New directions in peritoneal dialysis patient training
Gayle Hall
Since the emergence of home peritoneal dialysis (PD) as an alternative to incenter hemodialysis for chronic renal replacement therapy in the late 1970s, the percentage of dialysis patients on PD has continued to decrease each year. At the end of 1991, approximately 14% of dialysis patients were on PD; falling to 13.1% in 1996; 9.3% in 1999, and 8.0% in 2001 (United States Renal Data Service [USRDS], 2001, 2003).
A major element of any PD program is patient training. Upwards of 90% of the care received by home dialysis patients is self-administered in the home. The ability to convey information and facilitate learning as behavior change is imperative to cultivate and retain successful home dialysis patients.
Few nurses involved in PD patient training have had any formal education in patient education or training or any exposure to adult learning theory and curriculum development. “It is a common but erroneous belief that anyone can teach PD, but … success depends upon the approach adopted” (Uttley & Prowant, 2000, p. 365). There remains a great deal of variability from patient training program to program, with little measurable consistency or standardization. For these reasons it has been difficult to consider patient outcomes as a function of training received by patients.
Review of Literature
Literature is scarce regarding PD training programs. Lauder and Zappacosta (1998) described components of a successful continuous ambulatory peritoneal dialysis (CAPD) training program based on adult education principles. The program they describe extends 7-10 days and proceeds at an individualized pace. Procedures are practiced repeatedly with nursing feedback and reinforcement. Problem solving is simulated as real life scenarios, requiring learners to identify problems and select appropriate solutions as they would at home.
The PD training setting was discussed by Hofmann and colleagues (2000) and Davies, Tatchell, Davies, Fallon, and Coles (2000). Hofmann et al. (2000) described increased patient, nurse, and physician satisfaction with home administered PD training. Training was individualized to the patient and to their environment. Davies et al. (2000) saw in-home patient training as more efficient than incenter training as measured by time required to train. Castro et al. (2002) concurred with the increased effectiveness of patient training in the home and found it correlated with a decrease in unit peritonitis rates from 1 episode per 24.5 patient mouths to 1 episode per 44.4 patient months.
Keeping, English, and Fleming-Courts (2001) examined informal learning in CAPD patients and found that learning increased when learners were asked to discuss their experiences or answer direct questions. Barriers to learning included low literacy levels and a diminished sense of personhood.
Norcott and Taylor (1998) described the importance of assessing patient abilities to perform PD self-care activities prior to discharge home. They utilized a patient self-assessment tool to determine patient perception of ability for self-care.
Compliance as a result of training has been examined as well. Kutner (2001) explained the importance of the locus of control utilizing proactive collaboration in acquisition of self-management skills. A non-authoritarian approach was found to help empower patients through partnering.
Curriculum Development
Due to the perceived need for effective, standardized PD patient training, a collaborative task force from Gambro Healthcare and Baxter Healthcare was formed in April 1997 to develop curricula. Dr. Terry TenBrink provided guidance on educational theory. The stated goal was to “improve clinical outcomes by standardizing patient education thus improving learning efficiency while maintaining/encouraging the flexibility needed to successfully meet individual patient needs.” The project eventually came to be named PD Directions.
The major premise of the PD Directions curriculum was to focus on what the learner needs to learn rather than on what the teacher needs to teach. This required the Task Force members to change their perceptions of teaching and learning 180 degrees. The learner role is to process information so that the desired learning outcome is reached (see Table 1). The teacher role is to provide information and help the learner process it until the desired learning outcome is reached.
A learning outcome can be described as an objective. An example would be: “When presented with a variety of supplies, the learner will be able to differentiate between sterile and unsterile items.” These clear learning outcomes/objectives help define when the learning has occurred. The lesson is not complete until the objective has been met. Depending on learner variables, such as cognitive function and prior knowledge base, completion of the objective ranges from immediate to prolonged.
