SETTING UP A CONTINUOUS AMBULATORY PERITONEAL DIALYSIS TRAINING PROGRAM

Proceedings of the First Asian Chapter Meeting ISPD December 13 15, 2002, Hong Kong Peritoneal Dialysis International, Vol. 23 (2003), Supplement 2 0896-8608/03 $3.00 +.00 Copyright 2003 International Society for Peritoneal Dialysis Printed in Canada. All rights reserved. SETTING UP A CONTINUOUS AMBULATORY PERITONEAL DIALYSIS TRAINING PROGRAM Irene L.L. Kong, Irene L.P. Yip, Grace W.S. Mok, Soso Y.M. Chan, Candic M.K. Tang, Sharon W.Y. Wong, Rebecca B.T. Tsui, Wai-kay Tsang, Samuel K.S. Fung, Hilda W.H. Chan, and Matthew K.L. Tong Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China Continuous ambulatory peritoneal dialysis (CAPD) training programs have become fundamental patient education programs in renal centers providing peritoneal dialysis (PD) services. Several key topics must be addressed in setting up a CAPD training program: Health care and organizational issues Multidisciplinary team approach Evidence-based practice Pre-training patient assessment Patient training Program evaluation The PD nurses should identify key learning objectives for patient training. The essential elements of CAPD training are the training content and schedule, training assessment, and teaching methods. Program set-up also includes establishing a back-up system and follow-up protocols, which are essential for continuity of care in renal patients. Outcomes such as rates of peritonitis and exitsite infection, unplanned readmission, and patient satisfaction are all important indicators when the results of CAPD training programs are reviewed. The development and successful implementation of a cost-effective CAPD training program has a significant impact on patient outcomes in the renal specialty. Perit Dial Int 2003; 23(S2):S178 S182 www.pdiconnect.com KEY WORDS: Set-up; CAPD training program; patient training. Continuous ambulatory peritoneal dialysis (CAPD) is one treatment modality for patients suffering from end-stage renal disease (ESRD). Use of peritoneal dialysis (PD) varies from country to country. However, with recent advances in PD both in technology and in treatment CAPD has become the modality Correspondence to: I.L.L. Kong, Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Lai Chi Kok, Kowloon, Hong Kong SAR, China. pmhrenal@hotmail.com S178 of choice for new ESRD patients in some countries. As a result, CAPD training has become a fundamental patient-education program in renal centers that provide PD services. The development and successful implementation of a cost-effective CAPD training program has important implications for patients outcomes in the renal specialty. SETTING UP A Health Care and Organizational Issues: At the system level, a thorough needs assessment should be conducted before a patient education program is developed. The nurse administrators and the PD nurse leaders should establish detailed implementation schedules, resource plans, achievement indicators, and monitoring mechanisms to support the development plan. The potential benefits and the direct and indirect costs of developing and implementing the CAPD training program should be addressed. Direct costs refer to teaching, equipment, and materials directly associated with the actual education program. Indirect costs include staff training, coordination of the program, administrative overhead, and program evaluation (1). Training can be conducted at a satellite dialysis or a training venue attached to a renal unit. Patient outcomes or benefits to patients are the end results of an education program. Hence, program implementers should identify specific, appropriate outcomes on which the cost-effectiveness of the training program can be evaluated. Multidisciplinary Team Approach: Peritoneal dialysis nurses work collaboratively with other renal health care providers. The multidisciplinary team approach in delivering care to CAPD patients is most desirable. The team includes renal physicians, surgeons, renal nurses, social workers, dietitians, physiotherapists, occupational therapists, psychologists,

