http://informahealthcare.com/rnf ISSN: 0886-022X (print), 1525-6049 (electronic) Ren Fail, 2014; 36(7): 1029–1032 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/0886022X.2014.927771
Implementation of a continuous quality improvement program reduces the occurrence of peritonitis in PD Jianwen Wang, Hao Zhang, Jun Liu, Ke Zhang, Bin Yi, Yan Liu, Jishi Liu, Xianming Zhang, and Ying Ji
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/30/15 For personal use only.
Department of Nephropathy, Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
Abstract
Keywords
Objective: To investigate the causes of peritonitis in patients with peritoneal dialysis (PD) using continuous quality improvement (CQI) to develop effective interventions and reduce the occurrence of peritonitis. Methods: A quality control team consisting of 10 members, including the department head, four nephrologists and four nurses, all specialized in PD care, and the head nurse, was established at the Peritoneal Dialysis Center of the Third Xiangya Hospital of Central South University. All patients with peritonitis occurring between 1 July 2010 and 31 December 2011 (pre-CQI period) were analyzed and compared with data obtained between January 2012 (implementation of CQI) and March 2013 to investigate possible causes of peritonitis and to develop corresponding interventions. Fishbone analysis, including laboratory parameters, was carried out monthly. Results: Gastrointestinal tract dysfunction, nonstandard procedures and malnutrition were found to be the top three risk factors for peritonitis. Gastrointestinal tract dysfunction was the likely cause of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p50.05). Nonstandard procedures were the cause of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (p50.05). The overall incidence of peritonitis reduced from once every 40.1 patient months before the CQI to once every 70.8 patient months after CQI (p50.05). The incidence of Grampositive bacteria peritonitis reduced from once every 96.9 patients per month before CQI to once every 209.1 patient months after CQI (p50.05), whereas the incidence of Gram-negative bacteria peritonitis reduced from once every 234.2 patient months before CQI to once every 292.8 patient months after CQI. Conclusion: CQI can effectively reduce the occurrence of PD-related peritonitis.
Continuous quality improvement, peritonitis, peritoneal dialysis
Introduction As one of the most common complications of peritoneal dialysis (PD), peritonitis is a significant cause for drop out from PD.1–3 Reducing the occurrence of peritonitis and providing effective treatment for PD patients has been a common but difficult problem for PD centers.4 Currently, there is no consensus on the risk factors for peritonitis, and there are no systematic or standardized global guidelines for monitoring and controlling the risk factors for peritonitis.5 Continuous quality improvement (CQI) is a concept of enterprise and system management that was developed in the 1950s.6 CQI enhances quality through the collection and quality assessment of data which targets a specific problem.7 CQI requires the co-participation of doctors, nurses, patients, and their relatives in quality-control activities. CQI was implemented in our PD program to decrease the incidence of peritonitis. Effective interventions which target the risk factors for peritonitis were used to reduce
Address correspondence to Hao Zhang, Department of Nephropathy, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province 410013, China. Fax: 0731-88618010; E-mail: [email protected]
History Received 21 December 2013 Revised 11 April 2014 Accepted 11 May 2014 Published online 18 June 2014
the occurrence of peritonitis and improve the quality of PD through four steps: Plan–Do–Check–Act.
Methods Subjects All subjects undergoing continuous ambulatory PD (CAPD) at the Department of Nephrology of the Third Xiangya Hospital of Central South University between 1 July 2010 and 30 June 2013 were enrolled in this study. CQI was implemented on 1 January 2012, and the occurrence of peritonitis before (1 July 2010 to 31 December 2011) and after the CQI implementation (1 January 2012 to 30 June 2013) was compared. At the same time, drop-out rate (DOR) and time on therapy (TOT) before and after CQI implementation were compared. DOR was calculated as: the number of patients quitting PD during 12 months / (the number of patients 12 months ago + the number of newly added patients during 12 months / the number of patients quitting PD between 2 and 12 months / 2). TOT (months) was calculated as: the total patient months / number of drop outs. ‘‘Total patient months’’ refers to the total number of months on PD for those patients withdrawing. DOR ¼ number of drop out / [N1 + (1/2) N2 (1/2) N3]; N1 ¼ initial number of
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Table 1. Laboratory tests in patients with and without PD-related peritonitis before CQI.
