Partnering with patients to improve peritonitis rates.
Article Type: Report
Subject: Peritonitis (Care and treatment)
Peritonitis (Prevention)
Nurse and patient (Management)
Self-care, Health (Methods)
Chronic diseases (Care and treatment)
Chronic diseases (Prevention)
Authors: White, Sharon
Vinet, Angela
Pub Date: 01/01/2010
Publication: Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136
Issue: Date: Jan-March, 2010 Source Volume: 20 Source Issue: 1
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 223216276
Full Text: Abstract

The London Health Sciences Centre (LHSC) peritoneal dialysis (PD) service is an active PD unit caring for approximately 100 patients. The service strives for optimal patient outcomes and, in doing so, regularly analyzes infection rates.

In 2003, the LHSC peritonitis infection rate was one episode in 56 patient months (1:56). Peritonitis rates remained acceptable in 2004 (1:41) and 2005 (1:57). In 2006, the PD team became concerned when the peritonitis rate demonstrated a significant deterioration to 1:31, with a further decline to 1:27 in 2007. Because the latter rate is below the accepted Canadian benchmark of 1:30, the PD team needed to respond to the downward trend.

The principles of E.Wagner's chronic disease care model and P. McGowan's patient-provider partnerships theory were used to guide the development of an intervention plan. A significant improvement in the peritonitis rate was demonstrated in 2008 and acceptable rates have been maintained for 2009.

Keywords: peritonitis, chronic disease, partnerships, patient self-management


The London Health Sciences Centre (LHSC) Regional Renal Program provides comprehensive care for patients with both progressive and end stage renal disease. It serves a large geographic region with a population catchment of approximately one million. The LHSC is academically affiliated with the University of Western Ontario, providing the clinical setting for medical, nursing, and other health care students.

Patients and methods

A common cause of PD failure is peritonitis, and these failures are no exception at LHSC. The PD team strives to meet or exceed the most commonly accepted Canadian benchmark of one peritonitis incident in 30 months on therapy (1:30) (Mujais, 2006).

The peritonitis problem

Figure One shows the annual peritonitis rates in the unit for 2001-2007. The poor rates in 2001 and 2002 were thought to be the result of a program merger of two units, each using different systems and products. Every nurse on the team was not familiar with two different vendors' systems, making standardization of care more difficult. It is believed this lack of standardization, along with many other challenges that mergers create, resulted in poor peritonitis rates at this time. Peritonitis rates improved with a targeted continuous quality improvement initiative in 2003. However, results slid in 2006 and did not meet benchmark in 2007. An action plan was required to reverse this downward trend.


Key measures for improvement

The PD team uses the Baxter Peritonitis, Organisms, Exit Sites and Tunnel Infections (POET) database to review its outcomes data to better understand the causes of PD failure rates prior to intervention on a quarterly and annual basis.

Intervention strategies process

Self-administered PD therapy is used to treat life-threatening chronic renal failure. In order to provide effective, therapeutic interventions for patients living with chronic disease, it is essential that health care providers (HCP) appreciate the significant differences between acute and chronic illnesses. Many HCPs are principally exposed to acute care and its corresponding interventions in their didactic and practical education as students. The interventions appropriate for acute care are often inappropriately applied to patients living with chronic disease. Table One demonstrates the differences between chronic and acute disease and important implications for the role of both the HCP and the patient (Lorig et al., 2004).

An effective HCP understands his or her role as teacher and partner in the care of people with chronic disease. A patient effectively coping with chronic disease is also a partner and fully engaged in daily management.

According to E. Wagner at the MacColl Institute for Healthcare Innovation, several key success factors required to achieve excellent outcomes have been identified in the chronic care model (Wagner, 1998) (see Figure Two). The LHSC change initiative focused on the development of an informed activated patient through enhanced partnerships with the health care team.