PDI DECEMBER 2003 VOL. 23, SUPPL 2 PROCEEDINGS OF THE FIRST ASIAN CHAPTER MEETING ISPD and patients. The team has a rehabilitative role and assists patients in maintaining optimal health (2,3). Renal physicians focus on treatment. Dietitians provide dietary advice to patients. Social workers assist patients with financial and social problems. Physiotherapists can design exercise programs for CAPD patients, and occupational therapists help patients in employment matters. Patient education and psychosocial care are essential elements in the CAPD training program. Supportive counseling can be provided to patients and their families to facilitate adjustment to chronic illness, and to enhance acceptance of, and compliance with, CAPD treatment. The PD nurse plays an important role in the success of the CAPD training program. Qualified renal nurses should carry out CAPD training. The PD nurse trains the patient or a helper (or both) to perform CAPD preferably at a ratio of one nurse per patient. When setting up a CAPD training program, PD nurses with the following important qualities (4) are needed: Independence in nursing skills, for making therapy decisions and recommending action plans. Enthusiasm and motivation, to inspire staff and patients to do their best. Sound knowledge of CAPD and competence in patient teaching. (The teaching skills are important so that the patient becomes independent and confident at home.) Organizational skills, so as to provide structure and continuity to therapy regimes for individual patients, including priority setting and time management. Great patience, for working effectively with ESRD patients over the long term. Effectiveness in communication, so as to establish good nurse client relations with patients and their family members. (Good communication is especially important during CAPD training, because it has a direct bearing on the satisfaction of patients with their care.) Evidence-Based Nursing Practice: Evidence-based practice is increasingly important in both medicine and nursing. Guidelines for PD nursing practices are systematic statements that address the care of PD patients or management of PD phenomena. Publications and sites on the Internet provide information on PD clinical practice guidelines. Some examples are the Dialysis Outcomes Quality Initiative guidelines from the National Kidney Foundation, and the guidelines/ recommendations for clinical practice from the International Society for Peritoneal Dialysis (ISPD) (5 10). In setting up a PD service and CAPD training program, the medical director and the health care professionals in the renal specialty should develop PD guidelines and care protocols. The PD guidelines should be based on both the best available scientific evidence and local consensus (11 14). The clinical outcome of PD has clearly improved (lower peritonitis rates) with the use of disconnect systems. Disconnect systems are preferred for use in CAPD patients (15). The peritonitis rate is one of the key outcome indicators that should be regularly monitored. Adequacy of dialysis is another important outcome indicator (11 14). The availability of PD guidelines, protocols, and standards can help nurses to provide safe, efficient, cost-effective, and quality care to renal patients. The evidence-based approach in patient education and delivery of care means that nurses can explain why certain interventions are being used and what the expected outcomes are. Nurse leaders should also set practice standards for PD nursing. The American Nephrology Nurses Association sets the practice standards for nephrology nursing (16). The publications Guidelines for Specialty Nursing Services: Renal Care (17) and Standards for Renal Nursing Practice (18) guide renal nursing practices in Hong Kong. A PD unit needs guidelines, protocols, and standards for PD services. The guidelines and protocols recommended for PD services (12) are these: Guidelines from the national authority and health authority for CAPD services Guidelines for nursing management of patients on CAPD Guidelines for the CAPD training program Exchange procedures for various CAPD systems Procedures for transfer-set change Guidelines for treatment of infection (peritonitis and PD catheter exit site) Guidelines for care of the peritoneal access (including peritoneal catheter and exit site) Protocols for management of dialysis-related complications Procedure guide for the peritoneal equilibration test Procedures for PD adequacy assessment Guidelines for patient education on fluid and dietary restrictions These guidelines are recommended for a CAPD training program (19,20): Assess patients (needs, benefits, and feasibility of treatment) before admittance into the program. Train patient one-to-one. A designated nurse should be responsible for the whole training program for an individual patient. S179

