percent of the 32 centers of excellence for modality selection practices identified by Baxter ..... and physician must be on call 24 hours/day. Because most ...
CHAPTER 3
Quality systems in the dialysis center: Peritoneal dialysis BARBARA F. PROWANT, KARL D. NOLPH, ZBYLUT J. TWARDOWSKI, LOIS M. SCHMIDT, LEONOR PONFERRADA and RAMESH KHANNA
The goal of this chapter is to discuss the characteristics of systems (structure) and activities (process) within a peritoneal dialysis program which contribute to optimal outcomes (quality) for peritoneal dialysis patients. The text is organized around the eight characteristics or attributes of successful companies identified by Peters and Waterman in their book In Search of Excellence [I].
Hands-on, value driven Peters and Water found that successful companies have a sound set of beliefs and values upon which they premise all policies and actions and summarizes these as "hands on and value driven" [1].
Program integration
One value embraced by successful peritoneal dialysis programs is that it is essential for the peritoneal dialysis program to be integrated with acute and chronic hemodialysis units [2] and a renal transplantation program. There are many advantages of a truly integrated program. Decisions concerning optimal therapy can be made without the bias of how it will affect the income to the program and/or physician. The patient can transfer back and forth between therapies when necessary with relative comfort and ease.
Philosoph) of self-care
Another value imperative for achieving quality in a peritoneal dialysis program is the conviction that chronic peritoneal dialysis is an acceptable treatment for ESRD and that it can be successfully managed as a self-care therapy. Although not all patients are totally responsible for self-care, almost all patients L W. H~nd~rson and R.S. ThumtJ (eels.), Qualiry Assurtu~ce in Dialysis, 23-45. e 1994 Khlwer Academic Publishers. Printed in the N~th~rlands.
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dialyze at home either independently or with the assistance of a partner. It is imperative that the administrative staff and all team members believe that patients and their families can learn to dialyze safely and effectively at home, and that self-care, home dialysis offers advantages to the patient in tenns of independence, control, and quality of life. Appropriate goals for a home peritoneal dialysis program are: (a) to enable patients to dialyze safely and effectively and; (b) to assist patients in maintaining an optimal level of function at home. Patient involvement in choosing a chronic dialysis therapy
Another value inherent to successful peritoneal dialysis programs is that the patient and family should be encouraged to participate in the choice of a therapy which best meets their needs and fits their lifestyles. Ninety-three percent of the 32 centers of excellence for modality selection practices identified by Baxter Healthcare allowed the patient to make the final choice of chronic dialysis modality after receiving professional assessment, education and recommendations. These centers had an impressive technique survival of 85% at three years [3]. Data from 326 patients beginning dialysis therapy in our own program over the past 2 years indicate that significantly more patients who received predialysis education at least one month prior to the need for dialysis chose a self-care home dialysis therapy compared to patients who presented with uremic symptoms and in need of immediate dialysis [4]. A number of models for dialysis modality selection have been developed [S, 6]. The Missouri Kidney Program has published a predialysis patient education program [7] which as been adapted by Baxter Healthcare [8]. Key features of successful predialysis education programs are listed in Table I. Table I. Key components of successful prcdialysis patient education programs. • Education is initiated 3-6 months prior to the need for chronic dialysis. • There an unbiased presentation of all treatment options and pros and cons of each. • Classes supplement one to one sessions. • Families and significant others arc included in the education process. • Patients meet patients on various ESRD therapies. • The patient is assessed by the renal team. • Medical advantages and/or contraindications for a therapy are discussed with the patient. • The patient is included in the decision-making process.