Teaching and Learning Concepts
The PD Directions curriculum uses adult learning theory to teach home PD patients. One technique, Getting the Learner Ready, prepares the learners by telling them what they will learn, what the teacher will do, what the learners needs to do, and how teacher and learners will recognize when learning has occurred. Each learning plan begins with a sample script for getting the learner ready (see Table 2). This method was studied by Ley et al. (cited in Redman, 2001) and found to produce considerable increases in recall.
Cognitive Processing
Teaching is segmented into the type of cognitive processing needed in order to learn. At any time, one of three domains of learning is engaged (see Table 3). The cognitive domain includes memorization, concept formation, application of principles, making judgments and decisions, and problem solving. The psychomotor domain includes motor skill acquisition. The affective domain includes acquiring attitudes and changing behaviors (TenBrink, 1989). Example learning outcomes for each kind of learning in the cognitive and psychomotor domains are displayed in Table 4.
Cognitive domain. The lowest level of learning in the cognitive domain is memorization. The goal of memorization is to drive words or images into long-term memory. These images learn and fade fast–generally within seconds to minutes (TenBrink, 2002). Organizing and linking information to previously acquired knowledge expedite learning. Utilizing activities perceived as fun increases the likelihood of retention. Mnemonics are used to facilitate learning. The first letters of each word of an unrelated phrase are used to represent the information to be memorized. An example from the PD Directions curriculum would be: “Mother bakes perfect chocolate chip cookies for people” is used to represent the supplies necessary for an exchange (mask, bag, pad, clamps, caps, cleaner, flowsheet, and pen).
Two kinds of memorization learning are recognized. Paired associate learning involves cause and effect relationships (e.g., medications). Medications can be learned through paired-associate learning, using five-piece puzzles, uniquely shaped and colored, each piece of which represents name, dosage, administration, how the medication works, and special precautions. Serial learning involves information that must be learned in a certain order, such as the steps of a procedure. As discussed below, serial learning is utilized in the cognitive stage of motor skill learning.
Concept formation involves placing information into categories, based on critical characteristics such as “sterile” versus “unsterile” items. Learning concepts is not the same as memorizing facts. Merely trying to memorize all possible presentations of a concept without learning the critical characteristics does not result in concept formation. A learner who truly understands a concept will be able to recognize the same situation in an unfamiliar context. The objective of the concept learning plan is for the learner to be able to differentiate between items/situations that illustrate the concept and those that do not.
Concepts are taught by giving the learner a definition of the concept; then providing examples and non-examples illustrating the concept. The teacher asks the learner to state which examples illustrate the concept and gives feedback. Illustrations begin with items that are very different, progressing to more similar examples and then to single illustrations. When the learner is selecting the correct response the majority of the time, the teacher then asks the learner to give a definition of the concept in his or her own words.
Principle learning links concepts to form rules in an “if/then” relationship. Learners must master underlying concepts before moving on to principles. To learn principles, learners are first presented with the principles then work through a variety of situations illustrating the principles, and finally restate the principles in their own words.
Judgment/decision learning involves discrimination–being able to identify change. The learner learns to identify the situation (judgment) and describe the action steps that need to be taken (decision). The teacher gives sample problems and states the correct action(s). The learner is then asked, for example, “If you saw a drain bag that looked like this (showing picture of cloudy bag), tell me what you would do.” The learner should be able to describe to the teacher the action steps to be taken.
Problem solving is the highest form of learning in the cognitive domain. In order to problem solve, the learner must realize that a problem exists, understand the nature of the problem, search the problem space for a suitable solution, and enact the solution. This is best taught through demonstration. Role playing with simulated problems allows learners to practice what they would do if the same situations occurred at home. As an example, when teaching about contamination, the teacher could present several situations that might cause peritonitis: a pet in the exchange area, an uncapped transfer set on a lap pad, a hole in the catheter tubing. The learner must recognize the situation as a problem (this represents contamination), state the nature of the problem (it can lead to peritonitis), and perform the appropriate action (remove the pet, cap the transfer set, clamp and cover the tubing, then call the unit). Role play might involve looking up the clinic number and using a phone simulator when calling the nurse is indicated. This ingrains the pattern so that in a stressful situation, the learner can “pull” the problem solution from memory.
