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Abstract of thesis entitled
An evidence-based patient education programme for reduction of peritoneal
dialysis-related infection
Submitted by
Lau Sai Kuk
For the Degree of Master of Nursing
At The University of Hong Kong
in July, 2013
Background:
End Stage Renal Disease (ESRD) is one of the commonest diseases in Hong
Kong. Patient with ESRD needs to start dialysis for life maintenance. Peritoneal
dialysis (PD) is the predominant dialysis modality for home dialysis patients. More
than 80% of dialysis patients in Hong Kong receive PD. However, it also brings out
some PD-related infectious complication such as tenckhoff exit-site infection,
tenckhoff tunnel infection and PD peritonitis. These complications markedly
contribute to treatment failure in PD patients. Especially PD peritonitis, it remains a
leading complication of PD. Also it is a main cause of patients switch to
haemodialysis (HD)and discontinue PD. Nevertheless, if the primary prevention of
PD education do better, research evidences have shown that peritonitis infection rate
of PD patients can be effectively reduced. It can be achieve by the utilization of
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effective education strategies and advanced training skills to enhance patients ’
knowledge and skills of peritoneal dialysis.
Purpose:
This written proposal aims to identify the best evidence of PD education and to
develop a guideline for this health education programme. The goal of the programme
is to reduce the rate of PD-related infection for patients who started PD treatment at
home after first CAPD training and education.
Method:
A total of 12 studies which focused on PD education and strategies for reducing
PD-related infections were searched from electronic databases. Data extraction and
critical appraisal were performed on these 12 studies. After the integrative review, the
implementation potential was assessed. The results shown that the transferability of
finding is high and it is feasible to conduct the proposed innovation. Then, the
evidence-based guideline for PD education programme were developed and based on
the high and medium level of evidence with grades of recommendation stated.
Before implementing the proposed innovation, a communication plan
was developed and targeted the various stakeholders (the administrators,
nurses, patients and their relatives). The proposer would initiate the change
and the programme leading group would guide and sustain the proposed
innovation.
The next process was planning a pilot study to examine the feasibility of the
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proposed innovation before implementation.
Finally, different outcomes of the programme has been identified and evaluated
in the evaluation plan. The methods for data analysis were formulated.
Conclusion:
The proposed peritoneal dialysis education programme with best evidences
support is worthy to be adopted in the clinical setting for the beneficial of PD patients
to reduce their PD-related infectious complications.
4
An evidence-based patient education programme for reduction of peritoneal
dialysis-related infection
by
Lau Sai Kuk
A thesis submitted in partial fulfillment of the requirements for
the Degree of Master of Nursing
at The University of Hong Kong
July, 2013
5
Declaration
I declare that the thesis and the research work there of represents my own work,
except where due an acknowledgement is made, and that has not been previously
included in a thesis, dissertation or report submitted to this University or to any other
institution for a degree, diploma or other qualifications.
Signed............................................................................
Lau Sai Kuk
6
Acknowledgements
I would like to express my gratitude to my supervisor Professor Agnes Tiwari
for her expertise suggestions and guidance throughout the preparation of this thesis. I
also want to express my thanks to Dr. William Li, Dr. Daniel Fong and all staffs of
HKU School of Nursing for their helping and teaching during my master study.
Lastly, I must offer my heartfelt thanks to all my classmates of the programme:
Master of Nursing for their support in my project.
7
Table of Contents
Declarations................................................................................................................ 5
Acknowledgements.....................................................................................................6
Table of Contents........................................................................................................7
Appendixs................................................................................................................... 8
Abbreviations..............................................................................................................9
CHAPTER 1 Introduction......................................................................................10
1.1 Background......................................................................................................11
1.2 Affirming the Needs....................................................................................... 11
1.3 Question, Objectives and Significance........................................................... 15
CHAPTER 2 Critical Appraisal.............................................................................17
2.1 Searching and Appraisal Strategies................................................................ 17
2.2 Result.............................................................................................................. 20
2.3 Summary of Findings......................................................................................25
2.4 Synthesis of Findings......................................................................................27
2.4.1 Evidence-based recommendations.........................................................28
CHAPTER 3 Implementation potential
3.1 Target Setting..................................................................................................30
3.2 Target Audience..............................................................................................30
3.3 Transferability of the proposed programme................................................... 31
3.4 Feasibility........................................................................................................34
3.5 Cost Benefit ratio of the innovation................................................................36
CHAPTER 4 Evidence-based Practice guideline.................................................. 37
4.1 Guideline Title................................................................................................ 37
4.2 Aims of establishing the guideline..................................................................37
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4.3 Intended Users................................................................................................ 37
4.4 Target Patients................................................................................................ 38
4.5 Primary outcome consideration...................................................................... 38
4.6 Recommendations...........................................................................................38
CHAPTER 5 Implementation plan........................................................................43
5.1 Communication plan.......................................................................................43
5.2 Pilot testing plan............................................................................................. 47
CHAPTER 6 Evaluation plan................................................................................ 49
6.1 Nature and number of clients to be involved..................................................49
6.2 When and how often to take measurements................................................... 50
6.3 Data analysis...................................................................................................50
6.4 Effectiveness of the guideline.........................................................................55
CHAPTER 7 Summary..........................................................................................55
Appendices
Appendix 1 Table of evidence.....................................................................58
Appendix 2 Quality assessment of studies...................................................63
Appendix 3 Search result in databases.........................................................87
Appendix 4 Level of evidence.....................................................................88
Appendix 5 Comparison of demographic data............................................ 89
Appendix 6 Estimated cost.......................................................................... 90
Appendix 7 Coding system of level of evidence......................................... 91
Appendix 8 Grades of recommendation...................................................... 92
References.................................................................................................................93
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Abbreviations used in the study
APD Automated Peritoneal Dialysis
CAPD Continuous Ambulatory Peritoneal Dialysis
ESRD End-Stage Renal Disease
ESRF End-Stage Renal Failure
HA Hospital Authority of Hong Kong
HD Haemodialysis
K/DOQI Kidney Disease Outcomes Quality Initiative
PD Peritoneal dialysis
SIGN Scottish Intercollegiate Guidelines Network
RCTs Randomized Controlled trial
RRT Renal Replacement Therapy
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CHAPTER 1
Introduction
Renal failure is a continued deterioration of renal function in which too low to
sustain normal life. These people will receive Renal Replacement Therapy (RRT) in
the form of renal transplantation or dialysis in developed countries. Patient with
End-Stage Renal Disease (ESRD) needs to start dialysis for life maintenance.
Peritoneal dialysis (PD) is the predominant dialysis modality for home dialysis
patients. It is the most widely used treatment for End-Stage Renal Failure (ESRF)
patients in Hong Kong. Continuous Ambulatory Peritoneal Dialysis (CAPD) is a
well-established mode of dialysis (Lo, 1998). But, it also brings out some PD related
infectious complication such as tenckhoff exit-site infection, tenckhoff tunnel
infection and PD peritonitis. These complications markedly contribute to treatment
failure in PD patients. (Gertrude, 2009) Especially PD peritonitis, it remains a leading
complication of PD. Also it is a main cause of patients switch to haemodialysis
(HD)and discontinue PD. Therefore, the PD expert continues to focus attention on
treatment and prevention of PD-related infectious complications. The ongoing rates of
infectious complications of home PD patients are also the key performance index of a
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PD education programme. This study focus on CAPD which is the majority of PD
modality (92%) in Hong Kong and purposes to summarize various modern strategies
of patient education for CAPD patients, so as to gather the best evidence to enrich the
patient education programme which aims to reduce the local rate of CAPD related
infections.
1.1 Background:
ESRD is an incurable, life-threatening chronic disease. The prevalence rate of
ESRD in Hong Kong 2009 was 1078.8 patients per million populations (pmp) (HK
renal registry report 2010). Nearly 93% of the RRT are provided by the Hospital
Authority of Hong Kong (HA). All new patients need RRT begin with CAPD unless
there are contraindications to do so. The PD came first policy of Hong Kong results a
large portion (81.5%) of dialysis patients managed by PD. The remaining (18.5%)
patients receive HD treatment at HA renal centers. Among PD patients, a majority of
92% by CAPD. The remaining 8% PD patients by Automated Peritoneal Dialysis
(APD) which PD is achieved by the operation of a programmed PD machine (Lui et al.
2005). More than 80% of RRT patients with reports on rehabilitation were active and
had normal activities (Hong Kong J Nephrol, 2010)
1.2 Affirming the Needs:
12
CAPD training is an important element of a peritoneal dialysis programme to
prepare patients or their helpers to perform home CAPD. CAPD was achieved by
means of twin bags disconnect systems (Baster Healthcare) with lactate buffered
dextrose containing dialysate solutions. Home CAPD training is provided by renal
nurse whom was being trained as a trainer. No selection of patient by nurse can be
made since the allocation of patient to trainer is by rotation. CAPD training started
about 4 weeks after the implantation of a tenckhoff PD catheter. The location of PD
training is at the renal dialysis clinic. Usually last for 5 hours a day on average. The
total time spend for training depends on the learner. The trainer should determine the
learners have achieved the minimum objectives set by the programme. If a patient is
incompetent of self-care and cannot perform CAPD, a member from his/her family
will be needed for assistance. This helper must understand the procedures and be
ready to help voluntarily, whose assistance must not be stopped abruptly or taken over
by another person. In the present time, none of any standards were issued to guide the
educational process. The current routine home CAPD training programmes in Hong
Kong were very briefly train the patients or their assistant helper (or both) the
procedures of CAPD bag exchange. Nurses first explain the theory and demonstrated
the bag exchange technique. Patient can practice several times using a dummy as a
13
teaching aid. Emphasis put on the non-touch technique involved and successful return
demonstration of bag exchange procedures. Usual education program also included
knowledge of end stage renal disease, different modality of treatment, principle of
CAPD, nutrition and dietary advice, signs and symptoms of complication, infection
control at home and common troubleshooting solution. An individual one to one
dietary counselling session will also offer to patient. Video CD and reading materials
were free to provide to patients or their caregivers. In Hong Kong, the ratio of training
nurse to patient is from 1:1 to 1:2 depends on manpower of staffing. Although
different learners have different learning abilities, memory, and motor skills, they
might not finish PD training at the same time. Actually, training is tailored for each
patient or helper as in 1:1 teaching model, the one with slower would be coached
individually after the first one finished training. A home visit will arrange after the
first month of training but further home visit is not a routine. The needs of retraining
are identified by physicians or by nurse specialists for suspected improper PD
exchange technique as a result causing PD peritonitis.
The overall CAPD peritonitis rate in Hong Kong was 31.8 patient-months per episode
in 2009 ( i.e. the average time taken for all CAPD patients in Hong Kong to get one
episode of PD peritonitis is 31.8 months). The most common type of PD peritonitis is
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Gram-positive peritonitis. It is usually caused by contamination of the disconnect
system which is a technique related factor. In short term, during the incident of
peritonitis, patients will experience excessive pain and may require hospitalization. In
a six-year retrospective study involving 101 incident patients on PD in which patients
were hospitalized for peritonitis, 65% were hospitalized, with a mean length of stay of
8.7±7 days (Lecame, 2006). Mortality from peritonitis is 7% to 10%, and
approximately 40% to 45% of patients transfer to hemodialysis as a result of
peritonitis (Vargemezis & Thodis, 2001). Peritonitis is a major contributor to
technique failure along with psychosocial factors, catheter-related problems, and
difficulties with clearance and ultrafiltration (National Kidney Foundation, 2006).