A recent review of 63 patients who selected peritoneal dialysis [4] indicated that the predominant reason (25%) was to maintain independence, activities and flexibility in scheduling. Motivation to perform one's own dialysis and maintain some control was the reason 15% chose peritoneal dialysis and an additional 12% of the patients cited the ability to continue working. Although
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the majority of patients chose PD for positive reasons. fourteen percent selected peritoneal dialysis because of long distances to a hemodialysis unit and an additional 9% because they felt travel to center hemodialysis or the demands of home hemodialysis would impose an unacceptable burden on their families. Administrative support
A PD program cannot succeed and expand without strong and unified administrative support. For a PD program to thrive both the administrator and medical director must believe that peritoneal dialysis is a legitimate dialysis therapy and a valid treatment option on an equitable status with hemodialysis; and that PD is a revenue producing program. Only when there is such a philosophy will the PD program be able to obtain adequate space, personnel, equipment, budget and support. Allowing designated nursing staff to work solely in the home dialysis program is one indicator of administrative support. Of the 18 centers of excellence for patient education and training practices identified by Baxter Healthcare, 92% assigned nurses to the peritoneal dialysis outpatient program only with no responsibilities for center hemodialysis or intermittent peritoneal dialysis [9]. Another example of strong administrative support is flexibility to choose from more than one peritoneal dialysis system, so that each patient has access to a system which will meet his or her unique needs. For example a handicapped or visually impaired patient may need an assist device, an active individual concerned about body image might desire a disconnect system, and a patient with recurring hernias might need overnight cycler dialysis. Three examples of the lack of strong administrative support follow. The first is a peritoneal dialysis program that chooses not to provide nursing back-up evenings, nights and weekends in order to avoid paying nurses for call time. Patients often do not call on weekends to report complications because of difficulties communicating with the physicians, or because a physician may not perceive their concerns to be a legitimate problem. A second example is a unit that does not allow primary nurses to call their patients between clinic visits because they are unwilling to pay the long distance telephone charges. Consequently, patients visit the emergency room or are admitted for problems which could have been prevented or easily managed at home had they been identified early. The third example is a peritoneal dialysis program with more than 30 patients which operates out of two small treatment rooms, one of which is the only nurse's office. If clinic visits are scheduled during a training day the nurse has no place to speak confidentially to a patient who calls for assistance. Furthermore, patient records kept in the nurses office are not adequately secured.
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26 Philosophy of excellence
Finally, for a peritoneal dialysis program to achieve a consistent quality of care the administrative, professional and support staff must share a commitment to quality. they must believe that their program can and does provide a high quality of care and caring. They must be willing to go above and beyond the realm of routine activities, to try innovative approaches, and occasionally step oureide the bounds of the job description. The philosophy of excellence includes a willingness to individualize dialysis prescriptions and to provide an optimal dose of dialysis, and adequate support services. The highest possible level of health and rehabilitation is truly the goal for each patient. The patient is the staff's central focus and the difficult or complex patient is seen as a challenge, not a nuisance or problem.
Productivity through people Productive companies treat their employees with dignity and respect. Employees are partners, experts and team members [1]. The peritoneal dialysis team
Peritoneal dialysis as a subspecialty has emphasized the importance of interdisciplinary collaboration and a team approach to patient care [10, 11]. The peritoneal dialysis team becomes a continuous quality circle responsible for the quality of care provided to their patients. Typically the team responsible for the care of peritoneal dialysis patients is composed of a physician, nurse, dietitian and social worker. The major physician responsibilities are to prescribe appropriate therapy for end stage renal disease and other medical problems, to diagnose and treat complications of ESRD and dialysis therapy. The physician can also facilitate the effectiveness of the team by clarifying and/or validating the roles of the other team members, to patients, other physicians or other depanments and institutions. Table II lists the areas in which we believe a physician must be knowledgeable and competent to effectively manage peritoneal dialysis patients. In order to prescribe appropriate therapy physicians caring for peritoneal dialysis patients must understand peritoneal dialysis kinetics and how to assess peritoneal membrane transport rate. Furthermore, the physician should be able to assess the adequacy of dialysis based on: (a) quantifying dialysis; (b) combined renal and dialysis urea and/or creatinine clearances; (c) interpretation of laboratory values; (d) nutritional status, and (e) patient well-being. Roles of the nurse are to provide the education, guidance, support, supervision and assistance patients require to perform PD at home, to adhere to the treatment regimen and to experience the highest possible quality of life.
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27 Table II. Areas of physician knowledge and competence required for a successful peritoneal dialysis practice. General competence in hemodialysis Peritoneal dialysis Catheter insertion protocols Diagnosis and treatment of catheter related problems Types of peritoneal dialysis therapy Various systems for peritoneal dialysis procedures Recognition. prevention and treatment of complications Diagnosis and treatment of peritonitis Management of diabetes melliws and regulation of blood sugar with intraperitoneal insulin
Because most nurses do not come to peritoneal dialysis programs with experience in nephrology or peritoneal dialysis an extensive orientation and education program is required in order to achieve a high level of nursing care. One such program lasts for 6 weeks during which the nurse learns theoretical infonnation about peritoneal dialysis as well as learning to perform peritoneal dialysis procedures. A competency based learning system which allows the learner to demonstrate the requisite knowledge and/or skills in each specific area can be used efficiently and effectively for initial orientation. The new nurse observes home dialysis education, clinic visits, home visits and outpatient nursing management. The new nurse begins working with patients with a preceptor so he or she has a readily available resource and support. As the nurse learns or reviews ESRD and peritoneal dialysis content and principles of adult education he or she begins teaching patients in familiar topics such as monitoring blood pressure, then moves on to other topics. The number of primary patients is gradually increased, and patients requiring more complex care are added as the nurse gains experience. Nurses wait three months before taking call, and then another nurse is available for consultation and back up support. The social worker's role is to assess the patient's (and family's) financial and psycho-social status and to provide psychosocial support, counseling and referrals as needed. The dietitian's role is to assess the patient's nutritional status and make recommendations regarding the diet regimen. The dietitian teaches the patient and significant others about the therapeutic diet, assists them in meal planning, and helps them incorporate the dietary regimen into their lifestyle. To achieve a high quality of care for peritoneal dialysis patients the renal dietitian needs to have a basic understanding of dialysis, and how it is related to nutrition, the typical diet orders [12]: and which parameters to routinely monitor. The dietitian needs to understand basic principles of adult education and have adequate time to teach patients and families and to evaluate their adherence to the diet plan. The Council on Renal Nutrition provides guidelines for staff patient ratios based upon the extent of services [13]. Finally, the patient, the focus of services provided by the team, may actively
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28 participate in the team's decision making process. Some institutions recommend that self-care or home dialysis patients participate in team care conferences to develop the long term care plan. In other units the team·s recommendations and/or care plan are later reviewed with the patient.