Psychomotor domain. The psychomotor domain includes motor skill learning. Motor skills are those activities that the average adult must practice. Examples include giving an injection, spiking a dialysate bag, or connecting to the dialysis tubing.
Motor skills involve three distinct stages of learning and involve three areas of the brain. First is the cognitive stage, during which the cerebral cortex employs serial memorization of the steps to take. The learning outcome of the cognitive stage is that the learner will repeat the steps of the skill. This is best accomplished through three demonstrations of the skill from the learner’s perspective. At first, the skill is demonstrated silently, just as the procedure is normally performed. During the second demonstration, the teacher again performs the skill while describing each step with great detail–describing hand movements, finger positions, supply and equipment particulars. During the third demonstration, the teacher uses collapsed steps or “labels” as descriptors while the actions are being performed. An example of labels: “set up–break blue–remove pull ring–remove cap–connect.” Once the learner can repeat the labels, the cognitive objective has been met.
Next is the practice stage, during which the cerebral cortex teaches the memorized steps to the muscles. The learner practices with teacher supervision, until the skill is learned. First, the teacher gives constant feedback, verbally reinforcing the learner on everything the learner is doing right. As performance continues, the learner begins to give self-feedback, independently monitoring, and correcting errors. The teacher’s feedback fades as the learner takes over, preventing the learner from becoming dependent on the feedback.
Errors in performance are corrected immediately. Interrupt errors are serious lapses and require starting over at a logical point. Non-interrupt errors are remedied with a simple verbal or physical demonstration of the desired action. All corrections are done in a positive manner to avoid planting suggestions of undesired behaviors. The learner is told what the desired behavior is (“keep your hands in the center of the sink”) rather than the undesired (“don’t touch the sides of the sink”). Throughout the curriculum, every effort is made to model only desired behaviors.
Last is the autonomic stage, where the pattern of movement reaches the cerebellum. At this point, the skill is relatively permanent. The upper brain (cerebral cortex) is freed to make judgments and decisions and to problem solve. While the learner is practicing the skill, the teacher tests for this phase by asking unrelated questions. If the learner is able to converse and perform the skill without hesitation or error, the autonomic stage has been reached.
Perceptual Styles
Three kinds of perceptual styles are associated with learning. Visual learners learn best through sight: tools such as pictures, flashcards, and videos promote learning. Pictorial learning- has been shown to be superior in triggering recognition and recall (Redman, 2001). Auditory learners learn best through hearing. For them, involvement in the learning process is triggered through questions, verbal scenarios, and dialogue. Kinesthetic learners learn best through touch: providing a wealth of tactile experiences through manipulation of pictures, flashcards, puzzles, supplies, and equipment supplements the learning process (Clark, Stanhope & Lancaster, 2002). The PD Directions program provides tools to engage learners of each perceptual style.
Patient Training Study
The comprehensive question of the study was: Would use of this training methodology improve patient outcomes? A prospective, multicenter study was designed. The study hypothesis was, “Does use of the PD Directions Curriculum (hereafter termed new teaching methodology) result in more efficient training time, decreased infections, improved retention on PD, improved fluid balance, improved compliance, decreased hospitalizations, and improved patient outcomes related to standards of care for anemia, adequacy, osteodystrophy, and nutrition?”
Design
The research design for this study was quasi experimental, with an experimental group (PG) of patients subjected to the new teaching methodology and a control group (CG) of patients trained by conventional means. The purpose of this design was to examine the effects of a standardized PD patient training curriculum, using adult learning methodology, on clinical outcomes compared with nonstandardized conventional training methods.
Sample
The target population was the home PD patient/learner. A non-probability convenience sample was utilized. Experimental sites were identified throughout the Gambro Healthcare PD clinics and through expressed interest by PD nurses after viewing a demonstration of teaching techniques. The sample was well stratified geographically, with 18 pilot sites representing 11 states. A comparable number of equivalent control centers were identified by their willingness to collect data and were equally well distributed geographically.
