There is no doubt that the COVID-19 pandemic changed all of our lives. It has changed the way we all live, and it has also changed the way we function as health service organizations. The influx of COVID-19 patients, and the far-reaching implications of such a pandemic, seems to have pulled focus from many other areas of hospital life. Yet, our profession requires that we continue to create, learn, and offer new therapies to improve patient outcomes. It begs the question, how can we continue to educate, create competencies, and roll out new therapies amid a global pandemic?

In mid-2019, St Louis Children's hospital began the initial planning stages to begin providing modified aquapheresis therapy in the neonatal intensive care unit (NICU). Modified aquapheresis is a form of continuous renal replacement therapy (CRRT) that uses an ultrafiltration device along with prefilter replacement fluid to provide both fluid removal and solute clearance to support small patients with abnormal kidney function requiring renal replacement therapy. It can be used to bridge infants to a point where they can be transitioned to a long-term dialysis modality, typically peritoneal dialysis (PD).1 PD catheters require time to mature, and this therapy can be used to support the patient's renal function during this time. Since this therapy was not previously available at our institution and novel for the NICU, the program was built with a focus on a complete education of the principles of dialysis, as well as pump and patient management for the NICU nurses. The goal was set to have the program ready for our first patient by March 31, 2020.

It was immediately recognized by the steering committee that there would be a very large education component to starting the program. Recruitment strategies focused on nurses with 2 or more years of NICU experience who were interested in advancing their intensive care unit skill set. All interested nurses were scheduled for an 8-hour in-person training session that would include a mixture of didactic and hands-on training. In addition to the in-person training, they were assigned prework using the online learning platform SABA. These modules, titled "Renal Failure in the Pediatric Patient" and "Continuous Renal Replacement Therapy," provided a background for the nursing staff. Since this therapy was new for our institution and the NICU staff had limited exposure to CRRT, these modules helped them begin their training with general knowledge of renal failure and CRRT.

In early 2020, COVID-19 brought our plans to a screeching halt. In-person training sessions were cancelled, in-hospital staff was reduced, and focus was pulled to managing the pandemic crisis. However, many COVID-19 patients nationwide needed renal replacement therapy and modified aquapheresis could be used to support patients if resources were to become scarce. Therefore, the decision was made to continue forward with rolling out the program. The nurses would still need the same amount of prework, training, and hands-on experience with the pumps; however, it was quickly decided to transition to a virtual learning platform. The proposed content was reviewed and all content that did not involve physically touching a pump was prepared in virtual format. The nurses would receive 4 hours of virtual learning, including the following topics: "Principles of RRT" (delivered by nephrology physicians), "Get to Know Your Aqua Machine" (focused on the parts of the pump and their functions), "Ultrafiltration" (discusses fluid balance, and considerations for fluid removal in the neonatal population), "Documentation, Communication, and Guidelines" (documentation, review of the aquapheresis guideline, and suggestions for team communication), "Central Line Maintenance and Management of a PD Catheter," and a live, virtual demonstration of setup. To ensure that the staff remained engaged throughout the 4-hour class, we utilized an online platform that enabled the members of the class to play content-specific question and answer games from their cellular phone with questions on the delivered content.

It was not possible to launch the program without first allowing the nursing staff to have hands-on education with the aquapheresis pumps, so the remaining content took place in person. Class sizes were reduced to no more than 4 learners and took place in a large conference room to allow for adequate social distancing. Masks were required, hand sanitizer was provided, and the machines were disinfected between users. The topics covered in the hands-on portion of the education were "Access: Connecting and Disconnecting" (which required the nurses to dress, heparin lock, and connect the lines to the circuit using dolls), "Documentation" (focused on the newly built EPIC flow sheet), "Loading and Priming," "Modifications" (focused on the modifications to the circuit), and "Troubleshooting" (covered common alarms and alarm management). The nurses each were given the opportunity to prime the pump and manage simulated pump alarms. They were also able to connect the patient to the circuit and practice setting up the modifications required for therapy.

While COVID-19 foiled our plans to begin therapy on March 31, 2020, our transition to a virtual format allowed us to proceed forward with education, although nearly all other education in the hospital was placed on hold. It was met with enthusiasm from the nursing staff, as they were not required to drive into the hospital for training, nor did they remain in close contact with others for 8 hours. Also, the 8 hours of training in addition to required clinical hours would have caused some nurses to go over their allocated full-time hours and would have required the hospital to pay overtime. By splitting the class into 4-hour sessions over 2 weeks, we were able to decrease the amount of overtime required to train the nursing staff while still meeting clinical hours' requirements.

We were able to go live with our first modified aquapheresis patient on July 15, 2020. We found that the combination of online and in-person training prepared our team to provide exceptional care for our first aquapheresis patient. There have been many lessons learned, and we have addressed issues with a combination of in-person just-in-time training at the bedside and utilization of our online learning platform. For example, it was determined quickly after go live that there was additional education needed for line maintenance, in particular alteplase administration. Patient access is crucial in performing effective renal replacement therapy, but alteplase was not previously administered in NICU patients. Therefore, additional educational content was created to supplement the virtual and in-person sessions. We performed bedside support and teaching on the unit, with only the 2 nurses staffed to the patient each day in order to keep the groups small. We also assigned additional training on the practice via our online learning platform.

Even in the era of COVID-19, the show must go on. As healthcare providers, we have a responsibility to our patients to provide newer, more advanced therapies, as well as a responsibility to our nursing staff to provide them with the most complete education and training as possible. Although COVID-19 delayed our go-live date, we were still able to move the program forward using a combination of in-person and online training, all to the benefit of one little infant and their family in the NICU who were there waiting for us.

-Sarah Franz, BSN, RN

CRRT Coordinator

-Lisa M. Steurer, PhD, RN, CPNP-PC, CPN

Manager, Research & Outcomes

St Louis Children's Hospital

St Louis, Missouri

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