Team approach and interactions
Assembling an interdisciplinary group to care for patients does not necessarily ensure that they will function as a team. It is essential that the patient and family be viewed as a whole and that there is a system which will prevent fragmentation of care by promoting communication and collaboration [14]. Team interactions take place in a variety of settings: however, some structured meetings are essential. Regularly scheduled team meetings provide opportunity to review the patient's current status, to discuss problems, to develop the team's long term plan of care, and for collaborative decision making. Hospital rounds by an interdisciplinary team also facilitate coordinated, continuous care. Mutual respect, similar goals, effective communication, and techniques to manage conflict among team members are essential for the team to function effectively. Physical proximity can enhance team function. Team members with adjoining desks or offices (or even offices in the same building or facility) are likely to have much more infonnal interaction with each other than with physically distant team members [ 14].
Professional enhancement/job enrichment
The ultimate goal of professional enhancement and job enrichment is to attract and retain staff. Short term goals are to improve morale, increase motivation and job satisfaction, and to reduce stress and absenteeism. Membership and active participation in professional organizations provides an avenue for professional enhancement. Continuing education for all team members is also essential for professional enhancement as well as optimal care. Team meetings, clinics and rounds provide almost continuous opportunities for informal teaching. Working with a panner or mentor is an effective way for professionals new to peritoneal dialysis to acquire knowledge and learn to make clinical assessments, diagnoses, and management decisions. Unit inservices and professional education meetings provide more structured learning as does formal education.
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29 Autonomy and entrepreneurship Successful companies allow employees to be independent, and creative. They encourage risk taking and support good tries with the attitude that a reasonable number of mistakes or failed attempts are requisite for success ( 1]. Primary nursing is a system that assigns the nursing care of each individual patient and family to one nurse. The primary nurse is responsible and accountable for providing individual, comprehensive, and continuous nursing care for a group of patients. The primary nurse may also coordinate health care services provided by other disciplines. A number of studies have shown that primary nursing enhances job satisfaction and professional development [ 15-18]. Primary nursing provides high levels of attainment on job enrichment criteria such as autonomy, direct feedback, identification with the ~hole product and task variability [ 19]. Primary care seems to be the most appropriate nursing modality for outpatient peritoneal dialysis and is the nursing modality most widely utilized in peritoneal dialysis programs in North America. Ninety-four percent of the centers of excellence for patient education and training practices utilized primary nursing during home training and 81% continued to utilize primary nursing for outpatient followup [9]. Assigning additional projects and responsibilities to staff members who are clinically competent and efficient also provides diversity, and an avenue for personal grow~h and professional development. Table III lists a number of such activities. Most of these tasks and activities are inherent components of a home dialysis program, so assigning such projects does not actually add additional work. Peritoneal dialysis staff are frequently asked to teach others about this therapy. These invitations provide opportunities to develop skills in planning and providing professional education and in public speaking. Opportunities to do technical or professional writing are also available to peritoneal dialysis staff members. Beginning writers may start with simple in-house projects such as policies and procedures or patient education materials. Table Ill. Staff projects to enhance professional growth and development.
• • • • • • • • • •
Write or revise policies and procedures. Evaluate new products and peritoneal dialysis systems. Develop patient education modules. Develop patient education mau:rials. Participate in quality improvement activities. Develop clinical expertise in related specialties, e.g. gerontology, diabetes. Serve as a liaison to long term care facility(s). Serve as a liaison to associated hospital(s}. Collect and analyze peritonitis, exit site infection data. Participate in or direct research projects. Serve on institutional committees.