PROCEEDINGS OF THE FIRST ASIAN CHAPTER MEETING ISPD DECEMBER 2003 VOL. 23, SUPPL 2 PDI Evaluate the patient before training to determine which system is appropriate for the patient. Ensure that all training equipment is on hand for patient training. Establish what to teach the patient, and communicate learning objectives to the patient. Develop a systematic CAPD training protocol. Encourage all health care providers to use consistent terminology and procedures in patient teaching. Teach for short periods of time, and ensure acceptance of new information. Set achievable goals. Achievable goals, together with positive reinforcement for tasks well done, will raise patient confidence. Keep a training checklist to ensure consistent training. Be aware of obstacles that can reduce learning for example, the patient s educational level, physical ability, emotional stability, social circumstances, and uremic condition. When appropriate, involve family members in CAPD training. Implement a predialysis orientation program (desirable). Hence, when setting up the CAPD training program, nurses should adopt appropriate nursing models, together with evidence-based practice to achieve optimal outcomes. To deal with the changing health care environment and the needs of the community, nurses should also keep abreast of current trends and advances in PD practice. Patient Pre-training Assessment: The PD nurse should assess the patient and tailor PD training to meet individual needs. The assessment focuses on the patient s physical status, psychosocial status, and environment, because these are linked to certain considerations and training implications. Based on an assessment of all the patient s characteristics, the nurse can modify the training program to train the patient in the most effective way. The nurse identifies who will be responsible for CAPD treatments. If the patient can perform self- CAPD, the nurse focuses on training the patient. Training can be provided to the patient and a family member if both are to be responsible. If a family member is to be responsible for the CAPD treatments, the nurse focuses on training that relative. Training may also be given to other care providers in the community when necessary. Certain considerations have implications for the CAPD training program (19): Family support of the patient: If a patient has good family support, the nurse can involve a family S180 member in training; otherwise, supportive options can be explored. Dexterity: A patient may need special assistive aids to be able to carry out self-care. Home environment: If storage space for CAPD supplies is limited, the nurse can develop an individual ordering system and explore alternatives with the patient. Patient motivation and willingness to learn: The PD team can provide supportive counseling to the patient. Educational background: The PD nurse should adjust training according to the pace at which a particular patient learns. Financial concerns: The nurse can make a referral to the medical social worker for review of the patient s financial situation. Patient activities and work: The PD nurse can develop alternatives with the patient. The CAPD Training Program: Patient training has five important elements: Learning objectives for the patient Schedule for training Training assessment Teaching methods and aids Follow-up care and home visits Patient training is adult learning. Teaching and learning principles should be applied appropriately. The nurse should develop specific teaching plans and identify key learning objectives. The aim is to train the patient or a helper (or both) to perform CAPD bag exchanges and to have the confidence to continue CAPD treatment at home. A training schedule should be developed for the CAPD program. The training schedule shows specific components of the CAPD program and target dates for their completion. Over time, the schedule gradually increases the role of the patient and changes the role of the PD nurse. The training should cover this content (19,20): Basic knowledge of kidney diseases and renal failure Principles of PD and understanding CAPD Knowledge of aseptic technique Details of CAPD systems and PD fluid Exchange procedures in the patient s selected system Troubleshooting the procedures Care of the peritoneal catheter exit site Daily observation and recording Management of complications, including peritonitis and exit-site infection