Inclusion criteria were new patients trained on PD. Exclusion criteria were non-English speaking patients, legally blind patients without a sighted caregiver, patients residing in nursing homes, and those who had received previous training in PD. A total of 620 patients enrolled; 246 in the PG and 374 in the CG, representing 5,023 patient months: 2,160 in the PG, 2,863 in the CG.
Demographic Information
About half of the sample (49%) was female. They were not equally distributed between the two groups. Chi-Squared test showed that there were significantly more females (54%) within the PG than within the CG (46%). The ethnic composition was 54% Caucasian, 36% African-American, 5% Hispanic, and 5% Other. There was no difference in the ethnic distribution between the two groups, except for Hispanic patients, who were slightly more represented on the PG group. Diabetic patients represented 50% of the sample and they were equally distributed between the two groups. The mean age at start on the study was 53.7 years with a standard deviation of 24.4. The t-test for comparison of the means showed no difference in age between the two groups (PG = 53.9, SD = 15.1; CG = 53.6, SD = 29.0) (see Table 5).
Instrumentation
Initial baseline data from 1999 regarding census, overall peritonitis rates, and retention on PD were obtained from the pilot and control centers. During the years 2000-2001, data was collected from the pilot centers on new patients trained using the new teaching methodology. The same data was collected from the control centers on all new patients trained during the same period, but with no change in the centers’ teaching programs. Data during the study period were obtained from Gambro Healthcare’s computer system (RIMS) and two manual data collection tools used to track the selected outcome criteria.
According to the DHHS (1991), research on regular or special educational strategies and conducted in commonly accepted educational settings is exempt from Institutional Review. Furthermore, this study represented no known risk to patients and involved no procedures for which written consent is normally obtained outside of the research context. Consent to PD therapy implies consent to be trained. Therefore, additional written consent outside consent for treatment was waived.
Results
Training time. Mean training time in the PG was 29.0 hours versus 22.6 hours in the CG (p < .0001). Mean retraining time was 8.7 hours in the PG versus 12.5 hours in the CG, but this did not reach statistical significance (p = .1324). When added together, the average total training and retraining time differed by only 2.6 hours (PG = 37.7, CG = 35.1 hours).
Infection. The occurrence of infection was measured in two ways: the time to the first infection and the number of infections per patient-month. Two types of infections were considered: peritonitis and exit site infections (ESIs). Cox Regression Analysis was performed to test if the time to the first infection showed any difference between the two groups. A test for comparison of proportion was applied to test if the number of infections per patient-month showed any difference between the two groups. The Cox regression analysis did not show any difference between the two groups with regard to the first peritonitis, the first ESI, or to any infection.
The comparison of proportions showed enough evidence to imply that the number of ESIs per 1,000 patient-months was smaller within the PG (18.5 ESIs per 1,000 patient-months) than within the CG (31.8 ESIs per 1,000 patient-months) (see Figure 1 and Table 6) The interval between ESIs was 53 patient months in the PG versus 30.5 patient months in the CG (p=.003.19) (see Figure 2 and Table 6).
The peritonitis rate per 1,000 patient months was 28.2 episodes in the PG versus 36.7 episodes in the CG (see Figure 3 and Table 6). The average interval between peritonitis episodes was longer in the PG (one episode every 34.4 patient months) than in the CG (one episode every 26.3 patient months). This was in comparison to the pre-study peritonitis interval of 1:20 patient months in the PG and 1:33.2 patient months in the CG (see Figure 4 and Table 6). Neither of these values reached statistical significance (p = 0.9783) (see Tables 7 and 8).
Retention related to infection was higher in the PG than in the CG. Twenty-one patients (5.6%) in the CG dropped out to hemodialysis secondary to infection (peritonitis and ESIs) as compared to 4 patients (1.6%) in the PG (p = .0069) (see Figure 5).