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Simultaneous loose tight properties Peters and Waterman noted that top companies are both centralized and decentralized. They encourage autonomy at all levels. yet hold a core set of values [1]. An example of this in the dialysis unit is the professional team approach which encourages autonomy in patient care within a discipline, yet strongly promotes the communication and continuity of care among team members and in a number of settings (the home, outpatient clinic, hospital}. The shared value system discussed above is another example of the tight properties which contribute to success.
Simple form, lean staff The organization structure of successful companies is described as "elegantly simple" with lean staffing at the top levels (1]. When the organization matrix gets too complex, the priorities and accountability become confused. It might be worthwhile to evaluate the corporate structure of dialysis programs to assess whether the organization is simple and streamlined, and whether it truly supports quality in patient care.
Stick to the knitting The most successful companies stick close to the central skill or product and this enables them to perform more effectively than the competition [1]. Because of the highly specialized nature of peritoneal dialysis programs, few units branch out into other types of care. This discussion will focus on what is required to provide a high quality of peritoneal dialysis. First of all, peritoneal dialysis programs have physical space requirements. Eighteen centers of excellence for patient education and training practices identified by Baxter Healthcare had significantly higher technique survival and patient survival rates than their counterparts. All of these units had space devoted solely to the home peritoneal dialysis program [9]. Eighty-two percent of these centers had a PD training room, a separate PD clinic area, and a PD nurses' office. All of the units also had separate storage and utility areas for peritoneal dialysis [9]. . One of the most basic requirements is a set of standards of clinical practice. A standard is the yardstick of the quality of a service and Mason states that nursing standards "define unequivocally what quality care is and provide specific criteria that can be used to determine whether quality care has been provided" [20]. A standard describes what should be done and how the patient will benefit from the care. The American Nephrology Nurses Association has published standards of clinical practice for nephrology nursing [21]. Appropriate standards can be selected and adapted for use in a particular dialysis unit.
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A policy and procedure manual that guides safe practice is also essential. Policies for all nursing procedures, machine and equipment maintenance. emergencies, and ma_naging problems will help ensure consistent, safe care. A unit's standards and policies and procedures are also used by inspectors and surveyors to evaluate the program. Although clinical policies and procedures are developed primarily by the nursing staff we recommend consultation with administration regarding legal issues, with the medical director regarding nursing protocols to manage complications. and with patients regarding the self-care procedures. An annual review and update of policies and procedures is appropriate. Examples of the types of policies and procedures required for a peritoneal dialysis program are listedin Table IV. Table IV. Selected Types of Peritoneal Dialysis Unit Policies and Procedures. General Procedures
Handwashing Measuring blood pressure Quantitative urine collection Peritoneal dialysis procedures Exit site care procedures Exchange procedure (for each system used) Cycler procedures Machine set up for closed drain Machine set up for open drain Adminisuation of intraperitoneal medication Catheter adapter change procedure Peritoneal equilibration teSt Quantitative dialysate collection Protocols for managing problems and complications ObstrUction of flow Fibrin in dialysate Contamination of the system Crack or bole in catheter Hypervolemia Peritonitis Emergency procedures Cardio-pulmonary arrest Fire Hurricane or Tornado
Medical protocols and procedures also contribute to quality. For teaching institutions a manual for housestaff and renal fellows is essential for consistent care. Examples of content are listed in Table V. Catheter placement
Establishing a permanent access is a prerequisite for successful peritoneal dialysis. Preoperative preparation for peritoneal catheter insertion typically
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32 Tabl~
V. Selected Content from
~tanual
for Houscstaif and Fellows.
Peritoneal Dialysis Acute catheter insertion procedure Chronic catheter insertion Current policies Marking catheter exit site Preoperative orders Catheter placement video Catheter Break-in Chronic dialysis orders Peritoneal equilibtation test Exit site infection protocol Peritonitis protocol
includes the choice of catheter type, determination and marking of the exit site, and cleansing the abdomen with a disinfectant scrub. Determining the exit site is usually a joint decision and the surgeon. PD nurse, patient and/or nephrologist may be involved. Factors to consider for optimal exit site placement are: avoiding skin folds, the beltline, and scar tissue; and placement where the patient can observe and manipulate that catheter for ease of exit care [22, 23]. Broad spectrum prophylactic antibiotic therapy is generally recommended [23, 24]. Catheters can be medically inserted with a trocar or peritonesocopy or surgically inserted. For optimal results a few general guidelines apply to either procedure. • Catheter placement should be limited to experienced surgeons or .nephrologists [24]. • Local anesthesia combined with a sedative is adequate for uncomplicated insertion [24]. • A lateral or paramedian insertion site is preferred [25]. • The catheter should be soaked in sterile solution prior to insertion to saturate the cuffs and expel air [23, 24, 26]. • Sutures should not be used at the exit site [23, 26]. . • Solution should be infused and drained prior to closure to evaluate catheter function [24, 26]. • Nonreative, absorbable sutures should be used for the initial incision [23, 24]. • A sterile dressing is applied and the catheter is anchored at the exit site to prevent movement [24]. The catheter should be immobilized well during healing to avoid tension and torquing of the catheter. Tight clothing or other external pressure and trauma to the exit site should be avoided [24]. Ambulatory dialysis should be delayed for 10 to 14 days. During this time intermittent peritoneal dialysis can be administered with the patient resting supine and with graduaiiy increasing solution volumes, or the patient may receive hemodialysis [27].
