One of the benefits for individuals choosing peritoneal dialysis (PD) as their renal replacement therapy is that they remain in their home setting. Unfortunately, there are times when a patient on PD requires specialized care outside of the home, such as in a hospital, rehabilitation facility, or nursing home (Lijten, 2006).  Since the current United States PD population is approximately only 25,000 (United States Renal Data System [USRDS], 2007), this can result in minimal exposure to patients on PD for acute/extended care facility (AECF) nurses who work in these settings.

In order for patients on PD to have consistent care, the outpatient PD facility needs to assume responsibility in creating a partnership with the AECF (Prowant, Nolph, Ponferrada, Khanna, & Twardowski, 1999).  A consulting relationship between the two entities should result in a seamless transition from home to the AECF, and hopefully, back home again.  Two-way communication is the key to success.

The goals during the AECF stay should include providing safe and effective PD and preventing infections.  Meeting the dialysis prescription is essential along with maintaining the volume status of the patient. 
Ideally, admittance should be to an AECF accustomed to caring for patients undergoing PD (Bender, Bernardini, & Piraino, 2006). This, however, is not always an option.

Reasons for Lack of PD Experience and Knowledge
The AECF nursing staff can lack experience with patients on PD because:

• There can be many referring hospitals within a given location providing a variety of services competing for the small number of patients potentially needing PD.
• Many nurses are not exposed to PD during their nursing education and are not familiar with the concepts specific to the care of a patient with kidney failure (Lijten, 2006).
• Facilities are dealing with nursing shortages, high staff turnover (Gunn, Vasquez-Villagram, & Bird, 2006), and a large pool of nurses with little or no PD experience to provide training to new staff members.
• When the PD patient population is small within a given geographic location, an AECF may not be able to devote a dedicated floor specific to renal patients.
• With improvement in outcomes, fewer patients on PD are being hospitalized (USRDS, 2007), further limiting exposure to the modality for AECF nurses.

Even if the AECF staff members have had some experience in performing PD exchanges, there can still be problems performing PD. There are two different ways PD can be performed. The first is the manual form, continuous ambulatory peritoneal dialysis (CAPD), usually performed four to five times a day. The second type is automated peritoneal dialysis (APD), which uses a cycler machine throughout the night while the patient sleeps. CAPD and APD require different equipment and supplies.
 
In the United States, there are currently two manufacturers of PD products. Confusion can exist when the AECF is using one manufacturer’s supplies and the patient is using another in the home setting, or if both products are available to the AECF staff but they are not accustomed to using both. These products are not compatible or interchangeable and require distinct supplies in order to perform the treatment. Adapters/connectors are available from manufacturers that can be applied to the patient’s transfer set to convert from one product to another.

If the volume of patient referrals for APD to an AECF is low and infrequent, patients on PD should be converted to CAPD when admitted to promote safe and accurate patient care. Staff members can learn CAPD in minutes versus an hour or more with APD. CAPD does not require a machine, and fewer supplies need to be ordered/stocked.

Problem Identification
Outpatient PD staff need to determine if a problem exists within an AECF. An assessment can consist of querying patients about any issues specific to PD during recent admissions. Often, patients will tell PD staff if AECF nurses were not following the appropriate procedures (for example, not washing their hands prior to an exchange or not wearing a mask).

Often, the PD staff becomes aware there is a problem because:

• Patients on PD will voluntarily comment about issues without being asked by the PD staff.
• Patients on PD acquire exit site infections and/or peritonitis while in an ACEF.
• The PD staff receives frequent calls from the AECF with questions about PD.
• The nephrologist discusses concerns about the care of a patient undergoing PD with the PD staff when the patient is in an AECF.

Developing a Partnership
To try and correct a problem once it has been identified, an advocate should be sought. While it might seem desirable to have an advocate in place in advance, the AECF staff may not be receptive to or retain information presented when it is not on a “need to know” basis.  Identifying an advocate within the AECF facility where there may be concerns may facilitate the potential for successful problem resolution. An internal advocate enhances staff comfort with any proposed changes, taking advantage of the existing, established relationships. The advocate should have a vested interest in improving outcomes. Potential advocates include the nurse/staff educator, director of nursing, nursing administrator, nurse manager, assistant manager, charge nurse, clinical nurse specialist, clinical leader, or the referring nephrologist.  In some circumstances, the advocate initiates the call to PD staff to seek resolution/assistance.

The nephrologist can significantly influence the facility administration, such as seeking designation of a nursing unit to which patients on PD are admitted. Nephrologists with a large referral base of patients to an AECF may be more influential in achieving this. 