Technique failure occurs when patients discontinue PD for reasons other than death or
transplantation. Although sclerosing peritonitis is rare and is associated with
long-term PD, the mortality rate has been reported to be as high as 37.5% (Kawanishi,
2004). Repeated episodes of peritonitis can cause damage to the peritoneal membrane
by increasing membrane permeability and reducing ultrafiltration. These effects on
membrane transport can persist for years. Peritonitis has been shown to be an
important predisposing factor (Brown, 2005). The peritonitis rate is a suggested
domain for ongoing monitoring (National Kidney Foundation, 2006) Updated Kidney
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Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for PD
state that home-training providers should establish a quality improvement program
with the goal of improving patient outcomes..
1.3 Questions, Objectives and Significance
Questions
(1) What is the evidence that CAPD patient education can improve patients’ PD
knowledge and technique so as to reduce the rate of PD-related infections?
(2) How effective of a structured CAPD training programme in reducing the rates of
PD-related infection?
Objectives:
1. To evaluate and search the modern research findings on CAPD training or
education programme.
2. To investigate and incorporate the most effective evidence based interventions.
3. To summarize data from studies and create evidence tables and carry out quality
assessment.
4. To synthesize the summarized data.
Significance:
Home CAPD patients are perform PD bag exchange and tenckhoff catheter care
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by patients themselves or their helpers. PD peritonitis is the main cause of technique
failure, hospitalization and even mortality in PD patients. It remains the most common
complication in PD patients’ society. If left untreated, peritonitis can result in sepsis
and death. Research data show that 15% of deaths in PD patients can be primarily
attributed to peritonitis. Exit-site infection and tunnel infections are also considered
serious infections and independently predispose patients to PD peritonitis and its
consequences. Published peritonitis rates vary from 16 to 30 patient-months per
episode. Due to an increase in the proportion of unusual and complex infections over
the past decade, up to two third of PD patients with peritonitis need hospitalization.
The major cause of PD peritonitis is being contamination during a PD bag exchange.
Given that peritonitis can be prevented by strengthening training in connection
techniques and exit-site care. Training patients to manage PD safety is thus crucial for
the success of treatment modality. A structured training programme can also facilitate
the job of nursing staff, help them to conduct programme efficiently, consequently
enhanced staff morale.
17
CHAPTER 2
Critical Appraisal
2.1 Searching and Appraisal Strategies:
2.1.1 Electronic databases and search keywords
Based on the clinical questions identified above, a systematic review is
conducted and targeted to answer the above clinical questions. The primary outcome
of interest was focus on PD peritonitis. The secondary outcomes included: exit-site
infection, tunnel infection, PD exchange technique and infection control. The
following computer databases were used to identify studies for this systematic search:
CINAHL (1982 to May 2012), MEDLINE (1950 to May 2012), PsycINFO (1806 to
May 2012), PubMed (1901 to May 2012) and British Nursing Index (1994 to May
2012). The citation lists and reference lists of those high quality studies are manually
screened to identify more relevant studies that meet the inclusion criteria. The
inclusion and exclusion criteria were checked against with those abstracts to obtain
suitable English references. The methodological quality and the results of the
reviewed studies are then analyzed to obtain the best evidence on which types of
educational intervention have most effect on reduce CAPD related infectious
18
complications for local Chinese patients.
Keywords and medical subject heading use included: ‘peritoneal dialysis’,
‘program’, ‘training’, ‘education’, ‘CAPD’, ‘intervention’, ‘peritonitis’, ‘exit-site
infection’, ‘complication’, ‘infection prevention’, ‘tunnel infection’, ‘technique’,
‘mortality’ and ‘assessment’. There is no restriction of the language used by any
journal.
All these keywords used are interchangeably or used alone. A huge number of
papers obtained when searched by using the major keywords. But it has been lessened
when confined to CAPD peritonitis, CAPD patients, exit-site infection and tenckhoff
tunnel infection.
2.1.2 Inclusion and exclusion criteria:
Type of studies: Abstract indicated that the article appears to inform one or more of
the search questions. The search for best evidence on clinical outcomes was originally
focused on systematic reviews and randomized clinical trials (Melnyk and
Fineout-Overholt 2005). However, there are limited such papers on the effectiveness
on reducing PD related infectious complications. Therefore, case-control studies,
cohort studies were also included to fulfill some particular area of the education
programme. But conference proceedings, dissertation theses, unpublished studies or
19
descriptive studies of lower levels of evidence are excluded. Finally, papers which are
not written in English are also excluded because of difficulties in comparing the result
in different languages.
Type of participants: Patients already undergoing home CAPD or prepare to home
CAPD are included to enhance the generalizability of the interventions. Patients
performing home APD which using automated PD machine were excluded because
they involve different kind of training programme.
Type of interventions: Any set of training or educational activities designed to reduce
patients’ risk of PD related infectious complications as a nursing intervention are
included. Those interventions can be compared with conventional PD training
programme.
Type of outcome measure: The outcome measure of the clinical question is reducing
PD related infectious complications. Studies which outcomes other than improvement
of PD related infectious complications were excluded.
2.1.3 Quality Assessments of the Studies:
The evaluated grading of the level of evidence for interventions included in
those studies are performed (See appendix 4). The level of evidence was categorized
into 7 levels. Level I is the highest, level IV is the median and level VII is the lowest
20
by Melnyk and Fineout-Overholt (2005). They represent the quality of evidence ready
for select outcomes in the definite populations of interest. Among the twelve studies,
two were at level II, nine were at level III and one was at level IV of evidence.
The quality of the studies was assessed with the aid of a set of appraisal checklists
offered by Scottish Intercollegiate Guidelines Network 2012 (SIGN). Various
methodology checklists provided by SIGN to assess different methodological research
approach, such as systematic reviews and meta-analyses, randomized controlled trials,
cohort studies, case-control studies and diagnostic studies. The quality of a research
study can be justified by answering the questions set in the particular checklist. The
checklist also mentioned some critical criteria that a study should be met; otherwise
the study should be rejected.
Details of quality assessment content of this study were tabulated in appendix 2.
2.2 Results
The initial clinical evidence search was carried out on May 2012 to August
2012.
Keywords of peritoneal dialysis, program, training, education, CAPD, intervention,
peritonitis, exit-site infection, complication, infection prevention, tunnel infection,
technique, mortality and assessment were input into the database of CINAHL,
21
MEDLINE, PsycINFO, PubMed and British Nursing Index. It created a huge numbers
of search results in each of the database. When linked up all the main keywords, there
are totally 700 papers with full text available in all five databases. When limited to
inclusion criteria and absence of exclusion criteria, there are totally twenty-three
papers left and among eleven papers were duplicated. (Appendix 3)
Total twelve studies were selected after the systematic search. Data of each study
were extracted to form respective tables of evidence.
(See appendix 1)
All twelve studies had a sample size ranged from 30 to 620.
The length of follow-up ranged from 12 to 48 months.
2.2.1 Participants’ characteristics
All adult male and female patients of no mental disabilities are included. They
all got ESRD and underwent PD (CAPD or APD) or new patient whom prepared to
receive PD treatment. No matter self care or need assistant.
2.2.2 Interventions Used in the Reviewed Studies
Hall, (2004) suggested the use of adult learning theory-based curriculum for PD
training. Casey, (2000) suggested the routine daily application of mupirocin cream
which is a prophylactic antibiotic ointment to reduce tenckhoff catheter related
22
infections. Figueiredo, (2000) studied the effectiveness of PD peritonitis prevention
by put on a face mask during PD exchange procedure. Bernardini, (2005) suggested
the application of gentamicin cream which is more powerful than mupirocin cream as
a routine daily prophylactic agent. Gadola, (2012) introduced an Objective Structured
Assessment tool to test patients’ post CAPD training skills which can identify the
patient who are at higher risk of getting PD peritonitis. Moreover, Gadola, (2012) also
introduced a new multidisciplinary peritoneal dialysis education program (PDEP)
which can further lowering peritonitis rates. Chen, (2008) introduced a post PD
training test which helps to evaluate the learning process and provides immediate
feedback to the learner. Prasad, (2006) addressed the importance to maintain a good
nutritional status of CAPD patients against PD peritonitis. Dong, (2010) emphasized
the bag exchange procedure on risk of PD peritonitis. Mawar, (2011) emphasized the
importance of CAPD procedure compliance with increase risk of PD peritonitis. Xu,
(2011) raised PD training to patient or helper is of similar PD related infectious
outcomes. Therefore assisted PD is a good option for patients with poor self care
ability. Barone, (2011) concluded that patients with higher educational level will have
lower risk of PD peritonitis. Despite patients with lower educational level receive
longer training time. Chow, (2007) raised the importance of active continue learning
23
of PD nurses him/herself and apply adult learning principles to enhance CAPD
training.
2.2.3 Outcome Measures Used in the Reviewed Studies
Six studies were used peritonitis rates as the primary outcome measure. (Hall,
2004 ; Casey, 2000 ; Bernardini, 2005 ; Gadola, 2012 ; Chen, 2008 ; Barone, 2011).
Three studies were used peritonitis free period as the primary outcome measure.
(Figueiredo, 2000 ; Prasad, 2006 ; Xu, 2011). Two studies were used harzard ratio of
PD peritonitis as the primary outcome measure. (Dong, 2010; Chow, 2007) One study
was used the association with peritonitis and association with frequency of peritonitis
as the outcome measures (Mawar, 2011). Three studies were used exit-site infection
rate as the secondary outcome. (Hall, 2004 ; Casey, 2000 ; Chen, 2008). One study
was used tunnel infection rate as the secondary outcome (Chen, 2008). One study was
used mortality rate and survival time as the secondary outcome (Xu, 2011).
2.2.4 Randomization
Two studies reported patients were randomized (Figueiredo, 2000; Bernardini,
2005). Only one study specifies the randomization process. A randomization list was
generated by using a computer random-number generator (Bernardini, 2005).
Randomization eliminates the source of bias in treatments assignment; facilitates
24
blinding the type of treatments to investigator, participants and evaluators (M.
Saghaei, 2004). In this study, a few papers were randomized. Since four papers were
retrospective studies (Gadola, 2012; Chen, 2008; Barone, 2011; Chow, 2007) and one
paper was cohort study (Xu, 2011), randomization seems to be impossible. Three
papers of their participants have some specified characteristics such as malnutrition or
PD treatment more one and a half years (Mawar, 2011; Prasad, 2006; Dong, 2010).
Two papers had not specified the allocation of participants (Hall, 2004; Casey, 2000).
2.2.5 Blinding
Double blinded was used in the study Bernardini, (2005). Four other studies
were reported to use single blind that patients did not know to which group they
belong (Hall, 2004; Gadola, 2012; Prasad, 2006; Mawar, 2011).
2.2.6 Intention to Treat Analysis
Ten studies reported that data was analysis with the utilization of intention to
treat (Hall, 2004; Casey, 2000; Bernardini, 2005; Gadola, 2012; Chen, 2008; Prasad,
2006; Dong, 2010; Mawar, 2011; Barone, 2011; Chow, 2007). The high dropout rates
of some studies were being taken into consideration for data analysis.