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33 E.tit site care protocols
The impact of exit site care procedures on the incidence of exit site infec· tion has been evaluated post catheter insertion [27 -29] and an expert panel has also made recommendations for post operative exit care [24]. Common elements of these post operative exit site care procedures are listed in Table
VI. Table VI. Common elements of post operative procedures for peritoneal catheter exit site care. • • • • • • •
Preoperative prophylactic antibiotic coverage Resuict dressing changes to PO staff Strict aseptic technique Immobilize catheter Nontoxic cleansing agent Exit dried after cleansing (air, 4 x 4) Sterile dressings Continued for ~ 7 days
\
The chronic.exit site care procedures which have been recommended [24] and studied [29-33] are more varied. Common elements include cleansing and drying the exit site and securing the catheter. The ideal cleansing agent is not known and recommended frequency varies from daily to several times • weekly.
Patient edllcation
Nurses in home PD programs should be familiar with principles of learning~ and principles of adult and patient education. There are a number of excellent texts available [34-37], as well as information specific to the ESRD patient [21, 38] so this will not be discussed in detail here. Each PD program needs to develop a generic curriculum for PD patient education that can be modified for each individual patient and adapted for patients with special needs. Teaching materials such as an instructor's manual, printed information for patients or a patient education manual, patient procedures, audio-visual aids (posters, slides, videos), practice supplies, a PD model or "dummy tummy" for practicing exchanges, and patient record forms, need to be developed. Use of these materials will be individualized based on the characteristics of the teacher and learner. The initial PD nursing assessment typically includes an education assessment. Table VII lists items from a PD patient education assessment [39]. The patient education process typically proceeds from assessment of the patient's ability and readiness to learn to developing an individualized plan· for the patient's education. The plan includes developing behavioral objectives, outlining content, identifying specific teaching and learning activities. and
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34 Table VII. Components of initi3.l nursing assessment related to education. • • • • • • • • • • • • • • • • • • •
Educational background Work experience Previous involvement in self-care activities General level of health Level of cognitive function Psychiatric/emotional status Current knowledge of PO Concerns regarding ESRD and/or dialysis Current strcssors and symptoms or stress Factors that interfere with health care or following the medical regimen Level of activity and independence Dialysis partner or backup support Physical disabilities which could aifcct learning Motivation to learn and perfonn PO Best way to learn Best time to team Expectations of PO education program Reading test Memory test
planning for evaluation. The process continues through the actual implementation and evaluation phases. Most PD programs use a 1: 1 nurse patient ratio for initial patient education. Table VIII lists topics covered by over 90% of 18 facilities evaluated for the best demonstrated practices in patient education [9]. Lecture and discussion were the primary modes of patient teaching among the best demonstrated practice centers. Demonstration, return demonstration and simulated problem solving were also used by all of these facilities [9]. The patient education process is documented a number of ways. An account of the assessment, goals and progress is recorded in the progress notes or nurses notes. In addition, annotations are often made on the patient objectives or education checklist to document a patient's mastery of the subject, that a topic has been omitted, or that the routine approach or procedure has been modified. At the completion of training there is a comprehensive evaluation of the patient's (and/or partner's) knowledge and skills. A variety of testing methods are used: verbal and wrinen testing, return demonstration of procedures, simulated problem solving. It takes about 6 days for an average patient to complete PD training. Training time varies from 5-8 hours per day and ranges from 5-10 days [9]. The process of patient education is ongoing. so review, reassessment of learning needs and/or teaching take place at almost every patient contact.