Once there is an established facility advocate, a needs assessment should be performed. The documented issues/concerns should be reviewed from both the AECF perspective and the PD facility to establish “buy-in” from the AECF. A strategy can then be developed to correct the problem. The strategy needs to be positive and realistic while meeting the needs of the patient on PD and staff. Depending upon the size of the facility, it may be unrealistic to expect that all appropriate staff will be trained and remain competent in performing PD. A more achievable goal may be to train a few dedicated staff members who can then train the rest of the staff as needed.

The facility advocate may want to involve other team members to facilitate “buy in,” such as the staff educator if the advocate is a nurse manager. It is important to get a consensus with the nursing staff that the need exists for staff to learn how to correctly perform PD (Meddy, 1995).  Without agreement from staff, the problem will not be corrected.

Training the Trainer
It is impractical for the PD facility to train the entire AECF staff to perform PD due to the time commitment that would be required from both facilities. It is also not realistic to expect AECF staff to maintain their competencies when they have infrequent opportunities to perform PD exchanges.

One approach that can be effective is the concept of “Train the Trainer.” This consists of training specific staff members (for example, those interested in learning PD), mentors, team leaders, trainers, staff educators, staff members participating in a clinical ladder program, or those on the nursing unit where the majority of patients on PD are admitted. This author’s experience has suggested that these particular staff members are usually less inclined to leave the facility. The trainers receive specific education related to PD and then train the rest of the staff in their clinical area. They became the resident experts about PD.

A formal, theoretical class on PD basics and a hands-on workshop specific to treatment administration can be offered to trainers to promote staff comfort. It is important, however, to keep educational offerings simple and realistic within the facility setting. When planning the educational offering, it is important to consider the minimal information staff need to become comfortable and confident to care for a patient on PD. Table 1 provides typical “Train the Trainer” topics for theory and workshop sessions. Additional topics can be covered based on discussions with the facility advocate. PD facility staff should assist the AECF in developing policies and procedures for PD to help ensure the consistency of care patients on PD receive. PD staff should collaborate with the AECF facility advocate to determine how much time is needed to address the content for trainers. An hour is usually not enough time to cover the topics. Since the entire nursing staff is not being trained, but rather a dedicated few trainers, this will usually allow the AECF work scheduler to allocate staff time away from patient care for the education. The ACEF facility advocate can work with the administration to determine scheduling and compensation for staff training.


Communication
Ongoing communication is necessary to ensure success within AECFs (Gunn et al., 2006). A contact person, such as the facility advocate, should be identified within the AECF to work with the PD facility. Issues as well as educational needs can be identified after the completion of the training. The AECF can be kept up to date on new PD products and procedures specific to patients being admitted. The PD facility should establish the expectation of being contacted when a patient on PD is admitted and when the patient is being discharged. Discharge planning can be reviewed between the AECF and the PD facility as needed. 

The AECF should be provided with the PD facility work phone number and the phone numbers of the attending nephrologists. Procedures for addressing after-hours problems should be identified and appropriate contact information provided. 

Another option would be the creation of a PD admission information sheet for AECF staff. The information sheet presents the same information mentioned above in addition to indepth details specific to the facility and the patient. Items could include what type of PD the patient is performing (CAPD or APD), the name of the PD product manufacturer, and current dialysis prescription (see Table 2). The PD facility would provide the information sheet to  patients with instructions to bring it when admitted to an AECF. A review process should be in place to evaluate how well the processes are functioning based upon experiences, data, and feedback from patients. The ultimate goal would be to ensure the best possible patient outcomes using this quality improvement process.


The PD facility should review which PD product manufacturer used by patients. In addition, the following manufacturer-specific information should be provided to the AECF:

• Name and phone number of the local PD manfacturer sales person.
• Phone number to place a PD manufacturer order.
• After hours/weekend/holiday delivery policy.
• Cycler equipment support phone number.
• The PD product manufacturer’s Web site address.

The AECF should be encouraged to use the same PD product manufacturer that the PD facility uses to minimize confusion. A recommended extra step would be for PD staff to contact the local sales person about making an appointment to meet with the AECF to review the above in detail.

A collaborative approach to provide consistent care for the patient on PD should include the sharing and reviewing of current policies and procedures between the facilities. In addition, the creation of a reference guide to answer the most frequent type of questions when caring for patients undergoing PD can be beneficial (Pickering & Lewis, 1995). Responsibilities/expectations of the AECF and the PD facility should be reviewed. When working with a facility, a written contract specific to patients on PD in the long-term care setting can be helpful (Lijten, 2006). Special considerations for long-term care include:

• How often the patient will be seen in the PD facility.
• Who will order the PD supplies.
• Who are the contact staff for questions within both facilities (for example, billing issues).