2.2.7 Setting
Eleven studies were carried out at renal clinics or centers. Only 1 study was
25
carried out at different patients’ home during home visit (Mawar, 2011). Among the
eleven studies, two were carried in multi-centers (Hall, 2004; Bernardini, 2005); Nine
were carried out in a single center (Casey, 2000; Figueiredo, 2000; Gadola, 2012;
Chen, 2008; Prasad, 2006; Dong, 2010; Xu, 2011; Barone, 2011; Chow, 2007).
2.3 Summary of findings:
Twelve studies which published from 2000 to 2012 were selected. There are
two randomised control trials (Figueiredo, 2000; Bernardini, 2005). One longitudinal
quasi-experimental design study (Hall, 2004). One prospective historically controlled
study (Casey, 2000). Three prospective observational study (Prasad, 2006; Dong,
2010; Mawar, 2011). Two retrospective observational studies (Chen, 2008; Chow,
2007). Two retrospective analysis studies (Gadola, 2012; Barone, 2011). One
prospective cohort study (Xu , 2011).
Among those twelve studies, three of them carried out in USA (Hall, 2004;
Casey, 2000; Bernardini, 2005). Two were conducted in India (Prasad, 2006; Mawar,
2011). Other two were conducted in Republic of China (Dong, 2010; Xu, 2011). The
remaining were came from Brazil (Figueiredo, 2000), Taiwan (Chen, 2008), Uruguay
(Gadola, 2012), Argentina (Barone, 2011) and Hong Kong SAR (Chow, 2007)
respectively.
26
Related to the details of training programme, two studies emphasis the structure
of the programme is more important than the experience of training nurses (Hall, 2004;
Chow, 2007).
Short of description of the study’s methodology presented in few studies, for
instance, blinding was not tackled, only few with allocation concealment mentioned.
However double blinding is not an easy job as being assigned into a training
programme is obvious.
Two retrospective observational study and three prospective observational
study were regarded as relatively low level of evidence (Prasad, 2006; Dong, 2010;
Mawar, 2011; Chen, 2008; Chow, 2007); with higher risk of bias. The lack of
randomization can make selection bias; and do not use the strategy of intention to
treat for data analysis. On the whole, most of appraised studies achieved an
appropriate p-value (<0.05) except Chen, (2008). Therefore most results were
statistically significant. All high quality studies supported to initiate programme at
outpatient centers, which in accordance with the nature of CAPD clients as they are
not in-patient. Eight studies supported one to one, nurse to learner training programme
(Hall, 2004; Gadola, 2012; Chen, 2008; Dong, 2010; Mawar, 2011; Xu, 2011; Barone,
2011; Chow, 2007). Although Chow, (2007) supported one to one PD training, their
27
center still running one to two training practice owing to staffing limit at their center.
The duration of training session ranged from 4 to 5 hours. The total training
time vary from 22.6 to 40.0 hours depend on the learner’s ability (Hall, 2004; Chow,
2007; Chen, 2008). Barone, (2011) study the number of PD training lessons received
by patients in relation to peritonitis rates. But the time duration of each lesson was not
specified.
Long follow-up period >4 years was not recommended, moderate follow-up
around 18 months is advised. All PD programme in studies consisted of similar
components such as lessons, video show, booklets and video CD delivery.
Figueiredo, (2000) found out from their study that wear a facial mask during PD bag
exchange procedure was no significant different in peritonitis incident rate with no
mask while Dong, (2010) stated that the hazard ratio of peritonitis if not wearing a
mask was 7.26 (P<0.001). The main different may be due to all patients in Figueiredo,
(2000) study were well prepared to do the bag exchange except not wearing a mask.
But patients in Dong, (2010) study were being assessed various bag exchange
procedures including put on mask, hand washing, steps to connect and disconnect the
bag etc. That may lead to confound the outcome of the study.
2.4 Synthesis of findings
28
Preventing peritonitis through training is an effective approach. It is critical for
patients to adhere the proper technique of PD bag exchange procedure to prevent
peritonitis when utilizing CAPD. Demonstration and return demonstration are good
practice of CAPD training. The adult learning teaching strategies is a successful way
to implement education and training programme. Learning direction has been changed
nowadays. It should be focus on what the learner needed to learn rather than on what
the teacher needed to teach (Hall, 2004). Other approach, such as retraining, skill
updating, written tests, post training assessment or direct observation of patients’
technique are worthy to incorporate in the PD training programme. Renal nurses
training, support providing, individual patient monitoring and continuing connection
are directly contributed to the success of an education programme.
2.4.1 Evidence-based recommendations
After the first month of post CAPD training, weekly clinic follow-up should be
arrange to assess the patients’ performance of bag exchange technique until the whole
procedure is performed smoothly. Home visit is suggested within the first month of
post CAPD training. This is to prevent patients to develop any shortcut of bag
exchange procedure since this time interval is most likely for patients to do so. More
detailed and frequent peritonitis reviews decrease the overall peritonitis rates.
29
Semi-annual patient reviews are also important since patient is time for change a new
transfer set (transfer set of tenckhoff catheter should be change by renal nurse every
six months). Assessment of PD exchange sequence, technique reinforcement and
written test can be done during the peritonitis review. Details of the written test
should assess the patient’s cognitive response to some common CAPD problems that
will encountered at home.
The routine daily application of prophylactic antibiotic cream at tenckhoff
exit-site is an effective way to reduce catheter related infections.
It should be emphasize in the CAPD self-care education session. Especially for those
patients with diabetes mellitus, malnutrition or frequent PD peritonitis whom are
higher risk for PD infection.
An objective structured assessment tool should be introduced to guide the post
CAPD training assessment process (Gadola, 2012). It was specially designed to
evaluate only practical skills but not knowledge demonstrated by patient. The
evaluated result directly reflected the learner’s skill of bag exchange and
troubleshooting behavior. The step by step assessment can facilitate nurses to identify
the learner’s week points promptly and give immediate feedback.
30
CHAPTER 3
Implementation potential
3.1 Target Setting
The programme will be implemented in a public hospital situated at New
Territories of Hong Kong. It is an acute hospital with a designed capacity of 1,915
beds. The programme will be carried out in the renal unit of the hospital. The unit
consists of one renal subspecialty ward and one integrated renal centre which both
occupied ~10000 square feet area respectively. The renal subspecialty ward offers
50-60 hospitalization beds for renal disease patients and the integrated renal centre
offers Monday to Saturday day services for daily ~50 haemodialysis patients; 2
automated peritoneal dialysis patients; 2-4 patients receive peritoneal dialysis
education and training; renal nurse-led clinic; pre-dialysis renal assessment; and fast
track clinic for renal patients.
3.2 Target Audience
The target audience included the patients over 18 years old and was confirmed
to be suitable for home CAPD after pre-dialysis renal assessment and their related
home helper if any. Those patients who frequently got PD related infectious disease
31
and need retraining are also included.
3.3 Transferability of the proposed programme
Transferability refers to the degree to which the results of the selected studies
can be generalized or transferred to a new target context or setting. The study
situation must first compare with the specifics of the environment or situation which
we are familiar. If there are enough similarities between those study situations, it will
be able to infer that the results of those studies can be transfer to our context. To do
this effectively, these is a need to consider the similarities of the patients’
demographic data, clinical settings, amount of audiences and cultural differences. The
table of comparison on the similarities between the research studies and the target
population is shown in appendix 5. The disease nature of both target and study
populations are the same. Their demographic data such as the mean age and gender
ratio are similar. Those are adult patients with end stage renal disease that need
peritoneal dialysis. Most studies carried out in renal centre setting which match to the
proposed programme except one study that evaluates patients’ PD exchange technique
in patients’ home during home visit. But the same evaluation procedure can also be
done in a renal centre setting. However, the main difference would be the cultural
factor. Six out of twelve studies were carried out in Western countries like USA;
32
Brazil and Argentina. But, the remaining six studies were initiated in Asian areas such
as Taiwan and Republic of China. One study was a local one. This may greatly help to
strengthen the transferability of study findings to our local setting.
Moreover, the research studies share similar philosophy of care with our
hospital. Those researchers aim at improving and providing high quality and standard
of care by utilization of evidence-based findings to maintain clients’ health while our
hospital provided not only the best-possible services to cure our patients, so they will
not have to be readmitted, and secondly enable outpatients to enjoy the best-possible
health and quality of life. Its mission is to empower patients to regain their health and
stay healthy by offering support in the forms of medication, information, training,
education, encouragement and motivation. As well as continuously service quality
and safety improvement and build up a people-first culture.
Besides, the aim of the proposed programme shared the same objective of all
twelve research studies. That is: ‘to reduce the chance of peritoneal dialysis-related
infection of PD patients through an evidence-based education programme’ (Hall,
2004; Casey, 2000; Figueiredo, 2000; Bernardini, 2005; Gadola, 2012; Chen, 2008;
Prasad, 2006; Dong, 2010; Mawar, 2011; Xu, 2011; Barone, 2011; Chow, 2007).
Concerning the number of clients who could benefit from the programme, there
33
are 85; 92; 105 and 113 newly diagnosis ESRD patients in 2007; 2008; 2009 and
2010 year respectively of received PD education in our hospital. About 16% of total
Hong Kong newly started PD treatment patients every year, and the trend is
increasing. In addition to about 650 CAPD patients currently follow-up in our hospital,
among one thirteenth of that patients need CAPD retraining. Therefore, a significant
number of patients could benefit from the proposed programme.
Before the implementation of the programme, a 60-minute orientation training
session must be given to every renal nurse who response to educate and train patients.
We have 21 renal nurses in total who are eligible to conduct patient education. But
every week our unit only assigns 2 renal nurses responsible only for the task of CAPD
education and training. Therefore, the programme can start after the 2 renal nurses
have been trained. The remaining nurses can be orientated at any time when they are
not very busy during duty hours. The programme also takes place in the education
room of the integrated renal centre as mentioned before. It doesn’t need to make any
change. But a new guideline, new education contents and new assessment form must
be prepared prior to implementing the proposed programme. The evaluation process
may take up to one year because it takes time to follow-up all patients who have
undergone the programme to see if they have any undesirable PD related infectious
34
complications.
3.4 Feasibility
To assess the feasibility of the proposed project, some major concern must be
considered. For example, the support of administration team, the freedom of nurses to
carry out the innovation and the view point of patients and their care givers. Other
aspects such as available of resources, sufficient of manpower, resistance or friction
arises, readiness of necessary equipment and facilities, consensus among staff and
likely interfere with the current functions of staff need to be taken into account too
and are likely to be easier to overcome and resolve.
For the administration team of the hospital, they usually delegate the
management to the head of each department. For the renal team, the head of our unit
is a consultant physician. He usually welcomes any innovation which can improve the
quality of services of the unit provided that the proposed programme does not violate
the mission of the hospital. Our unit also preserves a certain amount of the budget
every financial year for initiation of various kinds of programme to improve our
services, such as specialty nurses home visit programme, phone follow-up programme
and physical exercise to improve renal patients’ quality of life programme, etc.
For the nurses, they have the autonomy to carry out the innovation or not. Even
35
though the proposed programme may be approved by the team head and unit
manager, nurses still have the freedom to decide whether or not to carry out the
innovation using their own professional judgment. Moreover, the proposed
programme is carried out entirely by nursing staff and does not involve any other
allied health care profession. Therefore, there are no collaborative problems with
other disciplines.