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35 Table VIII. Topics Required for Initial PO Training at IS Facilities (9). • • • • • • • • • • • • • • •
• • •
Asepsis• Handwashing Exchange procedure• Exit site care• Recommended diet. meal planning Fluid balance Record keeping Procedure for system contamination Causes of peritonitis Peritonitis prevention Peritonitis symptoms • Reponing pcritOftitis to unit Peritonitis treatment Catheter complications Supply inventory Vital signs Laboratory values Patient responsibilities Communications and call system
• Minimum knowledge required for all patients
Followup care PD patients require frequent monitoring, assessment, guidance and support after completion of self dialysis education as they begin to dialyze independently at home. This is most efficient and cost effective if the frequency and type of followup is tailored to the patient's specific needs. Many programs contact newly discharged patients two or three times during the first week and then gradually increase the intervals between telephone calls. The first clinic visit is usually scheduled a week or two post discharge and thereafter the frequency is adjusted depending upon how well the patient is coping and the number and type of problems. Clinic visits for nursing assessment and further teaching are sometimes scheduled independently. To our knowledge, most peritoneal dialysis programs require patients to be seen in clinic every 4 to 8 weeks. Activities during a routine clinic visit might include a review of home records or otherwise documenting the home dialysis regimen, measurement of vital signs (including supine and upright blood pressures), assessment of tlllid balance, physical examination, evaluation of the catheter exit site, selected blood chemistries and hematology, review of medications, evaluation of activity level and rehabilitation status. A more comprehensive assessment including more extensive bloodwork, x-rays, EKG and evaluation of residual renal function is usually done biannually. Home visits are a valuable adjunct to followup from the center. Assessing the patient and family in the home provides valuable insights about family
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36 interactions. the degree of self care, supply inventory and storage. general management of health. emotional adjustment and dietary practices (40]. Funhermore. home visits to both patients with perceived problems and those doing well resulted in recommendations for change [40].
Liaison with hospitals Outpatient peritoneal dialysis programs must work closely with affiliated hospitals. in order to assure that hospitalized patients receive continuous. coordinated care. Ideally, all PD patients would be admitted to a renal ward where the entire nursing staff understands ESRD and could perform PD procedures. Few programs enjoy such a luxury, or in fact, have a chronic dialysis population large enough to support a renal ward. Other options are a hospital PD staff; contractual arrangements allowing the outpatient PD nurses to provide PD and exit site care for hospitalized patients; or a few medicalsurgical nurses trained to do PD procedures. It is also imperative that the hospital(s) have supplies and PD systems compatible with those the patients use at home and that PD procedures are consistent with the procedures used and taught by the outpatient unit. Staff nurses caring for PD patients in the hospital need to understand basic principles of peritoneal dialysis and the routine medication regimens. Some dialysis units have formal programs where ESRD is included in staff orientation and continuing education programs are regularly scheduled. In large hospitals a renal clinical nurse specialist can provide consultation and education on an ongoing basis. When catheters are inserted at the hospital (either on an inpatient or outpatient basis) the nursing staff must be familiar with the preoperative care, the operative procedure and postoperative catheter care and communicate with the outpatient peritoneal dialysis staff at discharge [41]. Communication between the nurses responsible for outpatient and inpatient dialysis is essential. The current dialysis regimen, current medications, fluid status, PD related infections and other complications must be provided to the staff taking over the patient's care. The use of a standard form for hospital admission and discharge can facilitate effective communication of such details.
Liaison with extended tenn care facilities As the age of dialysis patients increases, some chronic dialysis patients require continuous skiiled nursing care and reside in long term care facilities. Peritoneal dialysis programs have successfully taught the staff at nursing homes to perfonn PD procedures and manage fluid balance and other aspects of care. The education outline is similar to that used for patient and family education. The patient receiving chronic PD in a long tenn care facility stili requires
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37
followup by the PD staff, and continuing education and support are provided to the staff. Back up support or on call program
Patients perfonning dialysis and managing their ESRD at home require 24 hour professional staff coverage to guide and assist them in identifying and managing problems or complications. Support is also essential for newly trained patients just beginning to dialyze independently at home. Both nursing and physician must be on call 24 hours/day. Because most questions or problems are related to dialysis procedures and/or are within the realm of nursing practice, in most programs the nurse is the initial contact. For medical problems the nurse consults with or refers to the physician on call. Although we are aware of programs with only physicians on call, this is not optimal, because problems other than medical emergencies are frequently not reponed by the patient, or are not dealt with until regular office hours when the nurse returns. Prescribing adequate dialysis
The traditional CAPD prescription (8-9 liter dialysis solution and 3-4 daily exchanges) does not provide adequate dialysis for all patients, especially after loss of residual renal function [43]. In order to determine the optimal individual patient the physician needs informadialysis prescription for tion regarding the patient's peritoneal membrane characteristics. The peritoneal . equilibration test [42] measures the dialysate to plasma ratio of creatinine at 0, 2, and 4 hours dwell time, dialysate glucose/dialysate glucose at 0 dwell time at 2 and 4 hours, and ultrafiltration volume. These values can be compared to or plotted on published curves to determine if solute transport is average, high or low. We recommend a peritoneal equilibration test at the time the patient begins chronic peritoneal dialysis therapy, and repeated when there are clinical indications that there may be a change in membrane transport characteristics. Such indicators include an increase or decrease ii(ultrafiltration, and an unexplained change in serum chemistries. Twardowski and colleagues (43, 44] and Diaz Buxo [45] have described patterns of ultrafiltration and clearances in relation to solute transport. Table IX indicates the most appropriate or preferred dialysis prescriptions based on solute transport rates. Obviously, if physicians are to prescribe the most appropriate therapy based on peritoneal membrane transport rates, there must be administrative and nursing support for CCPD, IPD and other cycler therapies. This includes policies and procedures, availability of machine installation and maintenance, nurses skilled in operating the cyclers, an educational curriculum and materials, and billing systems.
an
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38 Table IX. Dialysis prescriptions based on peritoneal equilibration test resultS (43}.