To maximize AECF nursing resources, the nephrologist should be encouraged, if possible, to refer patients to a facility with an established relationship (Neri, Viglino, Cappelletti, Gandolfo, & Barbieri, 2004). The more experience AECF staff have with patients treated with PD, the more it is likely to accept these patients in the future. This can decrease the amount of time PD nurses have to spend educating additional facilities.

Resources
There are a variety of resources available to help in the training and continuing education of the AECF nursing staff. The facility advocate should be made aware of the American Nephrology Nurses’ Association’s (ANNA) Web site, www.annanurse.org, as a reference to find further information specific to nephrology nursing and caring for the patient on PD. The Peritoneal Dialysis Nurse Resource Guide,  developed by ANNA’s PD Special Interest Group (ANNA, 2003), is available in a .pdf format for downloading from the Web site at no cost. This resource guide is divided into categories specific to the care of patients on PD and lists references along with information about where to obtain the resource. The Nephrology Nursing Journal published a monograph on PD in September 2004. This publication, developed by the ANNA PD Special Interest Group, addressed many facets of PD and would be extremely useful for the facility as resource for staff. The AECF may wish to post PD policies and procedures on their intranet site, if available (Smolen, 2002).
 
Resources are available from PD product manufacturers as well as from various organizations for both professional staff and patients (see Table 3). Materials can be obtained through Web sites, as well as and contacting the manufacturers or organizations, including videos in multiple formats as well as written information (see Table 4). AECF issues/concerns that have been uncovered should be discussed with the PD product manufacturer support team. A determination can be made if the manufacturer can provide additional assistance in training of AECF nursing staff.


Maintaining Competency
PD staff should determine with the AECF advocate how often training with AECF staff will be performed (Pickering & Lewis, 1995; Smolen, 2002). A minimum of yearly competency training with the trainers is recommended. The competency evaluation should consist of the same topics presented during the workshop session. A written test related to PD theoretical concepts could be incorporated on an annual basis. The PD staff should assess the need for additional educational support materials (posters, videos, procedure guides, etc.) for the AECF staff and provide them as needed. The need for repeating the “train the trainer” class and workshop should be evaluated periodically, depending upon staff turnover and the frequency of caring for patients on PD.

Once the initial ”train the trainer” class is completed, PD staff can encourage the AECF advocate to allow trainers to present inservice education to other nursing staff members as soon as possible. This will boost the trainers’ confidence with PD procedures and may minimize the time for PD staff to remain involved.

Conclusion
Continuous communication between the PD facility and the AECF facility advocate will ensure a smooth transition for the patient on PD, decrease the potential for complications to occur, and promote positive patient outcomes.

References
American Nephrology Nurses’ Assocation (ANNA). (2003). Peritoneal dialysis nurse resource guide. Pitman, NJ: Author.

Bender, F. H., Bernardini, J., & Piraino, B. (2006). Prevention of infectious complications in peritoneal dialysis: Best demonstrated practices. Kidney International, 70, S44-S54.

Gunn, J., Vasquez-Villagram, J., & Bird, S. (2006). A successful extended-care facility CAPD experience [Abstract]. Peritoneal Dialysis International, 26(Suppl. 1), S41.

Lijten, I. (2006). Successful training of nurses’ team in a nursing home in one day [Abstract]. Peritoneal Dialysis International, 26(Suppl. 1), S46.

Meddy,  J. (1995). Developing a peritoneal dialysis unit in a long-term care setting. Dialysis & Transplantation, 24(2), 62-68, 90.

Neri, L., Viglino, G., Cappelletti, A., Gandoflo, C., & Barbieri, S. (2004). Reduction in PD dropout caused by lack of assistance [Abstract]. Peritoneal Dialysis International, 24(Suppl. 1), S22.

Pickering, K., & Lewis, N. (1995). Developing renal competency for medical-surgical nurses [Abstract]. Peritoneal Dialysis International, 15(Suppl. 1), S74.

Prowant, B.F., Nolph, K., Ponferrada, L., Khanna, R., & Twardowski Z.J. (1999). Quality in peritoneal dialysis: Achieving improving outcomes. In L.W. Henderson & R.S. Thurma (Eds.), Quality assurance in dialysis (2nd ed., pp. 230-231). Dordrecht, The Netherlands: Kluwer Academic Publishers.

Smolen, D. (2002). Preventing infections in the hospitalized peritoneal dialysis patient [Abstract]. Peritoneal Dialysis International, 22(Suppl. 1), S49.

United States Renal Data System (USRDS). (2007). USRDS 2007 annual data report: Atlas of end-stage renal disease in the United States. Bethesda, MD: National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease. Division of Kidney, Urologic and Hematologic Diseases. Retrieved November 6, 2007, from http:// www.usrds.org/atlas.htm.