Abstract of thesis entitled. An evidence-based patient education programme for reduction of peritoneal. dialysis-related infection.

Transcription

1 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

2 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 2

3 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. 3

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,

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 5

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. 6

7 Table of Contents Declarations... 5 Acknowledgements...6 Table of Contents...7 Appendixs... 8 Abbreviations...9 CHAPTER 1 Introduction Background Affirming the Needs Question, Objectives and Significance CHAPTER 2 Critical Appraisal Searching and Appraisal Strategies Result Summary of Findings Synthesis of Findings Evidence-based recommendations...28 CHAPTER 3 Implementation potential 3.1 Target Setting Target Audience Transferability of the proposed programme Feasibility Cost Benefit ratio of the innovation...36 CHAPTER 4 Evidence-based Practice guideline Guideline Title Aims of establishing the guideline

8 4.3 Intended Users Target Patients Primary outcome consideration Recommendations...38 CHAPTER 5 Implementation plan Communication plan Pilot testing plan CHAPTER 6 Evaluation plan Nature and number of clients to be involved When and how often to take measurements Data analysis 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 Appendix 6 Estimated cost Appendix 7 Coding system of level of evidence Appendix 8 Grades of recommendation References

9 Abbreviations used in the study APD CAPD ESRD ESRF HA HD K/DOQI PD SIGN RCTs RRT Automated Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis End-Stage Renal Disease End-Stage Renal Failure Hospital Authority of Hong Kong Haemodialysis Kidney Disease Outcomes Quality Initiative Peritoneal dialysis Scottish Intercollegiate Guidelines Network Randomized Controlled trial Renal Replacement Therapy 9

10 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 10

11 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 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: 11

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 12

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 13

14 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 14

15 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 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 15

16 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. 16

17 CHAPTER 2 Critical Appraisal 2.1 Searching and Appraisal Strategies: 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 17

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 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 18

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 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 19

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 Results The initial clinical evidence search was carried out on May 2012 to August 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, 20

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 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 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 21

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 22

23 of PD nurses him/herself and apply adult learning principles to enhance CAPD training 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) 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 23

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) 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) 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 Setting Eleven studies were carried out at renal clinics or centers. Only 1 study was 24

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. 25

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 26

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 27

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 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. 28

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. 29

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 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 30

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; 31

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 32

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 33

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 34

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 35

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 36

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 37

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 38

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). 39

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 40

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 41

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 42

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 43

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 44