Fluid balance. Nurses rated patients’ fluid status monthly at the clinic visits based on a 5 point scale (0-4 points) with a maximum score of 4. Patients received 1 point each for weight within 5 pounds of dry weight, blood pressure less than 140/90, absence of symptoms of fluid overload (edema, dyspnea, crackles), and absence of symptoms of dehydration (dizziness, orthostasis). There was sufficient evidence to indicate that the fluid balance score was related to the training method. A Chi Squared test of independence was performed, and it was found that patients in the PG were more likely to score 4, while patients scoring in the CG were equally likely to score 4 than to score between 1 and 3. Within the PG, 1,141 patient scores (60.1%) were 4, while within the CG 1,110 patient scores (49.7%) were 4, and the rest (51.3%) were between 1 and 3. (p < .0001) (see Figure 6). Student's t-test comparing the mean fluid balance score demonstrated that the mean score within the PG (3.41) was significantly higher than the mean score within the CG (3.25). The test showed equal score variance between the two groups (see Figure 7).
Adherence to therapy. Nurses rated patients’ adherence to therapy monthly at their clinic visits based on a 5-point scale (0- 4 points) with 4 being the maximum score. Patients received 1 point each for attending clinic visits with completed home records, ordering enough dialysis supplies (as evidenced by the SIMPLE report, Baxter Healthcare, Deerfield, IL), avoiding expedited delivery charges, and bringing adequacy samples when requested. There was sufficient evidence to indicate that the compliance score was related to the training method. A Chi-Squared test of independence was performed, and it was found that patients in PG were more likely to score 3-4; while patients hi the CG were equally likely to score 4 than to score between 0 and 2. Within the PG, 1,761 patient scores (93.5%) were 3-4, while in the CG, 2,001 patient scores were 3-4 (89.7%) (p < .0001) (see Figure 8). Student's t test to compare the mean compliance scores demonstrated that the mean score within PG (3.62) was significantly higher than within the CG (3.52) (see Figure 9). The Satterthwaite method was applied because the two groups' variances were not equal.
Fewer hospitalizations. There were 1,370 hospitalizations, 478 in the PG versus 892 in the CG during the 24 months of the study. The average number of hospitalizations per patient-month within the PG was 0.1381, versus 0.1579 in the CG (p = .08).
Improved standards of care. Lab results were observed for 1 year starting on the 91st day of each patient’s enrollment in the program. Average results for each patient were calculated. T-test for comparison of means was applied to search for potential differences between the two groups on the mean of patents’ average for each lab test. There was sufficient evidence (t = -2.56, p = 0.0107) to indicate that the mean average Kt/V achieved by patients on the PG group was higher than the mean achieved by patients in the CG. Other laboratory results, although different between the groups, did not demonstrate statistical significance (see Table 9).
Discussion
Use of the PD Directions curriculum took an average of 28% longer than traditional, nonstandardized training methods. This was offset somewhat by the reduction in mean retraining time, although this did not reach statistical significance. Although Medicare has allowed 15 days for initial home PD training since the program’s inception, nurses have been pressed to train patients in less and less time. This study demonstrates a possible correlation not only between the methodologies but suggests increased training time may lead to better outcomes. It is important not to merely substitute quantity of time for quality of instruction and meeting of specific learning objectives.
The interval between ESIs was significantly longer in the PG (1:54 patient months) versus the CG (1:31.5 patient months) (p = .00349). The interval between peritonitis episodes lengthened from 1:20 patient months baseline in the PG to 1:34.4 patient months, while it shortened in the CG from 1:33.2 patient months baseline to 1:26.3 patient months over the 24 months of the study. Further study might demonstrate statistical significant differences in peritonitis rates between the two groups.
While this did not reach statistical significance, it is perhaps clinically significant. The statistically significant difference in the percentage of patients experiencing PD technique failure secondary to infection (1.6% in the PG vs. 5.6% in the CG; p < .0001) implies that even when Directions-educated patients were infected, they were better able to detect, report, and self manage through the recuperative process, thus avoiding dropout to hemodialysis.
Many anecdotal reports of success were achieved with the study teaching methods. Nurses reported that learners trained in this manner demonstrated better problem solving skills, made fewer phone calls to the unit, had improved ability to communicate with the health care team, and were more confident in their abilities.