PDI DECEMBER 2003 VOL. 23, SUPPL 2 PROCEEDINGS OF THE FIRST ASIAN CHAPTER MEETING ISPD Knowledge and technique for administration of intraperitoneal medication Knowledge about medication Knowledge about fluid and diet Follow-up and home dialysis Training assessment is an ongoing process, which assists in evaluating the competency of the patient to perform CAPD. Assessment of knowledge and technique proficiency is important. As teacher, the PD nurse helps the learner (patient) to make decisions that will lead to success. The nurse should incorporate various teaching methods and use teaching aids. Teaching methods include demonstration and return demonstration, simulated problem-solving, lecture, and discussion. The use of patient training manuals, procedure guides, posters, videos, and CD ROMs can also facilitate the teaching learning process (4,19). The PD nursing team needs to develop forms for documenting nursing assessments and interventions. Forms such as an Initial Assessment Record, a CAPD Training Checklist and Progress Record, Patient Daily Record Sheets, and CAPD Training Evaluation Form are recommended for use in the PD unit. Supplies ordering and discharge planning should be formulated before training ends. Follow-up care is important in the PD program. Clinic visits, telephone contacts, home visits, continuing patient education, community support, and patient record-keeping are essential for continuity of care in renal patients. Regular reassessment is preferable, and retraining is carried out when required (20). The PD unit should also establish a back-up system. A 24-hour renal consultation service is preferable. Otherwise, guidelines and protocols for management of common dialysis-related complications should be made available to the responsible oncall team. A back-up system should provide supportive hemodialysis services when required. Program Evaluation: The CAPD training program should be evaluated for its cost effectiveness. Outcome indicators such as rates of peritonitis and exitsite infection, adequacy of dialysis, rates of unplanned readmission, and patient satisfaction are all important in reviewing the results of the CAPD training program. A monitoring system should be established for quality improvement of the CAPD training program and the PD service. THE EXPERIENCE AT PRINCESS MARGARET HOSPITAL When experiences are shared within the renal nursing specialty, nurses can become inspired and explore better ways to take care of patients. The CAPD training program at Princess Margaret Hospital (PMH) was set up in 1982. Over the years, changes have occurred. Those changes included the launch of a formal predialysis education program in the late 1980s; the shift from the straight-line CAPD systems to disconnect systems; and the development of the 5-day and 7-day training schedules in the mid-1990s. Our CAPD training program was refined for continuous quality improvement so that positive patient outcomes would be achieved. Currently, the outpatient clinic at PMH follows 403 patients receiving CAPD treatment (as at 30 September 2002). The PD unit has trained 1112 CAPD patients. Our peritonitis rate is approximately 1 episode every 24 patient treatment months, which falls within the ISPD 2000 guidelines/recommendations (8). Several critical factors have contributed to the success of our CAPD training program: The multidisciplinary team approach, including PD nurses competent in teaching patients A predialysis education program and pre-training assessment that prepares patients for CAPD training Supportive counseling and effective communication that enhance patient acceptance of, and compliance with, CAPD treatment A focus on learning objectives and training tailored to the needs of each patient Special emphasis on accurate connection during CAPD bag exchange procedures Prompt management of dialysis-related complications Quality monitoring of the CAPD training, with a final assessment by PD nurse leaders for each patient completing CAPD training Continuous patient education, and retraining of patients when necessary All of the above factors are essential components in the success and sustainability of our CAPD program. The PMH renal center has a philosophy and mission. The renal health care professionals who work at PMH are committed to providing high-quality care to their renal patients. CONCLUSION Training for CAPD is an important activity in PD units. The planning, implementation, and evaluation of a cost-effective patient education program are critical aspects in setting up and developing a CAPD program. The PD team should adopt evidence-based practice with PD guidelines, protocols, and care standards. The training program should consist of patient S181