For the patients, CAPD training and education is a compulsory process. Patients
or their care givers must pass the necessary training before they are allowed to start
CAPD treatment at home. Since there is no existing evidence-based education and
training guideline in our hospital, a structured evidence-based guideline will certainly
facilitate their learning. Clients should be able to undertake the training because it is
flexible in terms of the hours of training. It vary from 22.6 to 40.0 hours depends on
learning ability of each client (Hall, 2004; Chow, 2007; Chen, 2008). According to
some feedback of former CAPD learners, they were more concern about the final
successful learning rather than the time spent to learn. They know that there is a long
way for them to wait for renal transplant and the most imminence matter is to learn
home CAPD to sustain their life. Therefore, most clients were very appreciating and
willing to try any innovative teaching strategies that offer by renal nurses. This is also
36
the consequence of the trustworthiness relation between renal nurses and renal
patients.
3.5 Cost Benefit ratio of the innovation
Before the implementation of the innovation, a cost-benefit analysis should be
performed. The following questions should be considered: What is the minimal cost
to achieve the programme? Will benefits outweigh cost? How soon will the benefits
accrue?
Consider the tangible costs and benefits to implement the innovation, the total
expenditure to carry out the programme is HKD $10,222. (Appendix 6) All the
expend is one-time budget, no recurring cost. Furthermore, the ongoing expenditure
was just same as the current one. All nursing staff, setting, training room, facilities
remain the same. Even the evaluation process has no change. It is to statistically
analysis all PD patients who follow-up in our hospital of their yearly PD related
infectious complications rates in terms of ‘patient-month per episode’. According to
the rationale of translational research, the evidence-based intervention is also effective
after being transferred to another similar situation. If the incident rate lowered for 1
patient-month per episode, it will reduce 42.4 hospitalization days in our hospital.
Assume that the peritonitis rate of our hospital (2010) was 38.4 patient-months per
37
episode, total PD patients (2010) were 634. If the non-subsidy charge of daily
hospitalization fee is $3,300 per day, then the hospital will save
$3,300x42.4=$139,920 per year. The overall peritonitis rate of CAPD patients in
Hong Kong (2009) was 31.8 patient-months per episode (HK renal registry report
2010) which is largely greater than our hospital.
CHAPTER 4
Evidence-based Practice guideline
4.1 Guideline Title
A nurse-delivered education programme for reduction of peritoneal
dialysis-related infection.
4.2 Aims of establishing the guideline
1. To summarize research evidence on CAPD training and education programme.
2. To formulate and incorporate the best evidence in a nurse-delivered education
programme in order to reduce peritoneal dialysis-related infection for PD patients.
3. To standardize the process of delivering the nurse-led CAPD training and education
to prepare patient for home CAPD treatment.
4.3 Intended Users
38
This guideline is intended for use by all trained renal nurses who are
responsible for CAPD patients’ training and education.
4.4 Target Patients
Adult patients of age 18 or above with end stage renal disease and plan to
receive home CAPD treatment.
4.5 Primary outcome consideration
The major outcome is the rate of reduction of PD-related infectious
complications for the target patients after the implementation of the proposed
programme.
4.6 Recommendations
The levels of evidence and grades of recommendations of this guideline follow
that of SIGN (Scottish Intercollegiate Guidelines Network, 2011) which is shown in
Appendix 7 and 8 respectively.
Recommended interventions
1. Adult learning theory such as (Speck, 1996) should be incorporated into the
curriculum of CAPD training and education programme. (A).
Available evidences:
Use of the adult learning theory-based training method curriculum was
39
positively associated with improved patient outcomes in the PD population (Hall,
2004). (1+)
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 answer for the nurses to teach the
patients (Chow, 2007). (1+)
Education programs with a theoretical basis, using cognitive framing and
motivational interviewing principles, are associated with improved outcomes (Gadola,
2012). (1+)
2. Teach patients the proper application of mupirocin cream which is a prophylactic
antibiotic ointment routinely prescribed by physicians for PD patients. (A)
Available evidences:
Our study contributes to the growing body of evidence that daily local
application of mupirocin cream at the PD catheter exit-site significantly reduces
episodes of peritonitis and exit-site infection. Widespread use of an antibiotic can lead
to the development of resistance. However, in a recently reported follow-up of the
(Thodis, 1998) study; there was no mupirocin resistance 1 year after institution of
local mupirocin at the PD catheter exit-site to prevent exit-site infection (Casey, 2000).
40
(1++)
Mupirocin applied to the exit site has proved to be very effective in reducing S.
aureus infections in PD patients. S. aureus exit-site infections are associated with
considerable morbidity, including peritonitis, catheter removal, and transfer to
haemodialysis. Therefore, maneuvers to decrease S. aureus infections are an
important part of improvement of outcomes in PD (Bernardini, 2005). (1++)
Mupirocin cream is recommended to be applied to the skin around the exit site
after daily cleansing with antiseptics (Dong, 2010). (1+)
3. An objective structured assessment should be used to test the patient’s or helper’s
post training PD skill and technique in the revised CAPD training programme. It is
specially designed to evaluate only practical skills but not knowledge demonstrated
by patient. (A)
Available evidences:
The training of PD patients is extremely important and may affect technique
success and clinical outcomes. Therapeutic education has been considered a key
factor in PD outcomes. The objective structured assessment is a reliable tool for
assessing patients’ skills, and it correlates with peritonitis rates (Gadola, 2012). (1++)
4. An integrated post PD training test should be introduced to assess the PD related
41
knowledge of PD learners. (A)
Available evidences:
The post-training test helps to evaluate the learning process and provides
immediate feedback to the learner. With repeated and sufficiently long training, even
patients with a minimum educational background can perform PD techniques
precisely (Chen, 2008). (1++)
5. Patients should be reminded to wear mask when performing PD bag exchange
procedure and doing every minor steps during PD exchange such as hang the new PD
bag to the drip-pod; remove the protective ring of PD bag; break the frangible stopper
of PD bag. (A)
Available evidences:
Among bag exchange items, only failure to wear a face mask and cap was a
significant predictor of peritonitis in the univariate regression model (Dong, 2010).
(1+)
Follow-up is suggested within the first month of post CAPD training. This is to
prevent patients to develop any shortcut of bag exchange procedure since this time
interval is most likely for patients to do so. Due to the chronic nature of CAPD,
patients tend to progressively alter CAPD procedure by skipping mandatory steps
42
thereby decreasing their attention to hygiene (Mawar, 2011). (1+)
6. Training of PD patients’ helpers (usually their family members) should be
considered for patient with poor self-care ability. (A)
Available evidences:
Although peritoneal dialysis has many advantages, such as ease of training and
accommodation, simple facilities, and good mobility, the procedure is difficult for
patients who are physically disabled or noncompliant. Accordingly, assisted PD
provides a good alternative in Europe. In China, assisted PD by well-trained and
compliant assistants can be as good as self-care PD with regard to peritonitis (Xu,
2011). (1+)
Summary
The PD come first policy of public hospitals in Hong Kong makes ESRD patients
with no choice of initial renal replacement therapy. Patients need to attend PD
education and training course before they can start PD treatment. Develop of a
structured evidence-based guideline not only facilitate the teaching process that make
the course more streamline but also enhance the learning outcomes of patients. The
success of a PD programme is dependent upon specialized nurses with appropriate
skills in assessing and training patients for PD, monitoring of treatment and with
43
sufficient resources to provide continued care in the community.
CHAPTER 5
Implementation Plan
To ensure smooth and successful carry out of the evidence-based innovation, a
well-organized communication plan is essential. It must make certain that all
stakeholders are fully informed of when, how and why communication will take place.
As a matter of fact that communication is always a very effective method to deal with
risks, to solve problems and ensure that projects are completed on time.
5.1 Communication plan
Stakeholder analysis
Stakeholders are those people who have influence and interest in the project. For the
implementation of the proposed innovation, it is required to gain the support from a
variety of stakeholders. Therefore, those stakeholders of the project innovation in
evidence-based PD education programme for patients with End Stage Renal Disease
(ESRD) should be identified. They included the unit manager of the renal ward and
the integrated renal centre, physicians (nephrologists) of the renal team, nursing staff
44
including registered nurses, enrolled nurses and renal nurse consultant; patients with
ESRD who follow-up in renal clinic and their carers; Department Operations Manager
(DOM) and General Manager of nursing services (GMN).
A good communication process between the proposer and stakeholders is an essential
component to achieve success of the programme innovation. At the beginning, a
senior staff of renal unit who is interested in the proposed innovation will act as a
proposer and initiate changes on existing practice. The proposer should identify what
improvement should be performing to replace the existing. Later on, the proposer will
search for any information and decide what should be included in the programme
innovation, for example; how the programme innovation will be implemented, for
whom, by whom, and where and when will it be took place. Furthermore, proposer
should identify what requires to be prepared in order to implement the proposed
innovation. For example, posters, training session, resource manual, information
board and who will be involved in the training. Next, the proposer should access a
peer group of colleague and inspire them to see the need for change. Having gained
the support of colleagues, the proposer needs to prepare a clear proposal to persuade
the stakeholders as identified above in terms of the need for changes. With the support
of the senior executives DOM and renal consultant, the proposer will start to
45
implement the change including a survey to assess support or potential obstacles. A
pilot study further revision of the proposed guideline as required before implementing
the project. Special attention will be given to the needs of the patients and their carers
to ensure they understand the changed practice will better address their needs and
provide support as required.
How to Sustain and Guide the Change
A programme leading group should be set up to sustain and guide the change in the
programme innovation. The proposer will be the leader of the group and responsible
for identify the needs of staff and introduce training. Other members included the unit
manager and a frontline nurse who act as a helper from the renal unit. They will meet
frequently and regularly at the beginning. In order to discuss, plan, and respond to any
queries related prior to the innovation. Other group members will prepare and provide
resources and equipment such as teaching aids and materials such as pamphlets,
stationery and audio-visual aids that will be used during the training programme. Staff
training will be provided for those nurse participants. A one-hour-training session is
offered to all 22 renal nurses. In the staff training sessions, specific new teaching
strategies to enhance patients’ learning of PD knowledge and skill are introduced.
46
Aims to improve patients’ self-care and their alertness of factors related to PD
infection. Assessment of nurse participants for their teaching skill and knowledge is
done by the proposer through a pre and post short test.
The proposer is also responsible for answering any questions rise by nursing staff if
they encounter any difficulties or problems during the implementation of the
innovation. The programme leading team should continue to promote the innovation,
continuous update of the latest PD information and maintain effective communication
throughout the programme. Furthermore all renal nurses are ensured to have the soft
copy of the education programme guideline through their hospital e-mail box and can
be downloading from hospital’s intranet for references. For any up-to-date
information on related topics such as research papers and journals, it should be
posting on the unit’s notice boards for staff to read.
A database which includes research articles related to ESRD, innovation in use and
the survey results related to the costs and benefits of the innovation will be set up in
hospital website for references too. Lastly, one of the elements in sustaining the
change process will be assessing the effectiveness of the innovation.
5.2 Pilot Study Plan
47
Purpose of conducting a pilot study
The pilot study is a small scale preliminary test which attempts to assess process and
outcome of the designed innovation. The process of testing included the availability
of resources for the innovation; the acceptability of the proposed innovation by ESRD
patients; and the costs of implementation. For the outcome testing, it includes the
study measure testing, and the satisfaction of users (Polit & Beck, 2010). The purpose
of conducting a pilot study is to evaluate and test the feasibility of the proposed
innovation in a small scale, which is more economical to determine if the innovation
can result in lengthen the time of first onset of PD related infection and enhance the
PD related knowledge of ESRD patients (Polit & Beck, 2010). Another purpose of the
pilot study is used to help identify design issues and allow programme to make
corrective changes or adjustments before the actual innovation implemented with the
target participants.