Parameter
Non-peritonitis group
Peritonitis group
Age 49.2 ± 10.6 50.8 ± 13.2 Dialysis duration 16.6 ± 21.1 15.3 ± 20.2 Blood pressure 142 ± 21 / 78 ± 11 143 ± 24 / 80 ± 13 Hemoglobin 75.91 ± 16.78 76.3 ± 23.73 Albumin 32.60 ± 4.92 26.05 ± 4.53* Blood urea nitrogen 20.55 ± 5.49 20.14 ± 11.57 Creatinine 915.7 ± 261.1 1017.1 ± 444.7 Middle molecular 292.8 ± 58.35 307.5 ± 36.62 substance Erythrocyte sedimentation 23.41 ± 9.13 89.61 ± 23.02* rate C-reaction protein 1.77 ± 0.34 6.77 ± 5.72* Parathyroid hormone 439.35 ± 368.26 451.99 ± 414.03
p Value 0.789 0.867 0.912 0.936 0.000 0.884 0.237 0.279 0.000 0.000 0.356
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Note: *p50.05 versus the non-peritonitis group.
patients; N2 ¼ number of new patients during the past 12 months; N3 ¼ number of patients who leave (for any reason such as death, transferring to hemodialysis or transplantation) during the past 12 months. ‘‘Number of drop outs’’ refers to those patients who stop PD during past the 12 months. Establishing a CQI team The quality control team consisted of 10 members, including: the department head (as the core of the team), four professional doctors, four professional nurses, and one head nurse. All members were retrained on the guidelines for the diagnosis, treatment, and prevention of peritonitis developed by the International Society of Peritoneal Dialysis (ISPD) at the time of CQI implementation. Identification of risk factors for peritonitis Data before CQI implementation were analyzed by dividing patients into two groups: with or without peritonitis. We found that serum albumin, erythrocyte sedimentation rate, and C-reaction protein levels in the peritonitis group were significantly worse compared with the non-peritonitis group (p50.05) (Table 1). Elderly patients, patients without social insurance, or those with lower educational levels had a higher risk of peritonitis (Table 2). When we looked at the causes of peritonitis, we found that gastrointestinal tract dysfunction (including abdominal pain and diarrhea), nonstandard operations, and malnutrition were the top three risk factors for peritonitis. A high incidence of Gram-positive bacterial infection was detected which was associated with nonstandard procedures, such as inappropriate hand washing or using broken catheters, or damaged solution containers (Tables 1–3). Action plans for improving existing problems To decrease the rate of peritonitis, based on what we found in the cause analysis, we implemented the following action plans: (1) Emphasized the importance of the standard exchange procedure and strengthened the training and retraining programs. Every new patient needs to pass an exam
Table 2. Characteristics of patients with peritonitis.
Parameter Gender Male Female Age 560 years 60 years Educational level Lower than senior high school Higher than senior high school Economic status Health insurance No health insurance Baseline disease Diabetes No diabetes
No. of cases
No. of cases with peritonitis (%)
112 98
42 (37.5%) 35 (35.7%)
40.05
161 49
53 (32.9%) 24 (49.0%)
50.05
99 111
42 (42.4%) 35 (31.5%)
50.05
171 39
59 (34.5%) 18 (46.1%)
50.05
46 164
15 (32.6%) 62 (37.8%)
40.05
p Value
Table 3. Possible causes for the occurrence of peritonitis. No. of episodes with peritonitis (%) Cause Gastrointestinal tract dysfunction Diarrhea Constipation Eating unclean food Operation-related causes Nonstandard operation Use of broken PD catheter or damaged PD bag Respiratory tract infection Inadequate treatment of previous episode Exit-site or tunnel infection Total
Before CQI n (%)
After CQI n (%)
18 (42.8%)
9 (36.0%)
10 (23.8%) 4 (9.5%) 4 (9.5%) 14 (33.3%) 10 (23.8%) 4 (9.5%)
4 (16.0%) 2 (8.0%) 3 (12.0%) 6 (24.0%) 4 (16.0%) 2 (8.0%)
3 (7.1%) 5 (11.9%)
5 (20.0%) 3 (12.0%)
2 (4.8%) 42 (100%)
2 (8.0%) 25 (100%)
including a PD exchange and a written test before being discharged from the hospital. If the patient is admitted to the hospital due to an episode of peritonitis, a retraining course should be done and a new exam should be passed. Since peritonitis has a high incidence during the summer and autumn due to sweating and seasonal diarrhea, additional retraining should be strengthened during these seasons. In addition, Cefoxitin was regularly given before and after the catheter implantation according to ISPD guidelines in our protocol. (2) Established a treatment process for patients at high risk of peritonitis. Subjects with diarrhea were given berberine hydrochloride tablets three times daily (three tablets each time) for 1 day. If they did not improve, norfloxacin was also prescribed (three times daily, one capsule each time). Patients were asked to seek medical care if norfloxacin was not successful within 2 days. For those patients suffering from continuous constipation, oral Maren capsules (a Chinese traditional medicine) were prescribed. Patients were asked to return to the center if symptoms persisted. As malnutrition is the
Implementation of CQI in peritonitis study
DOI: 10.3109/0886022X.2014.927771
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Table 4. Clinical data in patients undergoing PD before and after CQI.