Not all learners are created equal. By recognizing those who are unable to master judgments and decisions and problem solving, nurses can address their learning deficits through planning for care and proactively questioning them about problems. Nurses can reinforce contact information and health care team availability for those unable to attain the higher levels of cognitive learning.
It is recognized that some confounders to the study exist. The nature of PD programs and patient recruitment defied true randomization between the PG and the CG. Other than the exclusion criteria, all candidates selected for PD training were eligible and enrolled in the study. Although every effort was made to stratify the clinics by geography and community, it is recognized that the groups may not have been truly equal.
Both the experimental and control groups were composed of clinics that volunteered; both groups demonstrated the discipline required in collecting substantive data. In addition, the PG individuals demonstrated the willingness to explore new techniques for training, incorporate them into practice, and collect data as well. The questions might be asked if these individuals represent the norm in clinical practice and if other techniques and practices led to improved outcomes instead of the training methods. When one examines the peritonitis rates, for example, the PG rate improved from 1:20 patient months to 1:34.4 patient months, or 72%, while the CG rate declined from 1:33.2 patient months to 1:26.3 patient months, or 26.3%.
Even with evidence correlating these teaching techniques with positive patient outcomes, implementation is challenging. The primary concern voiced by clinician-teachers is perception of the time commitment for initial training. It is difficult to quantify time savings after training from fewer phone interactions and patient clinic visits with problems. These techniques require more upfront preparation than traditional explanations. To facilitate ease of use, the original study training materials, which were perceived as massive and intimidating, were extensively reformatted to make a simpler, more user-friendly process. Only through repeated use with positive patient feedback do clinician-teachers begin to realize the benefits of the learning methodology.
Conclusion
Utilizing scientific principles of adult learning to train home PD patients requires changing previously held beliefs about teaching and learning. Techniques such as Getting the Learner Ready, organizing curriculum by domain and kind of learning, and using materials relating to all perceptual styles facilitates transmission of content. Using the adult learning, theory-based training method curriculum was positively associated with improved patient outcomes in the PD population studied. While the study showed improvement in ESIs, retention related to infection, fluid balance, compliance, and Kt/V, further and longer study might demonstrate more statistically significant difference in other variables as well. The challenge of changing culture and practice remains the most daunting aspect of the process.
Table 1
Teacher/Learner Roles
Learner Role
To process information so the desired
learning outcome is reached.
Teacher Role
To provide the information and help
the learner to process it so that the
desired learning outcome is reached.
Table 2
Sample Script for Getting the Learner Ready
“At the end of this lesson, you will be able to tell whether something
is sterile or not sterile. I will tell you what makes something
sterile or unsterile. Then I’ll show you pictures representing items
that are either sterile or unsterile, and ask you to tell me whether
each item is sterile or unsterile. I’ll tell you if you are right or
wrong, and why. It’s OK if you make mistakes, because that is how you
learn. We will keep doing this until you are getting them all correct
and then we’ll know you’ve got it.”
Table 3
Domains of Learning
Cognitive
Memory
Concepts
Principles
Judgment/Decision
Problem Solving
Psychomotor
Motor Skills
Affective
Behaviors
Attitudes
Table 4
Example Learning Outcomes/Objectives
Cognitive Domain:
Memory: The learner will gather supplies needed for an exchange.
Concept: The learner will differentiate between sterile and
unsterile items.
Principle: The learner will recognize and state the principles: if
something sterile touches something unsterile, it is
contaminated; if contamination occurs, peritonitis may
result.
Judgment/Decision: The learner will recognize situations that may lead
to peritonitis and state the appropriate action to
take.
Problem Solving: The learner will recognize contamination and
demonstrate the action to take.
Psychomotor Domain:
The learner will demonstrate safe connection to the dialysis system.