Participants, Duration, and Location of the Pilot Study
The pilot study of the innovation will be carried out by the proposer of the programme
innovation, who is the member of programme leading group and lead the programme
innovation. The duration of the pilot study is about 6 months. Participants will be
48
nurses in renal unit and ESRD patients who follow-up in Renal Replacement Therapy
(RRT) Clinic of the hospital. Location of the pilot study will be take place in
integrated renal centre of the hospital which is the same location of the coming
innovation.
Inclusion Criteria for the Pilot Testing
The proposed sample size of the pilot study is 10 patients. Convenience sampling is
used to choose sample population. The inclusion criteria are the same as the final
programme innovation. Firstly, patients should over 18 years of age and diagnosed
with ESRD. Secondly, they should be first time training and then following-up in
RRT clinic of the hospital where the proposed innovation will carry out. It is very
important that the inclusion criteria must be similar to those in final programme
innovation and thus can truly reflecting the feasibility of programme innovation.
Summary
By identifying stakeholders who will be affected by the proposal, conducting effective
communication with the stakeholder and testing the feasibility of the proposal using a
pilot study, it is intended that the proposed guideline will be better prepared and
49
accepted prior to its full-scale implementation.
CHAPTER 6
Evaluation Plan
The purpose of evaluation plan is to assess the clinical benefits of the innovation by
identifying those outcomes to be achieved. The evaluation can be done in three
dimensions and includes patient outcomes, staff outcomes and system outcomes.
These will be elaborated as below.
6.1 Nature and Number of Clients to Be Involved
There are three criteria for those patients to be included in the evaluation plan. Firstly,
they should be adult over 18 years old. Secondly, they are diagnosed with ESRD.
Thirdly, they are first time trained by renal nurse and follow-up in RRT clinic of the
hospital between 1 June, 2013 and 31 May, 2014. For the sample size of evaluation
plan, the number of clients to be involved in the evaluation plan is 115. This is
calculated by making use of the sample size calculator of Raosoft (2011). The margin
of error is set at 5% and the response distribution is 50%. However, with assuming
that the anticipated population proportion is to be 50%, so extra 50% of patients
50
should be recruited to account for potential sample loss due to refusal of participation
or loss of follow-up. Thus the final number of patients required for the evaluation is
165. With reference to the patients’ statistics of the hospital, there are around 203 new
cases of ESRD prepare for PD within a year. Therefore, it is possible to achieve the
number of people to be involved in evaluation.
6.2 When and How Often to Take Measurements
The time duration of the innovation is 18 months for each patient. The total duration
of the innovative project is 2.5 years. Measurement will be taken by the proposer
depending on when (if any) PD peritonitis occurs. The overall PD peritonitis rate of
all participants within the 18 months and patient satisfaction score will be measured at
the end of 2.5 years. The proposer who is the leader of the programme is responsible
to collect data for evaluation.
6.3 Data analysis
Patient outcomes
The objective of the innovation in PD education programme for ESRD patients is to
extend the time of PD related infection occurring by using the best evidence-based
51
guideline.
The primary patient outcome is
1.) Time for the first onset of PD peritonitis for first trained PD patients and their long
term mean PD peritonitis rate in patient-month per episode.
The secondary outcomes are
1.) Time for onset of other form of PD related infections (e.g. tenckhoff catheter
tunnel infection, tenckhoff catheter exit-site infection) of newly started PD patients.
2.) Patients satisfaction on the innovation.
When evaluating the patient outcomes, the proposer will compare the data of two
groups of patients. The group of patients who receive innovated education programme
will be used to compare with the previous statistical patients’ data of the hospital
retrospectively.
Primary outcome—PD peritonitis
The time for first onset of PD peritonitis (if any) will be assessed at the end of 18
months, which is the end of programme innovation. Proposer will measure the time
intervals between the first day of intervention and the first day of PD peritonitis. Next,
the proposer will calculate the mean average time for the first PD peritonitis in
52
innovation groups and compare with the previous patients’ statistical data of last year
who received usual education. The effectiveness of the innovation is indicated by
extend in average time to onset of first PD peritonitis of ESRD patients and their rate
of occurrence within 18 months in the innovation group.
Secondary outcome--client satisfaction
The level of client satisfaction will be determined for knowing whether patients
accept and satisfy with the new education programme or not. It is useful for further
improvement in conducting the same programme innovation. At the end of the
programme innovation, proposer will carry out various focus group discussions and
inviting some of the ESRD participants to join randomly. Questions based on the
topics of satisfactory level of education program, inclusion of all important points,
detailed elaboration, and whether the information is tailor-made for patients or not
will be asked to patients. Also, questions focused on the performance of nurses will be
asked, such as familiarity on latest ESRD knowledge and treatments, courtesy of
nurses, ability to concern patients’ needs and the competence of nurses. The results
will reported as percentage of positive comments. The effectiveness of the innovation
is indicated by the percentage of positive comments. At the 5% significance level,
53
more than 50 % of comments are positive will the innovation being regarded as
effective.
Staff outcomes
When evaluating the staff outcomes, the proposer will focus on evaluating the
satisfaction level of staff while implementing the programme, and their knowledge
and skill level and their confidence in them while providing education programme.
Thus, the two staff outcomes will mainly be the improvement in staff satisfaction and
the knowledge enhancement of staff after innovation.
Staff outcomes--Improvements in staff satisfaction
The level of staff satisfaction will be considered by asking or ascertaining of the
nursing staff appreciates with the new education programme or not. It is useful for
further improvement for conducting the same programme innovation in the future. At
the end of the programme innovation, proposer will carry out various focus group
discussions and inviting all the nursing staff in renal unit to participate. Questions
based on the topics of effectiveness of new health education programme, and whether
the innovation helps fellow colleagues to perform a better for patient education and
54
helps gaining professional knowledge will be asked. Moreover, comments on the
satisfaction of training provided before implementing the innovation and the
enhancement in confidence level of nurses in problem solving will be concerned too.
The results will reported as percentage of positive comments. The effectiveness of the
innovation is indicated by the percentage of positive comments. At 5% significance
level if more than 50 % of the comments are positive then the innovation will be
regarded as effective.
Staff outcomes-- Knowledge enhancement of staff after innovation
The knowledge enhancement of staff means the staff will be tested by experts on PD
related knowledge after they received training. A quiz designed by external experts,
but not the proposer, will be held for all nursing staff before and after the innovation.
It is used to compare the increase in knowledge score of staff. The results will be
reported as mean score of the test. Knowledge enhancement is indicated by the
increase in mean scores of the quiz test.
System outcomes
Cost of implementing the innovation
55
The cost of innovation will be calculated by Microsoft Excel software after the
innovation. It will be done by recording the expenditure of all materials and
non-materials cost during the innovation programme. However, this outcome will not
be considered for effectiveness. Proposer will compare it with the estimated material
cost and non-material cost of implementing the health education programme for 100
patients with ESRD.
6.4 Effectiveness of the Guideline
The guideline will be considered as effective if the primary outcome is proved as
effective, which is the time of onset of PD peritonitis. When the outcomes other than
the item mentioned above are not achieved, the proposer will not stop the innovation.
However, proposer will make use of these minor outcomes as a hint to get further
improvement of the programme in the future.
CHAPTER 7
Summary
Summarizing the best evidences, they supported that PD patient education
programme were effective in improving patients’ disease-related knowledge and
56
decrease the rate PD-related infectious complications. The evidence suggested that
incorporation of adult learning theory into the curriculum and the introduction of an
objective structured assessment to test the patients’ or helpers’ post training PD skills
are effective interventions to reinforce learners’ outcomes. In the written proposal, it
also discussed the transferability, feasibility and cost-benefit ratio of the programme
and found that it is possible to carry out in local setting. To enhance the effectiveness
of PD education, a structured programme should be implemented with a
comprehensive communication plan with potential users through appropriate
strategies, development of evidence-based guidelines and suitable educational
materials, as well as pilot study to assess the proposed plan and guideline. A
comprehensive evaluation plan assessing the patients and staff outcomes of the
programme is essential to assure it is effective in improving knowledge and outcomes
of ESRD patients and to ensure that the programme is also supported by patients and
staff.
The major complication of PD is PD peritonitis. It is the major contributor to
technique failure and lead patients shift to haemodialysis. As a result increased the
burden of limited service from HA haemodialysis centres. Patients themselves also
will suffer from pain and greatly lowering their quality of life. However, if the
57
primary prevention of PD education do better, research evidences have shown that
peritonitis infection rate of PD patients can be effectively reduced. It can be achieve
by the utilization of effective education strategies and advanced training skills to
enhance patients’ knowledge and skills of peritoneal dialysis. Therefore, a structured
PD education programme with best evidences support is worthy to establish for the
beneficial of PD patients nowadays and in the future.
58
Table of evidence Appendix 1
Citation/Date/Country of
Origin
Evidence
level
Design, Setting, Sample Size
and Population
Intervention(s) Control Outcome measures/
Length of follow up
Effect size
1 Hall G, Bogan A, Dreis S,
Duffy A, Greene S, Kelley K,
Lizak H, Nabut J, Schinker V,
Schwartz N: New directions in
peritoneal dialysis patient
training. Nephrol Nurs J 31:
149 –154, 159 –163, (2004)
USA.
Ⅲ Design:
Setting:
Sample:
Population:
Longitudinal
Quasi-experimental
Controlled Study
32 Gambro
healthcare PD clinic.
CAPD adult patients
620 PD patients
Enrolled.
PD technique and
diet training using
theory-based
curriculum.
(n=246)
Using non-
standardized
conventional
PD training
programs.
(n=374)
(1) Peritonitis rates.
(2) Exit-site infections rates.
(ESI)
(3) Drop out from PD to
Haemodialysis secondary
to infection.
2 years
(1) 28.8 cases per 1000
patient-months (intervention)
vs 36.7 cases per 1000
patient-months (control)
(P=0.09783)
(2) 18.5 vs 31.8 (P=0.00349)
(3) 1.6% vs 5.6% (P=0.0069)
2 Casey M, Taylor J, Clinard P
et al. Application of
mupirocin cream at the
catheter exit site reduces
exit-site infections and
peritonitis in peritoneal
dialysis patients. Perit
Dial Int 2000; 20: 566.
USA
Ⅲ Design:
Setting:
Sample:
Population:
Prospective
historically
controlled study
Single home PD
training center
Adult PD patients
291 PD patients
Application of
2% mupirocin
cream daily to
exit-site.
(n=143))
Use older
practice of
liquid
antibacterial
soap and water
and gauze
dressing.
(n=148)
(1) Peritonitis rates.
(2) Exit-site infections rates.
(ESI)
12 months
(1) 0.42 episode per
patient-year (intervention)
vs 0.61 episode per
patient-year (control)
(P=0.003)
(2) 0.19 ESI per patient-year
(intervention) vs 0.39 ESI per
patient-year (control)
(P<0.001)
3 Figueiredo AE, Poli de
Figueiredo CE, d'Avila DO,
Peritonitis prevention in
CAPD: to mask or not?
Perit Dial Int. 2000
May -Jun;20(3):354-8.