Time Before CQI After CQI
No. of cases
Male/female
Age (years)
Duration of dialysis (months)
Hemoglobin level (g/L)
Albumin level (g/L)
Parathyroid hormone level (pg/dL)
268 354
160/108 195/159
51.8 ± 12.3 52.7 ± 14.2
24.8 ± 22.4 30.3 ± 24.68
70.12 ± 19.21 82.9 ± 19.54*
31.70 ± 3.49 38.24 ± 2.19*
662.21 ± 232.18 335.2 ± 198.34*
Note: *p50.05 versus before CQI.
Table 5. Clinical parameters in patients with peritonitis before and after CQI. Pathogens {[cases (%); patent months]}
Time
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Before CQI After CQI
Total patent months
Total cases of peritonitis
TOT
DOR
Occurrence of peritonitis (patent months)
2810 4392
70 62
22.31 28.80
25.32 22.58
40.1 70.84*
Gram-positive organisms 29 (41.4) 21 (33.9)
96.9 209.1*
Gram-negative organisms 12 (17.6%) 15 (24.2%)
234.2 292.8
Fungus
Negative culture
3 (4.3%) 2 (3.2%)
26 (37.1%) 24 (38.7%)
Notes: *p50.05 versus that before CQI; Statistical data were checked by a statistical expert.
major risk factor for peritonitis, nutritional supplements (dephosphorized animal proteins in addition to adequate supplementation of glucose and vitamins) and supplementation of a-keto acid compound or protein powder (Amway Nutrilite protein powder) were provided to subjects with serum albumin levels530 g/L. Anemia was treated using routine subcutaneous injections of erythropoietin, folic acid, and iron to maintain hemoglobin levels at 100–120 g/L. (3) Establishment of a green channel for peritonitis patients. A specialized outpatient clinic for PD was set up each week, and a special telephone line and Tencent QQ group were developed to respond to the patients’ questions at all times. A green channel for PD was established to provide timely treatment for patients with fever, abdominal pain, or turbid ascites. The follow-up period was shortened in patients at high risk for peritonitis. Statistical analysis SPSS 18.0 was used for statistical analysis. All measurement data were tested with normality and homogeneity of variance. Data with normal distribution were represented by mean ± SD The two groups were compared using independent samples t-test. Data with non-normal distribution were represented by median, the two groups were compared using the Wilcoxon rank sum test. Enumeration data were compared with v2 test. p Value50.05 was considered statistically significant.
Results Comparisons of clinical data in PD patients before and after a CQI There were no significant differences in gender and age among patients who started PD before and after the implementation of CQI (p40.05). Significantly elevated hemoglobin and albumin levels, and reduced parathyroid hormone levels were detected after CQI compared with
before CQI (p50.05) (Table 4). In addition, CQI resulted in an increase in hemoglobin levels from 70.12 ± 19.21 g/L to 82.9 ± 19.54 g/L, albumin levels from 31.70 ± 3.49 g/L to 38.24 ± 2.19 g/L, and parathyroid hormone levels from 662.21 ± 232.18 pg/dL to 335.2 ± 198.34 pg/dL, respectively, and there were significant differences in hemoglobin, albumin, and parathyroid hormone levels before and after CQI (p50.05). Comparison of peritonitis rates before and after CQI Gastrointestinal tract dysfunction induced the development of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p50.05). In addition, nonstandard procedures were also a common cause of peritonitis. After strict training and retraining courses, nonstandard procedures induced the development of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (Table 3). The overall occurrence of peritonitis significantly reduced from once every 40.1 patients per month before CQI to once every 70.8 patient months after CQI. The incidence of Gram-positive bacteria peritonitis reduced from once every 96.9 patient months before CQI to once every 209.1 patient months after CQI (p50.05), whereas the incidence of Gram-positive bacteria peritonitis reduced from once every 234.2 patients per month before CQI to once every 292.8 patients per month after CQI. DOR reduced from 25.32% before CQI to 22.58% after CQI, and TOT in PD patients increased from 22.3 months before CQI to 28.8 months after CQI (Table 5).