Response to standard C.-\PD (4 2 liter exchanges) Solute ttanSpon
Ultrafiltration
Clearances
Preferred prescriptions
High
Poor
Adequate
Nighdy IPD Nighdy TPO DAPO
High average PO
Adequate
Adequate
Standard dose (any regimen)
Low average PO
High
Adequate Inadequate
Standard dose High dose PO
Low HD
Excellent
Inadequate
High dose PO
IPD = intermittent peritoneal dialysis TPD = tidal peritoneal dialysis DAPO = dialy ambulatory peritoneal dialysis (no long overnight exchange)
AdequaQy of peritoneal dialysis may be judged in a number of ways. Table X indicates criteria for clinical assessment as summarized by Twardowski [44]. Determination of total (renal and dialysis) clearance of urea and/or creatinine can also be used to evaluate the adequacy of the peritoneal dialysis prescription. A minimum creatinine clearance of 40-50 liters per week (for body surface area of 1.72 m1) has been recommended by Twardowski. For anuric patients [44] 55.4liters per week was recommended by Boen [46]. Urea kinetic modeling has also been applied to evaluate the adequacy of Table X. Clinical assessment of adequacy of dialysis.
Clinical criteria Patient "feels well and looks good" Blood pressure controlled Good fluid balance Stable lean body mass Stable nerve conduction velocities Absence of uremic symptoms Anorexia Dysgeusia Nausea Vomiting
Asthenia Insomnia Laboratory criteria EleCtrOlytes within normal range Serum creatinine< 20 (muscular persons) < 15 (non muscular persons) Hematocrit > 25% without EPO or steroids
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39 CAPO (47-50]. Applying urea kinetic modeling to clinical studies which quantified dialysis has shown that patients with a weekly Kt/V~ 1.7 have better clinical outcomes [51] and fewer deaths [52] than those with a weekly Kt/V urea < 1.2.
Prevention of peritonitis There are a number of approaches to peritonitis prevention. Matching the peritoneal dialysis system to the patient's abilities will reduce the risk of contamination to the system. Reevaluation of the patient's abilities and procedure technique after peritonitis has occurred enables the nurse to identify a problem with technique or determine if the current system is no longer appropriate for the patient. Even if no technique problems are identified, changing toy-set (53, 54] or an ultraviolet light (55, 56] system may reduce the incidence of peritonitis. Effectively teaching the patient how to identify a break in technique or contamination when they do occur and the appropriate response will reduce the incidence of peritonitis. The use of prophylactic antibiotics for known contamination of the system is recommended. Baxter Healthcare's best demonstrated practices program found that ten of 15 centers with a 1986 peritonitis rate of 1 episode every 18.7 months routinely used prophylactic antibiotics for a break in technique [57]: Thirteen of the fifteen centers routinely prescribed prophylactic antibiotics for a known contamination of the system. Ten of the same 15 centers also prescribed prophylactic antibiotic therapy for dental procedures to prevent hematogenous contamination of the peritoneal cavity [57].
Effective diagnosis and treatment of peritonitis Prompt diagnosis and effective treatment of peritonitis are essential for quality care in a peritoneal dialysis program. A high percentage of no growth on dialysate cultures (58, 59] during the early years of CAPD stimulated research to improve the effectiveness of laboratory cultures. There is abundant evidence that special procedures are required to culture small numbers of bacteria diluted in dialysate. Culturing large amounts of fluid [60, 61] using filtration [58, 62] or centrifugation [62, 63] to concentrate the sample, and removal of antibiotics present in the specimen [61] have been shown to increase the proportion of positive cultures. Bint et al. [64] suggest that the rate of positive cultures in clinical peritonitis should exceed 90%. Williams et al. recommended the use of a cytocentrifuge for the differential white cell count [65]. The cytocentrifuge concentrates the cells in a small area on the slide so there are enough cells for an accurate differential count. Two expert committees have issued recommendations for treatment of
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40 peritonitis [61. 66] and reviews of peritonitis treatment has been published [67. 68]. In addition, Twardowski er al. [69] and the North American expert panel [61] have developed decision trees for the medical management of peritonitis episodes.