Brazil.
Ⅱ Design:
Setting:
Sample:
Population:
Randomized
controlled trials
Single renal unit at a
university hospital
CAPD adult patients
64 PD patients
Patient perform
PD exchange
with a face mask.
(n=24)
Patient perform
PD exchange
without a face
mask.
(n=40)
Occurrence of first episode
of peritonitis and total number
of episode.
12 months
Only patients holding university
degrees shown evidence of
protection, relative risk 0.52,
(CI) 95%, 0.23-1.18. (P=0.109)
Incidence of peritonitis was not
significantly different between
groups.
59
Citation/Date/Country of
Origin
Evidence
level Design, Setting, Sample Size
and Population
Intervention(s) Control Outcome measures/
Length of follow up
Effect size
4 Bernardini J, Bender F, Florio
T, Sloand J, Palmmontalbano
L, Fried L,Piraino B.
Randomized, double-blind
trial of antibiotic exit site
cream for prevention of exit
site infection in peritoneal
dialysis patients. J Am
SocNephrol.
2005 Feb;16(2):539-45. Epub
2004 Dec 29. USA
Ⅱ Design:
Setting:
Sample:
Population:
Ramdomised
controlled trials
3 renal centers
Adult CAPD patients
133 PD patients
Application of
gentamicin cream
daily to exit-site
(n=67 )
Application of
mupirocin
cream daily to
exit-site
(n=66 )
(1) Peritonitis rates.
(2) Cathether infection rates.
12 months
(1) 0.34 episode per patient-year
(intervention) vs 0.52 episode
per patient-year (control)
(P=0.03)
(2) 0.23 episode per patient-year
(intervention) vs 0.54 episode
per patient-year (control)
(P=0.005)
5 Gadola L, Poggi C, Poggio M,
Sáez L, Ferrari A, Romero J,
Fumero S, Ghelfi G, Chifflet L,
Larre Borges P. Using a
multidisciplinary training
program to reduce peritonitis
in peritoneal dialysis patients.
Perit Dial Int. 2012 Jul 1.
Uruguay
Ⅲ Design:
Setting:
Sample:
Population:
Retrospective
analysis study
A single renal center
Adult CAPD
patients, at least 1
month on treatment
56 PD patients
Phase 1:
Apply assessment
tool of Objective
Structured
Assessment(OSA)
(n= 25)
Phase 2:
Implementation
of a new
multidisciplinary
peritoneal dialysis
education program
(PDEP)
(n=31)
Phase 1:
Correlated with
the prior year’s
peritonitis rate.
(n=25 )
Phase 2:
Correlated with
the prior year’s
peritonitis rate.
(n=31)
Peritonitis rates
12 months
Phase 1:
0.24 episode per patient-year
(OSA with an acceptable score)
vs 0.67 episode per patient-year
(OSA with an unacceptable
score) (P<0.05)
Phase 2:
0.28 episode per patient-year
(intervention) vs 0.55 episode
per patient-year (control)
(P<0.05)
60
Citation/Date/Country of
Origin
Evidence
level Design, Setting, Sample Size
and Population
Intervention(s) Comparison Outcome measures/
Length of follow up
Result
6 Chen TW, Li SY, Chen JY,
Yang WC. Training of
peritoneal dialysis
patients--Taiwan's experiences.
Perit Dial Int. 2008 Jun;28
Suppl 3:S72-5.
Taiwan
Ⅲ Design:
Setting:
Sample:
Population:
Retrospective
observational study
Single renal center
Adult new start
CAPD or APD
patients
100 PD patients
Implementation
of a post training
test for patients
(n=100).
Compare the
Post-training
score correlated
with peritonitis
rates, exit-site
infection rates
and tunnel
infection rates.
(n= 100).
(1) peritonitis rates
(2) exit-site infection rates
(3) tunnel infection rates
12 months
(1) not significantly different
from score for patients without
infection complications (P=0.8).
(2) higher score got higher
infection rates (P=0.036).
(3) higher score got higher
infection rates (P=0.043).
7 Prasad N, Gupta A, Sharma
RK, Sinha A, Kumar R.
Impact of nutritional status on
peritonitis in CAPD patients.
Perit Dial Int. 2007
Jan-Feb;27(1):42-7.
India
Ⅲ Design:
Setting:
Sample:
Population:
Prospective
observational study
Single renal center
Adult CAPD patients
56 CAPD patients
Patients divided
malnutrition and
normal nutrition
group by
Subjective Global
Assessment(SGA)
And then assess
correlation with
peritonitis
(n=56 )
Compare the
malnutrition
and normal
nutrition group
in terms of the
outcome
measure
(n=56 )
Peritonitis-free survival
period
4 years
42 months (normal nutrition
group) vs 21 months
(malnutrition group) (P=0.003)
8 Dong J, Chen Y. Impact of the
bag exchange procedure on
risk of peritonitis. Perit Dial Int.
2010 Jul-Aug;30(4):440-7.
RP China
Ⅲ Design:
Setting:
Sample:
Population:
Prospective
observational study
Single renal center
Newly started adult
CAPD patients
130 CAPD patients
Offer standard
initial training
program and
evaluation at
the 6th
month of
PD treatment.
(n=130 )
Compare 8
evaluation items
in relation with
peritonitis
(n=130 )
Hazard ratio of PD peritonitis
14 months
(1) Hazard ratio 7.26 (Not
wearing a face mask and cap)
(P<0.001)
(2) Hazard ratio 0.96
(anaemia) (P=0.005)
61
Citation/Date/Country of
Origin
Evidence
level Design, Setting, Sample Size
and Population
Intervention(s) Comparison Outcome measures/
Length of follow up
Result
9 Mawar S, Gupta S, Mahajan S.
Non-compliance to the
continuous ambulatory
peritoneal dialysis procedure
increases the risk of peritonitis.
Int Urol Nephrol. 2012
Aug;44(4):1243-9.
India
Ⅲ Design:
Setting:
Sample:
Population:
Prospective
observational study
Patients’ home
during home visit
Adult CAPD patients
at least 1.5 years of
treatment.
30 CAPD patients
Observe CAPD
exchange
technique during
home visit using a
structured
checklist and
determine the
compliance of
patient.
(n= 30)
Compare the
compliance of
CAPD
procedure
associated with
PD peritonitis.
(n=30 )
(1) Association with
peritonitis
(2) Association with
frequency of peritonitis
12 months
(1) significant association of
compliance with peritonitis
occurrence. (P<0.02)
(2) significant association of
compliance with higher
frequency of peritonitis.
(P<0.03)
10 Xu R, Zhuo M, Yang Z, Dong
J. Experiences with assisted
peritoneal dialysis in China.
Perit Dial Int. 2012 Jan-Feb;
32(1):94-101.
RP China
IV Design:
Setting:
Sample:
Population:
Prospective cohort
study
Single renal center
Adult CAPD patients
313 PD patients
Cohort study is
divided the
patients into
assisted and self
care groups.
Assisted group
(n=122 )
Self-care group
(N=191)
To compare the
outcome
variables of first
episode of
peritonitis and
all causes of
mortality
between the
two groups.
(n= 313)
(1) Peritonitis-free interval.
(2) Mortality rate
(3) Survival time
4 years
(1) 23.5±2.5 months (assisted
CAPD patients) vs 23.4±2.0
months (self-care patients)
(P=0.93)
(2) 69.7% (assisted CAPD
patients) vs 26.2% (self-care
patients) (P<0.0001)
(3) 43.8±2.3 months (assisted
CAPD patients) vs 69.8±2.1
months (self-care patients)
(P<0.0001)
62
Citation/Date/Country of
Origin
Evidence
level Design, Setting, Sample Size
and Population
Intervention(s) Comparison Outcome measures/
Length of follow up
Result
11 Barone RJ, Campora MI,
Gimenez NS, Ramirez L,
Santopietro M, Panese SA.
The importance of the Patient's
training in chronic peritoneal
dialysis and peritonitis. Adv
Perit Dial. 2011;27:97-100.
Argentina
Ⅲ Design:
Setting:
Sample:
Population:
Retrospective
analysis study
Single renal center
Adult APD or CAPD
patients. At least
undergone 3 months of
of treatment.
90 PD patients
Retrospective
analysis of
patients in 3
different length of
training groups
(n= 90)
Compare
peritonitis rates
of 3 different
groups with
group A (up to
8 lessons),
group B
(9-13 lessons),
group C (14 or
more lessons)
(n=90 )
Peritonitis rates
12 months
0.31 in group A (up to 8
lessons)
0.37 in group B (9-13 lessons)
0.47 in group C (14 or more
lessons)
(P<0.05)
12 Chow KM, Szeto CC, Law MC,
Fun Fung JS, Li PKT.
Influence of peritoneal dialysis
training nurses’ experience on
peritonitis rates. Clin J Am
Soc Nephrol 2007;2:647–52.
Hong Kong SAR
Ⅲ Design:
Setting:
Sample:
Population:
Retrospective
observational study
Single renal center
Newly started adult
APD or CAPD
patients.
200 PD patients
A standard PD
training is given
to patients by
three different
group of nurses
with different
lengths of training
experience
(n= 200)
Compare the
relationship
between PD
peritonitis
occurrence
in terms of
length of PD
training nurses’
experience.
(n=200 )
Hazard ratio of PD peritonitis.
3 years
1 for lower tertile (reference)
1.94 for intermediate tertile
(P=0.037)
2.13 for highest tertile
(P=0.022)
63
Quality Assessment Appendix 2
1 Hall G, Bogan A, Dreis S, Duffy A, Greene S, Kelley K, Lizak H, Nabut J, Schinker V,
Schwartz N: New directions in peritoneal dialysis patient training. Nephrol Nurs J 31:
149 –154, 159 –163, 2004.
Study type: Longitudinal quasi-experimental Controlled Study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
1.2 The assignment of subjects to
treatment groups is randomised
Adequately addressed. Number of
patients excluded from study was not
reported. No randomization was made.
1.3 An adequate concealment
method is used
Not addressed. Concealment was not
reported.
1.4 Subjects and investigators are
kept ‘blind’ about treatment
allocation
Not addressed. Blinding was not used
due to the study nature, blinding to
participants is difficult as they received
lessons. Issue on blinding was not
discussed.
1.5 The treatment and control
groups are similar at the start
of the trial
Well covered. Demographic data
between groups were similar
statistically.
1.6 The only difference between
groups is the treatment under
investigation
Well covered. No additional treatment was
introduced other than the study
interventions.
1.7 All relevant outcomes are
measured in a standard, valid
and reliable way
Adequately addressed. All outcome
measures were accounted for in the
analysis.
1.8 What percentage of the
individuals or clusters recruited
into each treatment arm of the
study dropped out before the
study was completed?
Intervention group: 0
Control group: 0
1.9 All the subjects are analyzed in
the groups to which they were
randomly allocated (often
referred to as intention to treat
analysis)
Well covered. The subjects were
analyzed under the principle of
intention to treat.
64
1.10 Where the study is carried out
at more than one site, results
are comparable for all sites
Adequately addressed. Results were
comparable with similar baseline
characteristic.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
No, no power calculation was made.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study. However, the
generalization of results was not addressed.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The use of adult learning theory-based training method
was positively improve patient outcomes.
65
2 Casey M, Taylor J, Clinard P et al. Application of mupirocin cream at the catheter
exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients.
Perit Dial Int 2000; 20: 566.