The differences between acute and chronic disease, as outlined by Lorig et al. (2004), have significant implications for the role of the HCP and the patient. Healthy partnerships between the HCP and the patient enable the patient to assume a more active role in his/her daily management. Wagner refers to this as an Informed Activated Patient. Positive role changes are required by both the patient and the HCP. The HCP must migrate from the traditional role of selecting and conducting therapy to that of teaching, coaching, and partnering. To become a better self-manager, the patient must migrate from following orders (adherence) to being truly responsible and accountable for daily management of his or her condition. Collaborative partnerships enable successful role changes, which, in turn, increase the likelihood of good outcomes or patient goal attainment (McGowan, 2008).

The required outcomes and successful role changes occur when team members and the patient develop collaborative partnerships. The key elements that define collaborative partnerships are: a recognition that the health care provider and the patient are both experts, provision for genuine two-way information exchange, provision for both partners to freely state preferences, and assurance that the partners can reach consensus on the treatment plan (McGowan, 2008). With these principles to work from, the team members redeveloped the peritonitis prevention teaching and maintenance program.

Intervention strategy tools

The team conducted a literature review to seek information regarding ongoing patient educational needs while on PD therapy. A general theme became apparent that with time, patient practice needs to be reassessed and refreshed to minimize risk. Age was not a risk factor and, in fact, patients less than 55 seemed to require the refresher to a greater extent than older patients (Russo et al., 2006).

Because of considerable staff turnover, the team first reviewed its own practice, standardizing all teaching materials and developing new "attention-grabbing" posters and brochures for patients.

Recognizing that the patient, as partner and provider, cannot afford knowledge gaps, the team developed a 48-question survey to identify learning needs. They administered this survey when the patient completed training, at six weeks on therapy, and in the event of a peritonitis incident. The patient's specific knowledge deficits were shared with the patient and re-education was based on these targeted learning needs. This targeted educational strategy supports the principle of adult learning by teaching/reviewing only those elements that the adult learner requires. The staff members were careful to share that the survey was not to be thought of as a test, but to be used to identify the patient's individual learning needs so that targeted education could be provided. Patient participation in the survey helped to achieve this informed activated patient (Wagner, 1998). The team intends to administer the survey annually for maintenance patients.

For patients who had developed a peritonitis incident, the results of the survey were reviewed with the patient, as already discussed. The patient was then asked to review a form titled, Patient Perception of Reason for Peritonitis (see Table Two) and to provide input as to the cause of the peritonitis. Once again, this form was not intended to test or scold the patient, but to recognize the patient as a full partner in care and to emphasize that the patient's technique and opinions both matter (McGowan, 2008).

The third document developed was a Flowchart for Peritonitis (see Figure Four). When a peritonitis incident occurred, the health care provider shared this flowchart and all the ensuing steps for treatment with the patient. The patient, in partnership with the staff, monitored each step of the process and became a better-informed and more willing participant in the overall process of care.


The final change included a monthly calculation and review of the peritonitis rate. Previously, this rate had been tracked quarterly. Not only is this information shared with the members of the health care team, but also it is now posted in the clinic waiting room to enhance patient awareness.

Peritonitis results

Most of the planning for this change occurred in the spring of 2007. Plans were tweaked in the fall of 2007, and full implementation occurred in January 2008. In 2007, the monthly peritonitis rate fell below the 1:30 benchmark in eight of 12 months, with the annual rate being 1:27. After implementation of the changes described earlier, the peritonitis rate fell below benchmark in only two of 12 months in 2008, with the annual rate being 1:47. Results year-to-date 2009 have not been as promising. The year-to-date average to the end of October continues to remain above 1:30 and is currently at 1:33 months (see Figure Three). In 2008, 15 PD patients (low acuity) were successfully transplanted. While hard data are not available, the nurses have "observed" an increase in patient acuity/co-morbidities from 2008 to 2009, which they feel is contributing to the greater incidence of peritonitis.



Implementation of the survey, patient perceptions of the reasons for peritonitis, use of the peritonitis flow chart, and frequent feedback on peritonitis rates demonstrated practical application of effective HCP/patient partnerships and enhanced the involvement of patients as partners in their health care. One of the PD nurses likes to say to the patients, "You're in the driver's seat; I'm here only to assist with occasional navigation." These changes resulted in significant improvements in the peritonitis rate in 2008 and an ability to achieve better than benchmark in 2009. The changes all occurred within a small period of time and, so, identifying any single strategy, as the most effective is difficult. Informal feedback from the health care team suggests that, if time constraints are a factor, the questionnaire may be the most effective tool because of frequency of administration and the resulting ability to customize teaching to the patients' specific learning needs.