PROCEEDINGS OF THE FIRST ASIAN CHAPTER MEETING ISPD DECEMBER 2003 VOL. 23, SUPPL 2 PDI pre-training assessment, training, and follow-up care. The PD nurses should identify key learning objectives for the training. The content and schedule of CAPD training, training assessment, and teaching methods are essential elements of patient training. Forms or checklists should be developed to facilitate training and documentation. Follow-up, home visits, and community support are essential for continuity of care in CAPD patients. Back-up dialysis support should be made available in the renal unit. Good patient outcomes will result from an effective educational program for CAPD patients. REFERENCES 1. Welch JL, Fisher ML, Dayhoff NE. A cost-effectiveness worksheet for patient-education programs. Clin Nurse Spec 2002; 16:187 94. 2. Schatell D, Sacksteder P, Curtin RB. Can forging a partnership with staff help patients believe they can live long and well on dialysis? Contemp Dial Nephrol 2001; 22:25 6. [Available online at: www.ikidney.com/ ikidney/infocenter/cdn/archive/canforginga PartnershipWithStaffHelpPatientsBelieve.htm] 3. McIntyre S. Team rehab: enriching life with kidney disease through patient rehabilitation. Contemp Dial Nephrol 2001; 22:19 21. 4. Collmenter A. Training and Education, Basics in Dialysis. Products and Services Peritoneal Dialysis. Corporate Marketing and Technology. Bad Homburg, Germany: Fresenius Medical Care; 1998. 5. Burkart J. The Dialysis Outcomes Quality Initiative guidelines: a new standard for everybody? Perit Dial Int 2000; 20(Suppl 2):S52 7. 6. Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001: 281 405. 7. Gokal R, Alexander S, Ash S, Chen TW, Danielson A, Holmes C, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. (Official report from the International Society for Peritoneal Dialysis). Perit Dial Int 1998; 18:11 33. 8. Keane WF, Bailie GR, Boeschoten E, Gokal R, Golper TA, Holmes CJ, et al. Adult peritoneal dialysis related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20:396 411. 9. Levy J, Morgan J, Brown E. Oxford Handbook of Dialysis. New York: Oxford University Press; 2001: 568 77. 10. National Kidney Foundation. NKF DOQI Clinical Practice Guidelines. Executive Summaries. New York: National Kidney Foundation; 1997: 28 52. 11. Lai KN, Lo WK. Optimal peritoneal dialysis for patients from Hong Kong. Perit Dial Int 1999; 19(Suppl 3): S26 34. 12. Li PK, Szeto CC. Peritoneal dialysis. In: Quality Initiative Recommendation in the Provision of Renal Services. Hong Kong: Hong Kong College of Physicians and Central Renal Committee for the Hospital Authority; 2002: 34 46. 13. Lo WK, Cheng IK, Lui SL, Chan TM, Li FK, Lai KN. Is target Kt/V and patient survival different between Asian and Western continuous ambulatory peritoneal dialysis (CAPD) patients? Perit Dial Int 1999; 19(Suppl 2):S27 31. 14. Szeto CC, Wong TY, Leung CB, Wang AY, Law MC, Lui SF, et al. Importance of dialysis adequacy in mortality and morbidity of Chinese CAPD patients. Kidney Int 2000; 58:400 7. 15. Li PK, Szeto CC, Law MC, Chau KF, Fung KS, Leung CB, et al. Comparison of double-bag and Y-set disconnect systems in continuous ambulatory peritoneal dialysis: a randomized prospective multicenter study. Am J Kidney Dis 1999; 33:525 40. 16. Youngblood B, Prowant BF. Peritoneal dialysis. In: Burrows Hudson S, ed. ANNA Standards and Guidelines of Clinical Practice for Nephrology Nursing. Pitman, NJ: American Nephrology Nurses Association; 1999: 71 84. 17. Wong YH, Chan A, Chan S, Chiu HF, Kong LL, Lee CW, et al., for the Working Group on Guidelines for Specialty Nursing Services. Guidelines for Specialty Nursing Services: Renal Care. Hong Kong: Coordinating Committee in Nursing for the Hospital Authority; 2001: 1 15. 18. Wong YH, Tam ML, Leung FY, Lee CW, Law MC, Kong LL, et al., for the Specialty Standards Subcommittee Renal Nursing. Standards for Renal Nursing Practice. Hong Kong: Hong Kong College of Nursing; 2001: 4 21. 19. Baxter Healthcare Corporation. A Peritoneal Dialysis Program Development Guide. Deerfield, IL: Baxter Healthcare Corporation; 1988. 20. Chau KF, Lo A. Guidelines for Ambulatory Peritoneal Dialysis Service in Hong Kong. Hong Kong: Hospital Authority; 1999. S182