Study type: Prospective historically controlled study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
1.2 The assignment of subjects to
treatment groups is randomised
Well covered
1.3 An adequate concealment
method is used
Not addressed
1.4 Subjects and investigators are
kept ‘blind’ about treatment
allocation
Not addressed
1.5 The treatment and control
groups are similar at the start
of the trial
Well covered
1.6 The only difference between
groups is the treatment under
investigation
Well covered
1.7 All relevant outcomes are
measured in a standard, valid
and reliable way
Well covered
1.8 What percentage of the
individuals or clusters recruited
into each treatment arm of the
study dropped out before the
study was completed?
Intervention group: 0
Control group: 0
1.9 All the subjects are analyzed in
the groups to which they were
randomly allocated (often
referred to as intention to treat
analysis)
Adequately addressed
1.10 Where the study is carried out
at more than one site, results
are comparable for all sites
Well covered
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
66
2.1 How well was the study done to
minimise bias? Code ++, +, or -
-
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The application of mupirocin cream is an effective way
to reduce PD catheter related infectious complication.
67
3 Figueiredo AE, Poli de Figueiredo CE, d'Avila DO, Peritonitis prevention in CAPD:
to mask or not? Perit Dial Int. 2000 May-Jun;20(3):354-8.
Study type: Randomised controlled trials
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
1.2 The assignment of subjects to
treatment groups is randomised
Well covered
1.3 An adequate concealment
method is used
Not addressed
1.4 Subjects and investigators are
kept ‘blind’ about treatment
allocation
Not addressed
1.5 The treatment and control
groups are similar at the start
of the trial
Well covered. Demographic data
between groups were similar.
1.6 The only difference between
groups is the treatment under
investigation
Well covered. No additional treatment was
introduced other than the study
interventions.
1.7 All relevant outcomes are
measured in a standard, valid
and reliable way
Adequately addressed
1.8 What percentage of the
individuals or clusters recruited
into each treatment arm of the
study dropped out before the
study was completed?
Intervention group: 0
Control group: 0
1.9 All the subjects are analyzed in
the groups to which they were
randomly allocated (often
referred to as intention to treat
analysis)
Well covered. The subjects were
analyzed under the principle of
intention to treat.
1.10 Where the study is carried out
at more than one site, results
are comparable for all sites
Adequately addressed. Results were
comparable with similar baseline
characteristic.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
68
2.1 How well was the study done to
minimise bias? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
No. There are also many factors affect the result. For
example: hand wash technique, bag exchange
technique etc.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The author concluded that the routine use of a facial
mask may not necessary during CAPD bag exchange.
But this is a risk factor of being contamination during
the procedure. It is not worth to eliminate just for
reduce costs of CAPD.
69
4 Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B.
Randomized, double-blind trial of antibiotic exit site cream for prevention of exit
site infection in peritoneal dialysis patients. J Am Soc Nephrol. 2005
Feb;16(2):539-45. Epub 2004 Dec 29.
Study type: Randomised controlled trials
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
1.2 The assignment of subjects to
treatment groups is randomised
Well covered.
1.3 An adequate concealment
method is used
Well covered.
1.4 Subjects and investigators are
kept ‘blind’ about treatment
allocation
Well covered.
1.5 The treatment and control
groups are similar at the start
of the trial
Well covered. Demographic data
between groups were similar.
1.6 The only difference between
groups is the treatment under
investigation
Well covered. No additional treatment was
introduced other than the study
interventions.
1.7 All relevant outcomes are
measured in a standard, valid
and reliable way
Adequately addressed. All outcome
measures were accounted for in the
analysis.
1.8 What percentage of the
individuals or clusters recruited
into each treatment arm of the
study dropped out before the
study was completed?
Intervention group: 0
Control group: 0
1.9 All the subjects are analyzed in
the groups to which they were
randomly allocated (often
referred to as intention to treat
analysis)
Well covered. The subjects were
analyzed under the principle of
intention to treat.
1.10 Where the study is carried out
at more than one site, results
are comparable for all sites
Adequately addressed. Results were
comparable with similar baseline
characteristic.
70
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes, the study was well controlled. There was no
different in groups by gender, age, race or previous
time on dialysi treatment.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The application of antibiotics cream on exit-site is an
effective way to reduce PD catheter related infectious
complication.
71
5 Gadola L, Poggi C, Poggio M, Sáez L, Ferrari A, Romero J, Fumero S, Ghelfi G,
Chifflet L, Larre Borges P. Using a multidisciplinary training program to reduce
peritonitis in peritoneal dialysis patients. Perit Dial Int. 2012 Jul 1.
Study type: Retrospective analysis study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
1.2 The assignment of subjects to
treatment groups is randomised
Adequately addressed. Number of
patients excluded from study was not
reported.
1.3 An adequate concealment
method is used
Not addressed. Concealment was not
reported.
1.4 Subjects and investigators are
kept ‘blind’ about treatment
allocation
Not addressed. Blinding was not used
due to the study nature, blinding to
participants is difficult as they received
lessons.
1.5 The treatment and control
groups are similar at the start
of the trial
Well covered. Demographic data
between groups were similar.
1.6 The only difference between
groups is the treatment under
investigation
Well covered. No additional treatment was
introduced other than the study
interventions.
1.7 All relevant outcomes are
measured in a standard, valid
and reliable way
Adequately addressed. All outcome
measures were accounted for in the
analysis.
1.8 What percentage of the
individuals or clusters recruited
into each treatment arm of the
study dropped out before the
study was completed?
Intervention group: 0
Control group: 0
1.9 All the subjects are analyzed in
the groups to which they were
randomly allocated (often
referred to as intention to treat
analysis)
Well covered. All subjects recruited were
being analyzed under the principle of
intention to treat.
1.10 Where the study is carried out
at more than one site, results
are comparable for all sites
Adequately addressed. Results were
comparable with similar baseline
characteristic.
72
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise bias? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study. However, the
generalization of results was not addressed.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The author concluded that the Objective Structured
Assessment is a reliable tool for assess patients’ skills.
The multidisciplinary PD education programm further
improve peritonitis rates.
73
6 Chen TW, Li SY, Chen JY, Yang WC. Training of peritoneal dialysis
patients--Taiwan's experiences. Perit Dial Int. 2008 Jun;28 Suppl 3:S72-5.
Study type: Retrospective observational study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Control: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Adequately addressed.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Well covered.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Adequately addressed
1.9 Exposure status is measured in a
standard, valid and reliable way
Well covered
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Not addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
74
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
-
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
There are many factors that can induce PD peritonitis.
The total scores of post training test only reflect the
learning abilities of individual patients.
75
7 Prasad N, Gupta A, Sharma RK, Sinha A, Kumar R. Impact of nutritional status on
peritonitis in CAPD patients. Perit Dial Int. 2007 Jan-Feb;27(1):42-7.
Study type: Prospective observational study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Well covered.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered.
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Controls: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Well covered.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Adequately addressed.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Adequately addressed
1.9 Exposure status is measured in a
standard, valid and reliable way
Well covered.
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Not addressed.
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes.
76
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The peritonitis rate is relatively high in malnutrition
patients. The authors concluded that the malnutrition
indices is the predictor of CAPD patients with
peritonitis.
77
8 Dong J, Chen Y. Impact of the bag exchange procedure on risk of peritonitis. Perit
Dial Int. 2010 Jul-Aug;30(4):440-7
Study type: Prospective observational study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Well covered.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered.
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Controls: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Well covered.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Adequately addressed.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Adequately addressed.
1.9 Exposure status is measured in a
standard, valid and reliable way
Well addressed.
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Not addressed.
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes
78
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
-
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
2 out of 8 items were identified as independent risk
factors for peritonitis.
79
9 Mawar S, Gupta S, Mahajan S. Non-compliance to the continuous ambulatory
peritoneal dialysis procedure increases the risk of peritonitis. Int Urol Nephrol. 2012
Aug;44(4):1243-9.
Study type: Prospective observational study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered.
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Controls: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Not reported.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Adequately addressed.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Well covered.
1.9 Exposure status is measured in a
standard, valid and reliable way
Well covered.
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Not reported.
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes
80
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The study shown significant association of frequency
of peritonitis with non-compliance. Non-compliance
can be improved by retraining, it is a correctable rick
factor.
81
10 Xu R, Zhuo M, Yang Z, Dong J. Experiences with assisted peritoneal dialysis in
China. Perit Dial Int. 2012 Jan-Feb; 32(1): 94-101.
Study type: Prospective cohort study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The two groups being studied are
selected from source populations that
are comparable in all respects other
than the factor under investigation.
Well covered.
1.3 The study indicates how many of the
people asked to take part did so, in each
of the groups being studied.
Not addressed.
1.4 The likelihood that some eligible
subjects might have the outcome at the
time of enrolment is assessed and taken
into account in the analysis.
Well covered.
1.5 What percentage of individuals or
clusters recruited into each arm of the
study dropped out before the study was
completed.
Assisted group: 17.2%
Self care group: 10.9%
1.6 Comparison is made between full
participants and those lost to follow up,
by exposure status.
Well covered.
ASSESSMENT
1.7 The outcomes are clearly defined. Well covered.
1.8 The assessment of outcome is made
blind to exposure status.
Well covered.
1.9 Where blinding was not possible, there
is some recognition that knowledge of
exposure status could have influenced
the assessment of outcome.
Well covered.
82
1.10 The measure of assessment of exposure
is reliable.
Well covered.
1.11 Evidence from other sources is used to
demonstrate that the method of
outcome assessment is valid and
reliable.
Well covered.
1.12 Exposure level or prognostic factor is
assessed more than once.
Adequately addressed.
CONFOUNDING
1.13 The main potential confounders are
identified and taken into account in the
design and analysis
Well covered.
STATISTICAL ANALYSIS
1.14 Have confidence intervals been
provided?
Yes
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding, and to establish a causal
relationship between exposure and
effect? Code ++, +, or -
-
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The authors concluded that assisted PD is a good
option for patients with poor self-care ability.
83
11 Barone RJ, Campora MI, Gimenez NS, Ramirez L, Santopietro M, Panese SA. The
importance of the Patient's training in chronic peritoneal dialysis and peritonitis.
Adv Perit Dial. 2011;27:97-100.
Study type: Retrospective analysis study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Well covered.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered.
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Controls: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Well covered. Demographic data
between groups were similar.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Not applicable.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Well covered.
1.9 Exposure status is measured in a
standard, valid and reliable way
Well covered.
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Not adddressed.
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
84
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
No, it is because the demographic data (education
level) between groups are different.
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
The result of the study shown that the lengths of CAPD
training received by patients is not associated with the
PD peritonitis rate. It only determinined that some
patients need more time of training is due to the present
of learning difficulties.
85
12 Chow KM, Szeto CC, Law MC, Fun Fung JS, Li PKT. Influence of peritoneal
dialysis training nurses’ experience on peritonitis rates. Clin J Am Soc Nephrol
2007;2:647–52.
Study type: Retrospective observational study
SECTION 1: INTERNAL VALIDITY
In this study this criterion is:
1.1 The study addresses an
appropriate and clearly focused
question.
Well covered. A clear and well defined
question is specified in the study.
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Well covered.
1.3 The same exclusion criteria are used for
both cases and controls
Well covered.
1.4 What percentage of each group (cases
and controls) participated in the study?
