Abstract
In the early days of continuous ambulatory peritoneal dialysis (PD), peritonitis was such a common event for patients that it was mockingly referred to as “continuous ambulatory peritonitis.” The challenge to determine the best treatment for peritonitis was surpassed by the challenge to determine the risk factors for peritonitis and to prevent peritonitis altogether.
As a result of years of extensive research in the field of PD, the risk of infection for PD patients is remarkably lower than in those early years and outcomes for patients are much improved. In the 1970s and 1980s, peritonitis was seen as often as once every 6 – 12 months in each patient, but is now reported in some centers as infrequently as once every 41 – 52 months, or 3.4 – 4.2 years (1-3). Thus, all steps taken to decrease patient risks are very significant to collectively improve patient outcomes. A recent review of the evidence for risk factors for peritonitis, both medical and non-medical, provides tangible steps to reduce infection (4). Unfortunately for patients, not all clinics apply evidence-based protocols and, as a result, many still report high peritonitis rates.
The study in this issue of Peritoneal Dialysis International, “Impact of the Bag Exchange Procedure on Risk of Peritonitis,” may seem on the surface to be a subject not likely to generate much attention (5). It is purely a clinical issue but deserving of scientific research if we are to continue the quest to reduce risks for patients. Despite all the technological advances in PD, there are still patients at home making a connection from their catheter to the solution, a moment when touch contamination erases all the other progress we had hoped for in preventing peritonitis. The authors began their study after patients were on PD 6 months, having determined that, after this amount of time on PD, the risk of peritonitis increases. It is not clear why patients experience more peritonitis after 6 months on the therapy but one can surmise that it may be because they have begun to take shortcuts or have simply veered off the prescribed steps they were so carefully taught at the start of PD. Educators tell us that repetition of tasks (or practice, as it is often called) causes the brain to learn both the cognitive and the physical steps. But there must be a point in time when imagination or cleverness allows slight changes in the procedure, and that is where patients get into trouble. So, while we do not know precisely why, we can certainly recognize that it happens and plan to retrain patients to help impose a renewed adherence to the connection procedure. This study demonstrated that, at the 6-month point, half the patients did not wash their hands according to procedure, nearly half did not check the bag for leaks, and 1 in 10 forgot to wear their mask.
In the only published study about retraining, a patient questionnaire and home visit found that 23% of 353 patients were found to be noncompliant with the exchange procedure (6). Noncompliance with PD protocols was significantly correlated to the incidence of peritonitis, with noncompliant patients 1.6 times more likely to develop peritonitis than those that were compliant. Patients needing retraining were those on PD less than 18 months or more than 36 months. This suggests, again, that after some relatively short period on PD, patients tend to not follow procedures as taught. And perhaps those on PD more than 36 months begin a different process of burnout, which promotes deviation from the required steps of procedures. The authors noted that “progressive modifications” were made by patients that considered themselves secure and expert in exchange procedures. Hand washing was incorrect in 6% and 9% did not wear a mask. False memory, a psychological mechanism, has been demonstrated in a pilot study of patient behavior (7). Patients demonstrated exchange techniques for nurses in which obvious mistakes were made but patients were unaware of their errors. So, while the reasons for noncompliance may not always be clear, the patterns indicate a need for retraining and home visits to reduce risks of peritonitis. In this study, the lowest rate of peritonitis (1 in 60 months, or 5 years) was in a unit with nurses dedicated exclusively to PD and where home visits were a regular part of patient care. The highest rate of peritonitis (1 in 20 months, or 1.7 years) was in a unit where PD nurses also cared for in-center hemodialysis patients and no home visits were made. While correlations between nurse:patient ratios and peritonitis rates were not reported, the data suggest that the more dedicated nurses one has in a PD unit, the more likely protocols will be implemented that reduce the risk of peritonitis.
What about the initial training of patients to reduce the risk of peritonitis? There is only one published study, involving 200 PD patients in Hong Kong (8). Paradoxically, they found that patients trained by nurses with more than 3 years of PD experience were twice as likely to have gram-positive peritonitis than patients trained by less experienced nurses. The association remained even when controlling for other potential risk factors for developing peritonitis. Thus, touch contamination is the likely risk behavior on the part of patients not properly trained. The authors speculate that nurses with less experience were more likely to have taught according to the principles of adult education, while nurses with more experience had not adapted to new training models, such as those indicated in the ISPD guidelines (9). Perhaps more experienced nurses were assigned more complex, high-risk patients, and this may account for the study results. The authors did not have the data to address this question. The study certainly indicates that ongoing efforts to prepare nurses to train patients and provide continuing education to update and improve teaching skills is an important part of a PD unit's responsibility. Far too many PD nurses are assigned to train patients but have little or no teaching preparation and are without an experienced mentor as recommended by the ISPD. An international survey found that only 23% of PD nurses had a formal background in adult education (10). The complexity of teaching patients is often overlooked, and many physicians, administrators, and nurses assume the skills will develop automatically. The reality is that, even with the best intentions, the results may be haphazard, inefficient, and ineffective. Experienced nurses need continuing education to improve their skills and not become complacent about learning new techniques and theories of learning.
Based on the small number of studies published, there are a few choices. We can prepare PD nurses to train patients using the principles of adult education and provide continuing education to hone their skills, and apply evidence-based and best-practice protocols to reduce the risks of peritonitis. We can retrain patients and make home visits, redirecting their behavior to reduce the risk of peritonitis, making sure there is sufficient nursing staff to implement these proactive protocols. Or we can wait until the patient makes mistakes and develops peritonitis. Reactive versus proactive: which will we choose for our patients? Who is willing to carefully study the effectiveness of training and retraining, randomizing patients to different models, and analyzing the most effective curriculum and duration of training or frequency of retraining? The majority of patients are trained for 5 or 6 days but there is no research to indicate if this is the best plan. Is there a minimum number of nurse: patient contact hours that is most effective in training? Who will research outcomes of home visits to help determine how often visits should be made? A Medline search of published PD studies in English, in humans, from 2006 through 2009, counted 2557 articles; 4 were on PD training. The need for further research seems clear.
Footnotes
The author is a consultant with Baxter Healthcare.