Discussion Based on the causes we analyzed and the actions we took via the CQI process, the incidence of peritonitis was effectively decreased within about 2 years.Our previous data showed that the rate of peritonitis in our center was not as good as those reported by other high-quality PD centers.8 Our data showed that age, gender, diabetes, and the time of dialysis had no significant associations with the occurrence
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of peritonitis, which was consistent with previous studies.4 However, gastrointestinal tract dysfunction and nonstandard procedures are common causes of peritonitis. Gastrointestinal tract dysfunction mainly includes diarrhea, constipation, and discomfort due to unclean food, whereas nonstandard procedures were mainly caused by inappropriate hand washing before the exchanges, the use of broken PD catheters, and damaged solution bags. Effective and timely training as well as preventive treatments for gastrointestinal tract dysfunction that we implemented in this study obviously have a significant role in preventing peritonitis. Nutritional management is part of the self-management of PD patients. As a common complication of PD, malnutrition may increase the mortality rate and the occurrence of other diseases.9 Inadequate protein intake and loss of nutrients are major causes of malnutrition.10 We evaluated the impact of nutritional status and intestinal function on the incidence of peritonitis in patients with CAPD, and compared the nutrition and inflammatory parameters between the peritonitis group and the non-peritonitis group during the same period. We found that erythrocyte sedimentation rates and C-reaction protein levels were significantly elevated and serum albumin levels were significantly reduced in the peritonitis group compared with the non-peritonitis group, and no significant differences in hemoglobin levels between the peritonitis and non-peritonitis groups. Logistic regression analysis showed that CAPD patients with albumin levels528.97 g/L easily developed peritonitis, which indicates that malnutrition was one of the causes of peritonitis. Gastrointestinal tract dysfunction was another risk factor for peritonitis. CQI was used to target these risk factors, and corresponding countermeasures were developed. Following the implementation of CQI, the nutritional status of the PD patients improved, serum albumin levels significantly increased, and the incidence of peritonitis significantly reduced from once every 40.1 patients per month before CQI to once every 70.84 patients per month after CQI. Other PD centers reported the same finding. Hall et al.11 reported that the overall incidence of peritonitis reduced from once every 28.2 per 1000 patient months to 36.7 per 1000 patient months with CQI. Single centers have reported the incidence of peritonitis up to once every 60 patient months.8,12 Analysis of peritonitis-associated microbial species showed a high incidence of Gram-positive cocci, which may be associated with nonstandard procedures. Patients were discharged from the hospital unless they and their family members passed the examination on aseptic operations, and the operation was checked again at the re-examination to correct the improper procedures. Patients with peritonitis were discharged from the hospital unless they and one of their immediate relatives passed the examination. Our findings
Ren Fail, 2014; 36(7): 1029–1032
showed a significant decline in the prevalence of peritonitis caused by Gram-positive coccus infection. The positive rate of bacterial culture was too low in our PD center, which affected the control of peritonitis and against antibiotic selection. We will strive to improve the positive rate of bacterial culture, which will be our next CQI direction. In summary, we effectively reduced peritonitis rate in our center by implementing CQI program.
Acknowledgments We would like to thank Dr. Anders Tranaues for his contribution to this article.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was funded by Renal Research Grant from Baxter, China.