Through many years of experience, the PD staff has learned that initial successes can slide unless vigilance is applied to constantly monitor, assess, and act, as needed. The team will continue to ground their interventions using sound principles of chronic disease management, emphasizing respectful partnerships and recognizing the key role that patients must play in maintaining their health.

By Sharon White, RN, BScN, MBA, and Angela Vinet, RN

Sharon White, RN, BScN, MBA, Director, Regional Renal Program, London Health Sciences Centre, London, ON.

Angela Vinet, RN, Peritoneal Dialysis Unit, Regional Renal Program, London Health Sciences Centre, London, ON.

Address correspondence to: Sharon White, RN, BScN, MBA, Director, Regional Renal Program, London Health Sciences Centre, Room ELL-409, Victoria Hospital, 800 Commissioners Rd E., PO Box 5010, London, ON N6A 5W9. E-mail:

Submitted for publication: October 7, 2009.

Accepted for publication in revised form: February 12, 2010.


We thank Susan McMurray and Sandee Matthews of Baxter Corporation for facilitating discussions on the LHSC's change process and all other members of the PD team for their contributions, including Peter Cordy (nephrologist), Peter Blake (nephrologist), John Johnson (nephrologist), Deborah Bezaire (manager, peritoneal dialysis and chronic kidney disease clinics, inpatient nephrology), Karen Peters (manager, regional and home dialysis units), Judith Szabo (registered nurse), Rita Baker (registered nurse), Darlene Wadsworth (registered nurse), Joanne Gullo (registered nurse), Joan Carter (registered nurse), Michelle Ivanouski (registered nurse), Neemera Jamani (registered nurse), Mary Racine (clerk), and Jill Dalke (clerk).


Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., Minor, M., et al. (2004). Living a healthy life with chronic conditions. Boulder, CO: Bull Publishing Company.

McGowan, P. (2008). 10 years of chronic disease self-management, BC experience. Keynote Address, Taking Charge of Our Health, Canadian Conference on Integrated Chronic Disease Self-Management, October 23-24, 2008.

Mujais, S. (2006). Microbiology and outcomes of peritonitis in North America. Kidney International, 70, S55-S62.

Russo, R.,Manili, L.,Tiraboschi, G., Amar, K.,De Luca,M., Alberghini, E., et al. (2006). Patient re-training in peritoneal dialysis: Why and when it is needed. Kidney International, 70, S127-S132.

Wagner, E.H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1(1), 2-4.
Table One: Differences between acute and chronic disease

                 Acute Disease    Chronic Disease

Beginning        Rapid            Gradual

Cause            Usually one      Many

Duration         Short            Indefinite

Diagnosis        Commonly         Often uncertain, especially
                 accurate         early

Diagnostic       Often decisive   Often of limited value

Treatment        Cure common      Cure rare

Role of          Select and       Teacher, partner
Professional     conduct therapy

Role of Patient  Follow orders,   Partner with health
                 adherence        professionals, responsible for
                                  daily management

Adapted from "Living Healthy Life with Chronic Conditions" by
K. Lorig, H. Holman, D. Sobel, D. Laurent, V. Gonzalez, M. Minor,
and P. McGowan. 2004. Bull Publishing Company.

Table Two. London Health Sciences Centre

Checklist for Patient Perception of Peritonitis. Complete when
treating patient with peritonitis protocol

Patient Perception of Reason for Peritonitis
What caused your peritonitis?

Date:                              RN:

Answer:                            Yes     No     Comments

Touch Contamination


Incorrect Procedure

Adding Medications



Tubing Separation

Unclean hands

Drying hands with paper towel

Pump soap


Warming solution

Other--State Patient Belief

Don't know

Is there a medical condition that
contributed to this peritonitis?

Nurse Assessment
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