ventilator	Supplemental iHD or CKRT was provided while patients were prone depending on patient location (some units did not have water connections available for iHD) as well as machine, dialysate, and nursing staff availability; patients received PD when supine but this was often limited to 1-4 exchanges depending on the duration of supination

Abbreviations: AKI, acute kidney injury; CKRT, continuous kidney replacement therapy; ICU, intensive care unit; iHD, intermittent hemodialysis; KRT, kidney replacement therapy; OR, operating room; PD, peritoneal dialysis.