References 1. Piraino B, Bailie GR, Bernardini J, et al. ISPD Ad Hoc Advisory Committee. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int. 2005;25(2):107–131. 2. Vakilzadeh N, Burnier M, Halabi G. Infectious peritonitis in peritoneal dialysis: an over-emphasized complication. Rev Med Suisse. 2013;9(375):446–450. 3. Yu XQ, Yang X. Clinical prevention strategies of gram negative bacterial peritonitis. J Nephrol Dialy Transplant. 2008; 17(6):534–535. 4. van Esch S, Krediet RT, Struijk DG. Prognostic factors for peritonitis outcome. Contrib Nephrol. 2012;178:264–270. 5. Bargman JM. Advances in peritoneal dialysis: a review. Semin Dial. 2012;25(5):545–549. 6. McLaughlin CP, Kaluzny AD, eds. Continuous Quality Improvement in Health Care-theory, Implementation and Application. Gaithersburg: Jones and Bartlett Publishers; 1999:38. 7. Clark DM, Silvester K, Knowles S. Lean management systems: creating a culture of continuous quality improvement. J Clin Pathol. 2013;66(8):638–6423. 8. Fang W, Qian J, Lin A, et al. Comparison of peritoneal dialysis practice patterns and outcomes between a Canadian and a Chinese centre. Nephrol Dial Transplant. 2008;23:4021–4028. 9. Kerschbaum J, Ko¨nig P, Rudnicki M. Risk factors associated with peritoneal-dialysis-related peritonitis. Int J Nephrol. 2012;2012: 483250. doi: 10.1155/2012/483250. 10. Kovesdy CP, Kopple JD, Kalantar-Zadeh K. Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: reconciling low protein intake with nutritional therapy. Am J Clin Nutr. 2013;97(6):1163–1177. 11. Hall G, Bogan A, Dreis S, et al. New directions in peritoneal dialysis patient training. Nephrol Nurs J. 2004;31:149–163. 12. Kim DK, Yoo TH, Ryu DR, et al. Changes in causative organisms and their anti-microbial susceptibilities in CAPD peritonitis: a single center’s experience over one decade. Perit Dial Int. 2004;24:424–432.
Implementation of a continuous quality improvement program reduces the occurrence of peritonitis in PD Jianwen Wang, Hao Zhang, Jun Liu, Ke Zhang, Bin Yi, Yan Liu, Jishi Liu, Xianming Zhang, and Ying Ji
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/30/15 For personal use only.
Department of Nephropathy, Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
Abstract
Keywords
Objective: To investigate the causes of peritonitis in patients with peritoneal dialysis (PD) using continuous quality improvement (CQI) to develop effective interventions and reduce the occurrence of peritonitis. Methods: A quality control team consisting of 10 members, including the department head, four nephrologists and four nurses, all specialized in PD care, and the head nurse, was established at the Peritoneal Dialysis Center of the Third Xiangya Hospital of Central South University. All patients with peritonitis occurring between 1 July 2010 and 31 December 2011 (pre-CQI period) were analyzed and compared with data obtained between January 2012 (implementation of CQI) and March 2013 to investigate possible causes of peritonitis and to develop corresponding interventions. Fishbone analysis, including laboratory parameters, was carried out monthly. Results: Gastrointestinal tract dysfunction, nonstandard procedures and malnutrition were found to be the top three risk factors for peritonitis. Gastrointestinal tract dysfunction was the likely cause of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p50.05). Nonstandard procedures were the cause of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (p50.05). The overall incidence of peritonitis reduced from once every 40.1 patient months before the CQI to once every 70.8 patient months after CQI (p50.05). The incidence of Grampositive bacteria peritonitis reduced from once every 96.9 patients per month before CQI to once every 209.1 patient months after CQI (p50.05), whereas the incidence of Gram-negative bacteria peritonitis reduced from once every 234.2 patient months before CQI to once every 292.8 patient months after CQI. Conclusion: CQI can effectively reduce the occurrence of PD-related peritonitis.
Continuous quality improvement, peritonitis, peritoneal dialysis
Introduction As one of the most common complications of peritoneal dialysis (PD), peritonitis is a significant cause for drop out from PD.1–3 Reducing the occurrence of peritonitis and providing effective treatment for PD patients has been a common but difficult problem for PD centers.4 Currently, there is no consensus on the risk factors for peritonitis, and there are no systematic or standardized global guidelines for monitoring and controlling the risk factors for peritonitis.5 Continuous quality improvement (CQI) is a concept of enterprise and system management that was developed in the 1950s.6 CQI enhances quality through the collection and quality assessment of data which targets a specific problem.7 CQI requires the co-participation of doctors, nurses, patients, and their relatives in quality-control activities. CQI was implemented in our PD program to decrease the incidence of peritonitis. Effective interventions which target the risk factors for peritonitis were used to reduce
Address correspondence to Hao Zhang, Department of Nephropathy, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province 410013, China. Fax: 0731-88618010; E-mail: [email protected]
History Received 21 December 2013 Revised 11 April 2014 Accepted 11 May 2014 Published online 18 June 2014
the occurrence of peritonitis and improve the quality of PD through four steps: Plan–Do–Check–Act.
