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Improving Peritonitis Rates in the ISLHD Renal Service

Illawarra Shoalhaven Local Health District
Project Added:
27 January 2016
Last updated:
11 February 2016

Improving Peritonitis Rates in the ISLHD Renal Service

Summary

The renal unit at Illawarra Shoalhaven Local Health District (ISLHD) developed a structured home visit program and implemented changes to the staff orientation program, as well as training for patients and staff. 

Aim

To reduce incidents of peritonitis in patients treated with peritoneal dialysis (PD) by 50% within 18 months.

Benefits

  • Reduces hospital admissions and improves patient outcomes.
  • Increases the number of patients treated with home-based therapies.
  • Delivers cost reductions and process efficiencies within the ISLHD Renal Service.

Background

The NSW Health Directive states that 50% of patients requiring PD treatment should be on a home-based therapy. Prior to project implementation, 35% of patients at the ISLHD Renal Service received a home-based therapy. In 2014-15, 33% of patients who discontinued PD did so due to peritonitis. Improving the peritonitis rates will increase the length of time patients will stay on a home-based therapy.

Peritonitis is the leading complication of PD and can contribute to technique failure, hospitalisation and patient death. For PD to be effective, close attention must be paid to preventing PD-related infections. Literature suggests that peritonitis caused by staphylococcus is most likely linked with touch contamination. In 2014-15, 32% of peritonitis cases were caused by staphylococcus bacteria.

The ISLHD home dialysis training unit (HDTU) provides training and follow-up care for around 70-75 patients on community-based renal replacement therapy. Twenty patients have haemodialysis at home and around 50- 55 patients have PD.

In the last three years, the service has improved its clinical practice by developing a range of materials, including:

  • training manuals
  • patient competency standards
  • PD manuals with local policies and guidelines
  • educational materials for staff who deliver PD care in nursing homes, rehabilitation centres and regional hospitals.

Despite these practice improvements, collected data showed that prior to the project, the HDTU was still not meeting the standards set by the International Society for Peritoneal Dialysis. These standards are calculated as a percentage of patients per month who are peritonitis free.

ISLHD Peritonitis rates  
2014 data: International Society for Peritoneal Dialysis standard compared with ISLHD HDTU peritonitis rates.

 
In the financial year 2014-15, 32% of peritonitis cases were caused by staphylococcus bacteria.


 

Implementation

  • A calmer training environment was created, by dividing the room into home dialysis and PD areas.
  • The isolation room was changed into a treatment room for unplanned activity.
  • Patients were asked to wait in the waiting room, rather than walking into the training room and disrupting training.
  • A strict patient allocation process was implemented by staff.
  • An orientation guide and program was developed for new staff, including a generic orientation to ISLHD, a specific orientation for the HDTU and a home dialysis and PD skills assessment.
  • A structured home visit program was developed and is currently being implemented.
  • A patient survey and information sheet was developed and received ethics approval in December 2015. The objective is to get feedback from PD patients about their experience with peritonitis and training provided by staff.
  • A standardised approach to patient training will be implemented via participation in PD research projects, which will give staff the tools to train patients based on the principles of adult education.

Key dates

  • Project start: 1 July 2015
  • Project finish: 1 October 2016

Project status

  • Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.

Implementation sites

  • ISLHD Renal Service
  • Home Dialysis Training Unit (HDTU), Wollongong Hospital
  • HDTU nursing staff during clinic visits, home visits and phone consultations.

Partnerships 

  • Clinical Leadership Program

Evaluation 

An evaluation of each solution will take place following three months of implementation, with all solutions evaluated by October 2016. Results will be discussed with the project team and improvements to each solution will be developed and implemented as required.

 

Lessons Learnt 

  • The process of seeking ethics approval can be daunting if you are not familiar with it.
  • Data that aimed to provide a better understanding of the first episode of peritonitis was not collected, as there was a transition to a new medical records warehouse and information was spread out across multiple boxes.
  • It’s important to consider change management at all stages of the project and empower staff to make changes.

Further Reading

  1. 2013 Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) Annual Report
  2. Alcaraz M, Brzostowicz M, Moran J. Decreasing peritonitis infection rates. Nephrology Nursing Journal 2008; 35(4): 421-3.
  3. Evans LM. Peritoneal dialysis: one unit’s response to improving outcome and technique survival. Renal Society of Australasia Journal 2012; 8(3): 114-119.
  4. Zhang L, Hawley C, Johnson DW. Focus on Peritoneal Dialysis training: working to decrease peritonitis rates. Nephrology Dialysis Transplant 2015. doi: 10.1093/ndt/gfu403
  5. Bernardini J. Training and retraining: Impact on peritonitis. Peritoneal Dialysis International 2010; 30(4): 434-436. doi: 10.3747/pdi.2009.00244
  6. Bernardini J, Price V, Figueiredo A. ISPD Guidelines/Recommendations: Peritoneal Dialysis Patient Training 2006. Peritoneal Dialysis International 2006; 26: 625-632.
  7. Blake PG, Quinn RR, Oliver MJ. Peritoneal dialysis and the process of modality selection. Peritoneal Dialysis International 2013; 33(3): 233-241. doi: 10.3747/pdi.2012.00119.
  8. Tranter R, Cuesta AC, Ong S. Evaluation of a pre-peritoneal dialysis assessment and education programme. Renal Society of Australasia Journal 2014; 10(3): 112-115.
  9. Walker A, Bannister K, George C et al. KHA-CARI Guideline: peritonitis treatment and prophylaxis. Nephrology 2014; 19(2): 69-71.

Contact

Margreet Gutker
Nurse Manager, ISLHD Renal Service
Illawarra Shoalhaven Local Health District
Phone: 02 4222 5881
margreet.gutker@sesiahs.health.nsw.gov.au

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