Table 5
Demographic Information
Study PG CG
Sex Male 51% 46% 54%
Female 49% 54% 46%
Race White 54% 54% 54%
Black 36% 36% 36%
Hispanic 5% 5% 5%
Other 5% 5% 5%
Diabetes 50% 50% 50%
Mean Age 53.7 53.95 53.6
SD 15.1 SD 29.0
PG = Experimental Group CG = Control Group
Table 6
Infection Data
ESI’s
Interval
No. of Rate/100 Between
Pt Mo. ESI’s Pt Mo. Episodes
CG 2,863 91 31.8 1:30.5
PG 2,160 40 18.5 1:53
Peritonitis
Interval
Pt Mo. No. of Rate/100 Between
Peritonitis Pt Mo. Episodes
CG 2,863 105 36.7 1:26.3
PG 2,160 61 28.2 1:34.4
Pt Mo. = Patient Months, CG = Control Group,
PG = Experimental Group
Table 7
Infection Data
ANY INFECTION
Standard 95%
Parameter DF Estimate Error Confidence Limits
Intercept 1 8.0312 0.2502 7.5408 8.5216
GROUP CG 1 -0.2127 0.2633 -0.7288 0.3034
GROUP PG 0 0 — — —
Scale 1 1.7113 0.1187 1.4938 1.9605
Weibull Shape 1 0.5844 0.0405 0.5101 0.6694
PERITONITIS
Standard 95%
Parameter DF Estimate Error Confidence Limits
Intercept 1 8.3767 0.2861 7.8158 8.9375
GROUP CG 1 -0.0071 0.2728 -0.5417 05276
GROUP PG 0 0 — — —
Scale 1 1.4638 0.1258 1.2369 1.7325
Weibull Shape 1 0.6831 0.0587 0.5772 0.8085
ESI
Standard 95%
Parameter DF Estimate Error Confidence Limits
Intercept 1 9.9184 0.5022 8.9342 10.9027
GROUP CG 1 -0.6316 0.4198 -1.4543 0.1911
GROUP PG 0 0 — — —
Scale 1 1.9265 0.1871 1.5926 2.3305
Weibull Shape 1 0.5191 0.0504 0.4291 0.6279
ANY INFECTION
Chi-
Parameter DF Square Pr > ChiSq
Intercept 1 1030.25 <.0001
GROUP CG 1 0.65 0.4193
GROUP PG 0 — —
Scale 1
Weibull Shape 1
PERITONITIS
Chi-
Parameter DF Square Pr > ChiSq
Intercept 1 856.98 <.0001
GROUP CG 1 0 0.9793
GROUP PG 0 — —
Scale 1
Weibull Shape 1
ESI
Parameter DF Chi- Pr > ChiSq
Square
Intercept 1 390.06 <.0001
GROUP CG 1 2.26 0.1324
GROUP PG 0 — —
Scale 1
Weibull Shape 1
Table 8
Calculating Infection Rates
In peritoneal dialysis, infection rates are most often measured in
episodes per patient-month. This can also be thought of as the
interval between episodes of infection. The longer the interval is
between infections, the better. Nationally, the average is about
1:24 patient months for peritonitis (Keane, et al, 2000) and about
1:18-24 patient months for exit site infections. It is essential
that peritonitis and exit site infection rates are monitored as
meaningful values; otherwise the mere number of infections in a
program may look deceptively small. Yet, when the same number of
infections is calculated cumulatively as infections per patient-
month, a serious problem may be identified in need of immediate
address.
Table 9
Mean Laboratory Test Values
Test CG PG
% T-Saturation 32.1 30.9
Albumin 3.5 3.5
Calcium 9.2 9.1
Ferritin 517.0 441.0
Hemoglobin 11.6 11.7
PTH 396.0 383.0
Kt/V * 2.3 2.4
* Statistically significant difference
Figure 1
Exit Site Infections Per 1,000 Patient Months
Experimental Group (PG) 18.5
Control Group (CG) 31.8
p = 0.00349
Note: Table made from bar graph.
Figure 2
Exit Site Infection Rate
Average Interval Between ESI’s
Patient Months
Control 30.5
Group
(CG)
Experimental 53
Group
(PG)
p = 0.00349
Note: Table made from bar graph.