Methods Subjects All subjects undergoing continuous ambulatory PD (CAPD) at the Department of Nephrology of the Third Xiangya Hospital of Central South University between 1 July 2010 and 30 June 2013 were enrolled in this study. CQI was implemented on 1 January 2012, and the occurrence of peritonitis before (1 July 2010 to 31 December 2011) and after the CQI implementation (1 January 2012 to 30 June 2013) was compared. At the same time, drop-out rate (DOR) and time on therapy (TOT) before and after CQI implementation were compared. DOR was calculated as: the number of patients quitting PD during 12 months / (the number of patients 12 months ago + the number of newly added patients during 12 months / the number of patients quitting PD between 2 and 12 months / 2). TOT (months) was calculated as: the total patient months / number of drop outs. ‘‘Total patient months’’ refers to the total number of months on PD for those patients withdrawing. DOR ¼ number of drop out / [N1 + (1/2) N2 (1/2) N3]; N1 ¼ initial number of
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Table 1. Laboratory tests in patients with and without PD-related peritonitis before CQI.
Parameter
Non-peritonitis group
Peritonitis group
Age 49.2 ± 10.6 50.8 ± 13.2 Dialysis duration 16.6 ± 21.1 15.3 ± 20.2 Blood pressure 142 ± 21 / 78 ± 11 143 ± 24 / 80 ± 13 Hemoglobin 75.91 ± 16.78 76.3 ± 23.73 Albumin 32.60 ± 4.92 26.05 ± 4.53* Blood urea nitrogen 20.55 ± 5.49 20.14 ± 11.57 Creatinine 915.7 ± 261.1 1017.1 ± 444.7 Middle molecular 292.8 ± 58.35 307.5 ± 36.62 substance Erythrocyte sedimentation 23.41 ± 9.13 89.61 ± 23.02* rate C-reaction protein 1.77 ± 0.34 6.77 ± 5.72* Parathyroid hormone 439.35 ± 368.26 451.99 ± 414.03
p Value 0.789 0.867 0.912 0.936 0.000 0.884 0.237 0.279 0.000 0.000 0.356
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Note: *p50.05 versus the non-peritonitis group.
patients; N2 ¼ number of new patients during the past 12 months; N3 ¼ number of patients who leave (for any reason such as death, transferring to hemodialysis or transplantation) during the past 12 months. ‘‘Number of drop outs’’ refers to those patients who stop PD during past the 12 months. Establishing a CQI team The quality control team consisted of 10 members, including: the department head (as the core of the team), four professional doctors, four professional nurses, and one head nurse. All members were retrained on the guidelines for the diagnosis, treatment, and prevention of peritonitis developed by the International Society of Peritoneal Dialysis (ISPD) at the time of CQI implementation. Identification of risk factors for peritonitis Data before CQI implementation were analyzed by dividing patients into two groups: with or without peritonitis. We found that serum albumin, erythrocyte sedimentation rate, and C-reaction protein levels in the peritonitis group were significantly worse compared with the non-peritonitis group (p50.05) (Table 1). Elderly patients, patients without social insurance, or those with lower educational levels had a higher risk of peritonitis (Table 2). When we looked at the causes of peritonitis, we found that gastrointestinal tract dysfunction (including abdominal pain and diarrhea), nonstandard operations, and malnutrition were the top three risk factors for peritonitis. A high incidence of Gram-positive bacterial infection was detected which was associated with nonstandard procedures, such as inappropriate hand washing or using broken catheters, or damaged solution containers (Tables 1–3). Action plans for improving existing problems To decrease the rate of peritonitis, based on what we found in the cause analysis, we implemented the following action plans: (1) Emphasized the importance of the standard exchange procedure and strengthened the training and retraining programs. Every new patient needs to pass an exam
Table 2. Characteristics of patients with peritonitis.