A bias for action Peters and Waterman found that the successful companies were not paralyzed by formal communications and procedures (1]. Employees from the top down communicated frequently and informally. Systems were simplified and evaluation of progress was based on a few key numbers. In addition, employees were encouraged to be innovative, and to experiment. Two of these qualities particularly apply to peritoneal dialysis programs: monitoring a few simple numbers, and encouraging innovation and experimentation. Evaluation of the incidence of peritonitis and characteristics of peritonitis episodes is a useful indicator of quality within a peritoneal dialysis program and should be continuously monitored. A simple ratio of peritonitis episodes over patient months exposure may be used to calculate the peritonitis rate or life table analysis may be used to determine the probability of the first (or subsequent) peritonitis episodes [70-72]. It is also of interest to compare infection rates for each type of peritoneal dialysis therapy and each type of peritoneal dialysis system which is used. Identifying the portal of entry (or presumed etiology) may help in identifying trends and developing strategies to reduce the incidence of peritonitis [59]. The incidence of exist site infection is also a useful indicator of the effectiveness of catheter placement and exit site care procedures. Although there is not a uniformly accepted definition of exit site infection in the literature, infection rates in a single program can be compared over time if the definition of exit site infection is consistent. Catheter removal and the reasons for peritoneal catheter removal should also be monitored. Patient survival and technique survival (the proportion of patients remaining on peritoneal dialysis therapy) determined by actuarial techniques should also be monitored as general indicators of program quality. Innovation and experimentation is probably a hallmark of most successful PD programs. We believe that all clinical research eventually results in improved patient care, whether from increased knowledge of physiology, improvements in patient assessment, development of new procedures, more effective education, improved documentation and communication, development of a new regimen or delivery system, development of new diagnostic techniques, alternative treatment methods, improved cost effectiveness, or identification of specific risk factors [73]. Participation in research can also enhance professional growth and increase job satisfaction resulting in improved staff retention for non-physician team members.
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Close to the customer
Successful companies provide unparalleled quality and service. They stay in touch with their customers, and many of their best ideas and innovations come from listening to the consumer [1]. These companies successfully satisfy the needs of their clients and "anticipate their wants". It seems to be a given that the members of a health care team will be close to the customer; however, this may not always be the case. A new nurse in our peritoneal dialysis program made the following observation after · a busy morning clinic: "There's a difference between the staff physicians and the residents and fellows in the way the communicate--with patients. The residents and fellows talk to the patients and tell them what they know; the staff physicians listen to the patients and find out how they're really doing." Although this example focuses on the physician, administrative staff and all professional team members need to spend time with patients, listening as they express their needs, and carefully evaluating their recommendations for improvements. • What are the patient's health-related goals? • Which problems or symptoms distress them most or interfere with their · activities? • What do they want to know? • What do they need to want from us? • Are there recom~endations or procedures that they do not follow? Why not? At each patient visit we should be certain that we have fulfilled not only our agendas, but have dealt with the perceived needs of the patient and family as well. A company also "stays close to the customers" by providing the services they want. There are many ways a peritoneal program can enhance patient services: • Offer flexible appointment scheduling • Return patient calls promptly • Provide a toll free number for patient calls • Arrange for repeat or additional laboratory tests to be done at a laboratory near the patient • Provide follow up clinics at satellites • Communicate effectively at hospital admission and discharge • Provide dialysis services in hospital One way to "anticipate the wants" of our patients is through the use of advance directives. At least one dialysis program has developed a formal patient education program on advance directives [74, 75] and all patients are offered the opponunity to complete the educational program and document their choices regarding the type of procedures they wish to undergo and designate an individual to make these decisions if they are unable.
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Peters and Waterman also point out that problems with .. product"" or service may be offset by caring [1]. On a recent patient satisfaction survey one of our patientS expressed dismay that the satellite unit near her home did not offer CAPD support. and that she could not be admitted to the local hospital because none of the nurses were trained to do peritoneal dialysis. In spite of this. she was quite positive about the dialysis unit. largely due to the ucaring .. she received...rm well pleased with all the services rendered to me by the nursing staff and the [other] personnel. ... I couldn't have been treated better." Measuring customer satisfaction is another hallmark of successful businesses. We recommend an annual evaluation of the quality of service using a survey or questionnaire. This must be written at an appropriate reading level and printed with a large hold typeface so as many patients as possible can read it. Another principle borrowed from good business practice is to conduct loss reviews. When a patient transfers to another dialysis program the reason needs to be identified and then the team should evaluate whether the transfer could have been prevented by changes in the structure or process or the level of caring.
Summary There are many facets to establishing and maintaining a peritoneal dialysis program. A comprehensive and integrated approach to building in quality, as recommended in this chapter, increases the chances for and degree of success.
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