Cases: 100%
Controls: 100%
1.5 Comparison is made between
participants and non-participants to
establish their similarities or
differences
Well covered. Demographic data
between groups were similar.
1.6 Cases are clearly defined and
differentiated from controls
Well covered.
1.7 It is clearly established that controls are
non-cases
Not applicable.
ASSESSMENT
1.8 Measures will have been taken to
prevent knowledge of primary exposure
influencing case ascertainment
Well covered.
1.9 Exposure status is measured in a
standard, valid and reliable way
Well covered.
CONFOUNDING
1.10 The main potential confounders are
identified and taken into account in the
design and analysis
Well covered.
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes
86
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to
minimise the risk of bias or
confounding? Code ++, +, or -
+
2.2 Taking into account clinical
considerations, your evaluation of
the methodology used, and the
statistical power of the study, are
you certain that the overall effect is
due to the study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group
targeted by this guideline?
Yes. The patient population of my
proposed guideline was similar to those
in the study.
2.4 Summarise the authors conclusions.
Add any comments on your own
assessment of the study, and the extent
to which it answers your question.
Negative association between nurses’ experience as a
trainer and peritonitis rate implied that active continued
education for nurses are very important for them to
train the patients.
87
Appendix 3 Search result in databases
MEDLINE
( 3-5-2012)
CINAHL
(3-5-2012)
British
Nursing
Index
(3-5-2012)
PsycINFO
(3-5-2012)
PubMed
(3-5-2012)
(1)program*OR training*OR
intervention*OR education* OR
assessment*
(Limit to English and
year=2000-2012)
264615
157945
47915
1175531
2003329
(2) peritoneal dialysis*OR CAPD*
(Limit to English and
year=2000-2012)
2252
472
142
375
26757
(3) complication* OR infection*
OR peritonitis*OR exit-site
infection* OR tunnel infection*
(Limit to English and
year=2000-2012)
285753
80149
11785
78324
3407907
(4) infection prevention* OR
technique* OR mortality*
(Limit to English and
year=2000-2012)
191638
42257
4912
186851
2202802
(5) #1 AND #2 AND #3 AND #4 63 77 13 23 524
(6) Limit #5 to inclusion criteria
and absence of exclusion criteria
4 4 2 5 8
(7) Final number of studies chosen 12
88
Appendix 4 Level of evidence
Bibliographic citation Study type Level of
evidence
1 Hall G, et al., 2004 Longitudinal quasi-experimental design
study
Ⅲ
2 Casey M, et al, 2000 Prospective historically controlled
study
Ⅲ
3 Figueiredo E, et al., 2000
Randomized controlled trials (RCTs) Ⅱ
4 Bernardini J, et al., 2005
Randomized controlled trials (RCTs) Ⅱ
5 Gadola L, et al., 2012
Retrospective analysis study Ⅲ
6 Chen T W, et al., 2008
Retrospective observational study Ⅲ
7 Prasad N, et al., 2006
Prospective observational study Ⅲ
8 Dong J, et al., 2010
Prospective observational study Ⅲ
9 Mawar S, et al., 2011
Prospective observational study Ⅲ
10 Xu R, et al., 2011
Prospective cohort study IV
11 Barone RJ, et al, 2011
Retrospective analysis study Ⅲ
12 Chow K M, et al., 2007
Retrospective observational study Ⅲ
89
Appendix 5
Comparison of demographics characteristics between the target population of 12
studies and the target population in the local setting.
Target population in local
Setting (Data from our
hospital starting from
January 2009 to December
2010)
Target population in the
studies (Data represent the
summary of all 12 studies)
Nature of
population
Patients preparing for
home CAPD
Patients preparing for
home CAPD
Number of
audiences
113 Average 174
Age
(Mean)
59.9 years 58.5 years
Gender
(Male)
61.4% Average 64.7%
Countries
(Geographical)
Hong Kong (Asia) USA x 3, Brazil, Uruguay,
Taiwan (Asia), India x 2
(Asia), China x 2 (Asia),
Argentina, Hong Kong
(Asia)
Setting Integrated renal center Renal center x 11,
patients’ home x 1
90
Appendix 6
Estimated extra cost to implement the proposed programme
Personnel:
21 Training time for staff 1 hour/each $230/hr $4,830
1 Working time for trainer
(Train 2 nurses each time)
11 hours $230/hr $2,530
1 Working time to prepare written
material, training material
10 hours $230/hr $2,300
Expenses:
Education rooms Available in hospital -----
Teaching aids Available in hospital -----
Training material (handouts) Paper, files $250
Miscellaneous e.g. stationery Pens, files, staplers, clips, etc $300
Pre & post questionnaires $0.3 / sheet x2 x21 $12.6
91
Appendix 7
The Coding System of the Level of Evidence from Scottish Intercollegiate
Guidelines Network (Scottish Intercollegiate Guidelines Network, 2010)
Level of
Evidence
Evidence Statements
1++ High quality meta-analyses, systematic reviews of
randomized controlled trials (RCTs), or RCTs with a
very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of
RCTs, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews of RCTs, or RCTs
with high risk of bias
2++ High quality systematic reviews of case control or cohort
studies High quality case control or cohort studies with a
very low risk of confounding or bias and a high
probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low
risk of confounding or bias and a moderate probability
that the relationship is causal
2- Case control or cohort studies with high risk of
confounding or bias and a significant risk that the
relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
92
Appendix 8
The Grades of Recommendation from Scottish Intercollegiate Guidelines
Network (Scottish Intercollegiate Guidelines Network, 2010)
Grade Explanation
A At least one meta-analysis, systematic review, or RCT
rated as 1++, and directly applicable to the target
population; or
A body of evidence consisting principally of studies
rated as 1+, directly applicable to the target population,
and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++,
directly applicable to the target population, and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+,
directly applicable to the target population and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
(Good Practice
Points)
Recommended best practice based on the clinical
experience of the guideline development group
93
References:
Barone RJ, Campora MI, Gimenez NS, Ramirez L, Santopietro M, Panese SA. The
importance of the Patient's training in chronic peritoneal dialysis and peritonitis.
Adv Perit Dial. 2011; 27: 97-100.
Bernardini J, Price V, Figueiredo A. on behalf of International Society for
Peritoneal Dialysis (ISPD) Nursing Liaison Committee. Peritoneal dialysis
patient training, 2006. Perit Dial Int 2006; 26: 625–32
Bernardini J, Price V, Figueiredo A, Riemann A, Leung D. International survey of
peritoneal dialysis training programs. Perit Dial Int 2006; 26: 658–63
Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B.
Randomized, double-blind trial of antibiotic exit site cream for prevention of
exit site infection in peritoneal dialysis patients. J Am Soc Nephrol. 2005
Feb;16(2): 539-45. Epub 2004 Dec 29.
Brown, E. (2005). Peritonitis: Limiting the damage. Nephrology Dialysis
Transplantation, 20(8) 1539-1541.
Casey M, Taylor J, Clinard P et al. Application of mupirocin cream at the catheter
exit site reduces exit-site infections and peritonitis in peritoneal dialysis
patients. Perit Dial Int 2000; 20: 566.
94
Chen TW, Li SY, Chen JY, Yang WC. Training of peritoneal dialysis
patients--Taiwan's experiences. Perit Dial Int. 2008 Jun; 28 Suppl 3: S72-5.
Chow KM, Szeto CC, Law MC, Fun Fung JS, Li PKT. Influence of peritoneal
dialysis training nurses’ experience on peritonitis rates. Clin J Am Soc Nephrol
2007; 2: 647–52.
Dong J, Chen Y. Impact of the bag exchange procedure on risk of peritonitis. Perit
Dial Int. 2010 Jul-Aug; 30(4): 440-7.
Figueiredo AE, Poli de Figueiredo CE, d'Avila DO, Peritonitis prevention in CAPD:
to mask or not? Perit Dial Int. 2000 May-Jun; 20 (3): 354-8.
Gadola L, Poggi C, Poggio M, Sáez L, Ferrari A, Romero J, Fumero S, Ghelfi G,
Chifflet L, Larre Borges P. Using a multidisciplinary training program to
reduce peritonitis in peritoneal dialysis patients. Perit Dial Int. 2012 Jul 1.
Gertrude KA, Paul K, Michael M, Friedrich P, Johannes MR, Martin W, Andreas V,
Exit-site care in Austrian peritoneal dialysis centers – A nationwide survey.
Perit Dial Int. 2009 May; 29(3): 330-9.
Hall G, Bogan A, Dreis S, Duffy A, Greene S, Kelley K, Lizak H, Nabut J, Schinker
V, Schwartz N: New directions in peritoneal dialysis patient training. Nephrol
Nurs J 31: 149 –154, 159 –163, 2004.
95
Kawanishi, H., Kawaguchi, Y., Fukui, H., Hara, S., Imada, A., Kubo, H., et al. (2004).
Encapsulating peritoneal sclerosis in Japan: A prospective, controlled,
multicenter study. American Journal of Kidney Diseases, 44(4) 729-737.
Lecame, L., Lobbedez, T., Allard, C., Huralt de Ligny, B., Haggan, W., & Ryckelnck,
J. (2006). Hospitalization of peritoneal dialysis patients: The impact of
peritonitis episodes on the hospitalization rate. Nephrologie & Therpeutique,
2(2) 82-86.
Li PKT, Szeto CC, Piraino B, et al. Peritoneal dialysis–related infections
recommendations: 2010 update. Perit Dial Int 2010; 30: 393–423
Lo CY, Chu WL, Wan KM, Ng SY, Lee WL, Chu MF, Cheng SW, Lo WK.
Pseudomonas exit-site infections in CAPD patients: evolution and outcome of
treatment. Perit Dial Int 1998; 18(6): 637-40.
Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, Kumar P.
Effect of local mupirocin application on exit-site infection and peritonitis in an
Indian peritoneal dialysis population. Perit Dial Int. 2005 Sep-Oct;25(5):473-7
Mawar S, Gupta S, Mahajan S. Non-compliance to the continuous ambulatory
peritoneal dialysis procedure increases the risk of peritonitis. Int Urol
Nephrol. 2012 Aug;44(4): 1243-9.
96
National Kidney Foundation (NKF). (2006). K/DOQI clinical practice guidelines and
clinical practice recommendations 2006 updates.
Prasad N, Gupta A, Sharma RK, Sinha A, Kumar R. Impact of nutritional status on
peritonitis in CAPD patients. Perit Dial Int. 2007 Jan-Feb;27(1):42-7.
Rudnicki M, Kerschbaum J, Hausdorfer J, Mayer G, König P. Risk factors for
peritoneal dialysis-associated peritonitis: the role of oral active vitamin D. Perit
Dial Int. 2010 Sep-Oct; 30(5): 541-8.
Russo R, Manili L, Tiraboschi G, et al. Patient re-training in peritoneal dialysis: why
and when it is needed. Kidney Int Suppl 2006; (103): S127–32
Speck Marsha. Best practice in professional development for sustained educational
change. ERS Spectrum, v14 n2 (1996) p33-41
Vargemezis, V., & Thodis, E. (2001). Prevention and management of peritonitis and
exit-site infections in patients on continuous ambulatory peritoneal dialysis.
Nephrology Dialysis Transplantation, 16(Suppl. 6), 106-108.
Xu R, Zhuo M, Yang Z, Dong J. Experiences with assisted peritoneal dialysis in
China. Perit Dial Int. 2012 Jan-Feb; 32(1): 94-101.
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