Parameter Gender Male Female Age 560 years 60 years Educational level Lower than senior high school Higher than senior high school Economic status Health insurance No health insurance Baseline disease Diabetes No diabetes
No. of cases
No. of cases with peritonitis (%)
112 98
42 (37.5%) 35 (35.7%)
40.05
161 49
53 (32.9%) 24 (49.0%)
50.05
99 111
42 (42.4%) 35 (31.5%)
50.05
171 39
59 (34.5%) 18 (46.1%)
50.05
46 164
15 (32.6%) 62 (37.8%)
40.05
p Value
Table 3. Possible causes for the occurrence of peritonitis. No. of episodes with peritonitis (%) Cause Gastrointestinal tract dysfunction Diarrhea Constipation Eating unclean food Operation-related causes Nonstandard operation Use of broken PD catheter or damaged PD bag Respiratory tract infection Inadequate treatment of previous episode Exit-site or tunnel infection Total
Before CQI n (%)
After CQI n (%)
18 (42.8%)
9 (36.0%)
10 (23.8%) 4 (9.5%) 4 (9.5%) 14 (33.3%) 10 (23.8%) 4 (9.5%)
4 (16.0%) 2 (8.0%) 3 (12.0%) 6 (24.0%) 4 (16.0%) 2 (8.0%)
3 (7.1%) 5 (11.9%)
5 (20.0%) 3 (12.0%)
2 (4.8%) 42 (100%)
2 (8.0%) 25 (100%)
including a PD exchange and a written test before being discharged from the hospital. If the patient is admitted to the hospital due to an episode of peritonitis, a retraining course should be done and a new exam should be passed. Since peritonitis has a high incidence during the summer and autumn due to sweating and seasonal diarrhea, additional retraining should be strengthened during these seasons. In addition, Cefoxitin was regularly given before and after the catheter implantation according to ISPD guidelines in our protocol. (2) Established a treatment process for patients at high risk of peritonitis. Subjects with diarrhea were given berberine hydrochloride tablets three times daily (three tablets each time) for 1 day. If they did not improve, norfloxacin was also prescribed (three times daily, one capsule each time). Patients were asked to seek medical care if norfloxacin was not successful within 2 days. For those patients suffering from continuous constipation, oral Maren capsules (a Chinese traditional medicine) were prescribed. Patients were asked to return to the center if symptoms persisted. As malnutrition is the
Implementation of CQI in peritonitis study
DOI: 10.3109/0886022X.2014.927771
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Table 4. Clinical data in patients undergoing PD before and after CQI.
Time Before CQI After CQI
No. of cases
Male/female
Age (years)
Duration of dialysis (months)
Hemoglobin level (g/L)
Albumin level (g/L)
Parathyroid hormone level (pg/dL)
268 354
160/108 195/159
51.8 ± 12.3 52.7 ± 14.2
24.8 ± 22.4 30.3 ± 24.68
70.12 ± 19.21 82.9 ± 19.54*
31.70 ± 3.49 38.24 ± 2.19*
662.21 ± 232.18 335.2 ± 198.34*
Note: *p50.05 versus before CQI.
Table 5. Clinical parameters in patients with peritonitis before and after CQI. Pathogens {[cases (%); patent months]}
Time
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Before CQI After CQI
Total patent months
Total cases of peritonitis
TOT
DOR
Occurrence of peritonitis (patent months)
2810 4392
70 62
22.31 28.80
25.32 22.58
40.1 70.84*
Gram-positive organisms 29 (41.4) 21 (33.9)
96.9 209.1*
Gram-negative organisms 12 (17.6%) 15 (24.2%)
234.2 292.8
Fungus
Negative culture
3 (4.3%) 2 (3.2%)
26 (37.1%) 24 (38.7%)
Notes: *p50.05 versus that before CQI; Statistical data were checked by a statistical expert.
major risk factor for peritonitis, nutritional supplements (dephosphorized animal proteins in addition to adequate supplementation of glucose and vitamins) and supplementation of a-keto acid compound or protein powder (Amway Nutrilite protein powder) were provided to subjects with serum albumin levels530 g/L. Anemia was treated using routine subcutaneous injections of erythropoietin, folic acid, and iron to maintain hemoglobin levels at 100–120 g/L. (3) Establishment of a green channel for peritonitis patients. A specialized outpatient clinic for PD was set up each week, and a special telephone line and Tencent QQ group were developed to respond to the patients’ questions at all times. A green channel for PD was established to provide timely treatment for patients with fever, abdominal pain, or turbid ascites. The follow-up period was shortened in patients at high risk for peritonitis. Statistical analysis SPSS 18.0 was used for statistical analysis. All measurement data were tested with normality and homogeneity of variance. Data with normal distribution were represented by mean ± SD The two groups were compared using independent samples t-test. Data with non-normal distribution were represented by median, the two groups were compared using the Wilcoxon rank sum test. Enumeration data were compared with v2 test. p Value50.05 was considered statistically significant.