Figure 3
Peritonitis Rates Per 1,000 Patient Months
Experimental Group (PG) 28.2
Control Group (CG) 36.7
p = 0.09873
Note: Table made from bar graph.
Figure 4
Peritonitis Rate
Average Interval Between Peritonitis Episodes
Patient Months
Pre-Study Period Post-Study Period
Control 33.2 26.3
Group
(CG)
Experimental 20.0 34.4
Group
(PG)
p = 0.09873
Note: Table made from bar graph.
Figure 5
Patients Transferring to Hemodialysis Secondary to Infection
Experimental Group (PG) 1.6%
Control Group (CG) 5.6%
p = 0.0069
Note: Table made from bar graph.
Figure 6
Fluid Balance Scores
Percent Scoring 4
Experimental Group (PG) 60.1%
Control Group (CG) 49.7%
p = <.0001
Note: Table made from bar graph.
Figure 7
Fluid Balance Scores
Mean Score
Experimental Group (PG) 3.41
Control Group (CG) 3.25
p = <.0001
Note: Table made from bar graph.
Figure 8
Compliance Scores
Percent Scoring 3-4
Experimental Group (PG) 93.5%
Control Group (CG) 89.7%
p = <.0001
Note: Table made from bar graph.
Figure 9
Compliance Scores
Mean Score
Experimental Group (PG) 3.62
Control Group (CG) 3.52
p = <.0001
Note: Table made from bar graph.
Acknowledgments: The authors wish to acknowledge the assistance of Dr. Juan Bosch, Linda Mattson, Rick Reese, Dr. Terry TenBrink, Dr. Steve Bander, the many nurses and dietitians who faithfully trained patients and collected data that validated the learning methodology, and the Gambro Executive Team without whose support this would not have been possible.
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Gaffe Hall, BSN, RN, CNN, is Peritoneal Dialysis Education Manager, Gambro Healthcare, Orange Park, FL. She is a member of ANNA’s Golden Isles Chapter.
Amy Bogan, BSN, RN, is a Chronic Kidney Disease Keymaster, Da Vita, Baltimore, MD. She is a member of ANNA’s Capitol Chapter. At the time of the project, she was Clinical Manager for Gambro Healthcare Peritoneal Dialysis programs in the Washington, DC, area.
Sandra Dreis, RN, CNN, is National Account Manager, Bone Care International, Rockledge, FL. She is a member of ANNA’s Treasure Coast Chapter. At the time of the project, she was Director of the Clinical Services Organization for Baxter Healthcare.
AnnMarie Duffy, RN, is Clinical Educator, Baxter Healthcare, Summit, NJ. She is a member of the Garden State Chapter of ANNA. At the time of the project she was a Peritoneal Dialysis Nurse for Gambro Healthcare in Summit, NJ.
Suzanne Greene, MEd, RD, LD/N, is Renal Dietitian for peritoneal and hemodialysis programs with Gambro Healthcare in Cincinnati, OH.
Karen Kelley, BSN, Rig, CNN, is Clinical Educator in the New York area, Baxter Healthcare Corporation Renal Division, Fairlawn, NJ. She is a member of ANNA’s PD SIG and Jersey North Chapter.
Holly Lizak, MSN, RN, CNN, is a Peritoneal Dialysis Program Director, Gambro Healthcare, Chula Vista, CA. She is a member of ANNA’s Nephros South Chapter.
Jose Nabut, MS, is Biostatistician, Gambro Healthcare Scientific Affairs and Clinical Research, Ft. Lauderdale, FL.
Vicky Schinker, MS, RN, CNN, is Clinical Educator, Renal Care Group in Wisconsin, West Allis, WI. She is a member of ANNA’s Wisconsin Chapter. At the time of the project, she was a Regional Education Coordinator for Gambro Healthcare.
Netta Schwartz, MEd, RD, LD/N, is Education and Development Manager, Gambro Healthcare Laboratory Services. Ft. Lauderdale, FL. At the time of the project, she was Dietitian Educator for Gambro Healthcare.
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