2026 Southeastern Residency Conference

Evaluation of Phosphorus Replacement Protocol Implementation during Continuous Renal Replacement Therapy (CRRT)
Emma Smits, Morgan Vincent, Mike Maccia
Cone Health at Moses Cone Hospital - Greensboro, NC

Background:
Continuous renal replacement therapy (CRRT) is a common modality of renal replacement therapy among critically ill patients. However, hypophosphatemia is a frequent complication of CRRT, with several studies reporting incidence of at least 60%. This risk increases with CRRT duration, especially when a phosphorus-free dialysate is utilized. The pre-filter, post-filter, and dialysate fluids for CRRT at Cone Health do not contain phosphorus.  Hypophosphatemia in critically ill adults has been associated with increased duration of ventilatory and vasopressor support, prolonged hospital and intensive care unit (ICU) stay, and increased 28-day mortality. In June 2025, Cone Health introduced a protocol for pharmacist-driven replacement of phosphorus among patients receiving CRRT. This study aimed to evaluate the effectiveness of this protocol in reducing the incidence of hypophosphatemia and related clinical outcomes.
Methods:
This was a retrospective, pre-post comparator study of adults hospitalized within Cone Health ICUs who received CRRT. Data was collected from February to May 2025 for the pre-intervention group and July to November 2025 for the post-intervention group. Patients were excluded for receipt of total parenteral nutrition (TPN), death within 72 hours of CRRT initiation, or receipt of CRRT for less than 72 hours in duration. The primary endpoint was the incidence of hypophosphatemia within the first 72 hours. Secondary endpoints included percentage of phosphorus levels in goal range, change in phosphorus level following replacement, number of phosphorus replacements, ordering user type, time to development of hypophosphatemia, time to phosphorus replacement from low phosphorus level, mechanical ventilation duration, and in-hospital mortality. Endpoints were compared using Chi square, t-test, Fischer’s exact test, or Mann-Whitney U test as appropriate.
Results:
Ninety patients were included in the evaluation (n=45 in each group). The rate of hypophosphatemia was 60% in the pre-protocol group and 68% in the post-protocol group (p=0.51). In the post-protocol group, pharmacists served as the ordering provider more frequently than either physicians or advanced practice providers (75% vs 45%, p=0.028).  Most secondary outcomes were similar between groups.
Conclusions:
Implementation of a pharmacist-driven phosphorus replacement protocol during CRRT did not reduce incidence of hypophosphatemia but did increase the proportion of phosphorus replacements completed by pharmacists. Potential limitations include limited sample-size, single-institution study, and possible variation in workflow or practice between individual ICUs. Future directions include assessment of barriers to utilization of the phosphorus replacement protocol and identification of strategies to increase utilization.