Results Comparisons of clinical data in PD patients before and after a CQI There were no significant differences in gender and age among patients who started PD before and after the implementation of CQI (p40.05). Significantly elevated hemoglobin and albumin levels, and reduced parathyroid hormone levels were detected after CQI compared with
before CQI (p50.05) (Table 4). In addition, CQI resulted in an increase in hemoglobin levels from 70.12 ± 19.21 g/L to 82.9 ± 19.54 g/L, albumin levels from 31.70 ± 3.49 g/L to 38.24 ± 2.19 g/L, and parathyroid hormone levels from 662.21 ± 232.18 pg/dL to 335.2 ± 198.34 pg/dL, respectively, and there were significant differences in hemoglobin, albumin, and parathyroid hormone levels before and after CQI (p50.05). Comparison of peritonitis rates before and after CQI Gastrointestinal tract dysfunction induced the development of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p50.05). In addition, nonstandard procedures were also a common cause of peritonitis. After strict training and retraining courses, nonstandard procedures induced the development of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (Table 3). The overall occurrence of peritonitis significantly reduced from once every 40.1 patients per month before CQI to once every 70.8 patient months after CQI. The incidence of Gram-positive bacteria peritonitis reduced from once every 96.9 patient months before CQI to once every 209.1 patient months after CQI (p50.05), whereas the incidence of Gram-positive bacteria peritonitis reduced from once every 234.2 patients per month before CQI to once every 292.8 patients per month after CQI. DOR reduced from 25.32% before CQI to 22.58% after CQI, and TOT in PD patients increased from 22.3 months before CQI to 28.8 months after CQI (Table 5).
Discussion Based on the causes we analyzed and the actions we took via the CQI process, the incidence of peritonitis was effectively decreased within about 2 years.Our previous data showed that the rate of peritonitis in our center was not as good as those reported by other high-quality PD centers.8 Our data showed that age, gender, diabetes, and the time of dialysis had no significant associations with the occurrence
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of peritonitis, which was consistent with previous studies.4 However, gastrointestinal tract dysfunction and nonstandard procedures are common causes of peritonitis. Gastrointestinal tract dysfunction mainly includes diarrhea, constipation, and discomfort due to unclean food, whereas nonstandard procedures were mainly caused by inappropriate hand washing before the exchanges, the use of broken PD catheters, and damaged solution bags. Effective and timely training as well as preventive treatments for gastrointestinal tract dysfunction that we implemented in this study obviously have a significant role in preventing peritonitis. Nutritional management is part of the self-management of PD patients. As a common complication of PD, malnutrition may increase the mortality rate and the occurrence of other diseases.9 Inadequate protein intake and loss of nutrients are major causes of malnutrition.10 We evaluated the impact of nutritional status and intestinal function on the incidence of peritonitis in patients with CAPD, and compared the nutrition and inflammatory parameters between the peritonitis group and the non-peritonitis group during the same period. We found that erythrocyte sedimentation rates and C-reaction protein levels were significantly elevated and serum albumin levels were significantly reduced in the peritonitis group compared with the non-peritonitis group, and no significant differences in hemoglobin levels between the peritonitis and non-peritonitis groups. Logistic regression analysis showed that CAPD patients with albumin levels528.97 g/L easily developed peritonitis, which indicates that malnutrition was one of the causes of peritonitis. Gastrointestinal tract dysfunction was another risk factor for peritonitis. CQI was used to target these risk factors, and corresponding countermeasures were developed. Following the implementation of CQI, the nutritional status of the PD patients improved, serum albumin levels significantly increased, and the incidence of peritonitis significantly reduced from once every 40.1 patients per month before CQI to once every 70.84 patients per month after CQI. Other PD centers reported the same finding. Hall et al.11 reported that the overall incidence of peritonitis reduced from once every 28.2 per 1000 patient months to 36.7 per 1000 patient months with CQI. Single centers have reported the incidence of peritonitis up to once every 60 patient months.8,12 Analysis of peritonitis-associated microbial species showed a high incidence of Gram-positive cocci, which may be associated with nonstandard procedures. Patients were discharged from the hospital unless they and their family members passed the examination on aseptic operations, and the operation was checked again at the re-examination to correct the improper procedures. Patients with peritonitis were discharged from the hospital unless they and one of their immediate relatives passed the examination. Our findings
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showed a significant decline in the prevalence of peritonitis caused by Gram-positive coccus infection. The positive rate of bacterial culture was too low in our PD center, which affected the control of peritonitis and against antibiotic selection. We will strive to improve the positive rate of bacterial culture, which will be our next CQI direction. In summary, we effectively reduced peritonitis rate in our center by implementing CQI program.
Acknowledgments We would like to thank Dr. Anders Tranaues for his contribution to this article.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was funded by Renal Research Grant from Baxter, China.
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