Focus on peritoneal dialysis training: working to decrease peritonitis rates

Patient training has widely been considered to be one of the most critical factors for achieving optimal peritoneal dialysis clinical outcomes, including avoidance of peritonitis. However, research in this important area has been remarkably scant to date. This article will critically review the clinical evidence underpinning PD patient training and will specifically focus on four key areas: who should provide training and how, when and where should it be performed to obtain the best results. Evidence gaps and future research directions will also be discussed.

Using a multidisciplinary training program to reduce peritonitis in peritoneal dialysis patients

OBJECTIVES

The present study evaluated the tool used to assess patients' skills and the impact on peritonitis rates of a new multidisciplinary peritoneal dialysis (PD) education program (PDEP).

METHODS

After the University Hospital Ethics Committee approved the study, the educational and clinical records of PD patients were retrospectively analyzed in two phases. In phase I, an Objective Structured Assessment (OSA) was used during August 2008 to evaluate the practical skills of 25 patients with adequate Kt/V and no mental disabilities who had been on PD for more than 1 month. Test results were correlated with the prior year's peritonitis rate. In phase II, the new PDEP, consisting of individual lessons, a retraining schedule, and group meetings, was introduced starting 1 September 2008. Age, sex, years of education, time on PD, number of training sessions, and peritonitis episodes were recorded. Statistical analyses used t-tests, chi-square tests, and Poisson distributions; a p value of less than 0.05 was considered significant.

RESULTS

In phase I, 25 patients [16 men, 9 women; mean age: 54 ± 15 years (range: 22 - 84 years); mean time on PD: 35 ± 30 months (range: 1 - 107 months)] were studied. The OSA results correlated with peritonitis rates: patients who passed the test had experienced significantly lower peritonitis rates during the prior year (p < 0.05). In phase II, after the new PDEP was introduced, overall peritonitis rates significantly declined (to 0.28 episodes/patient-year from 0.55 episodes/patient-year, p < 0.05); the Staphylococcus peritonitis rate also declined (to 0.09 episodes/patient-year from 0.24 episodes/patient-year, p < 0.05).

CONCLUSIONS

The OSA is a reliable tool for assessing patients' skills, and it correlates with peritonitis rates. The multidisciplinary PDEP significantly improved outcomes by further lowering peritonitis rates.

Influence of peritoneal dialysis training nurses' experience on peritonitis rates

BACKGROUND

This study examined the clinical impact of peritoneal dialysis (PD) training nurses regarding Gram-positive peritonitis among incident dialysis patients.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This study included 200 consecutive inception PD patients in a single center from September 1999 through April 2003. Effects of PD nurse trainers on the clinical outcomes of Gram-positive peritonitis were evaluated.

RESULTS

A total of 81 patients of 200 incident PD patients (mean age 56.9 yr) developed Gram-positive peritonitis. Mean Gram-positive peritonitis-free time for patients who were trained by nurses with years of experience in the lowest tertile was 58.8 mo, as compared with 47.0 mo in those who were trained by nurses within the intermediate tertile of experience (log-rank test, P = 0.044). After adjustment for diabetes and relevant coexisting medical factors, PD trainers' having > or =3 yr of experience, body mass index, and baseline serum albumin were the only independent risk factors for the time to a first Gram-positive peritonitis. Training nurses with > or =3 yr of experience was associated with more than two-fold increased likelihood of subsequent Gram-positive peritonitis, with an adjusted hazard ratio of 2.24 (95% confidence interval [CI] 1.14 to 4.41; P = 0.020). When the lowest tertile group of trainers was used as the reference group in the Cox proportional hazards regression model, the hazard ratio was 1.94 (95% CI 1.04 to 3.61) for the intermediate tertile and 2.13 (95% CI 1.12 to 4.06) for the highest tertile. Experience of the PD trainers was not predictive of Gram-negative peritonitis.

CONCLUSIONS

The finding of negative association between the trainers' length of time in practice and peritonitis incidence reminds us that active continued learning and applying principles of adult learning might be the answers for the nurses to teach the patients.