A defined peritonitis clinical pathway in the emergency

department improves outcomes for peritoneal dialysis patients

Ginger Chu
Chu, G. (2014). A defined peritonitis clinical pathway in the emergency department improves outcomes for peritoneal dialysis
patients. Renal Society of Australasia Journal, 10(1), 30-33.
Submitted: November 2013, Accepted December 2013

Abstract
Background Peritonitis is the most common infection and cause of treatment failure for patients receiving peritoneal dialysis
(PD). Peritonitis can be life-threatening if treatment is not initiated in a timely manner. We have identified in our facility that
patients presenting to the emergency department (ED) with peritonitis often have delayed treatment. This could be due to a
lack of understanding from ED clinicians and/or poor communication between ED and the renal department. Therefore, a local
clinical pathway was developed to optimise peritonitis patient care.
Aims To evaluate the effectiveness of a local peritonitis clinical pathway designed to reduce time for patients with PD-related
peritonitis receiving their first antibiotic treatment.
Setting All patients with PD peritonitis presenting through a tertiary hospital ED.
Main outcome measured Time for patients with PD-related peritonitis receiving their first antibiotic treatment in hospital.
Results The average time for peritonitis treatment decreased from 6 hours and 49 minutes to 5 hours and 18 minutes after
the clinical pathway was implemented. Currently there is no published data to benchmark our result, even though the results
indicated that the local clinical pathway may have been effective.
Implications for clinical practice Since the implementation of this project, three patients were able to be safely discharged
from ED without needing hospital admission and this is due to prompt management and good communication between ED
and the renal department. Delayed treatment not only causes increased demand in ED service, but also results in unnecessary
hospital admission, which impacts on both the patient and the overall health care system.

Keywords
Emergency department, ED, peritoneal dialysis, PD, peritonitis.

Introduction
with PD treatment? The common example identified through
There are many reasons a renal dialysis patient presents to
our internal investigation is that of ED physicians mistaking a
an emergency department (ED); it depends on the dialysis
PD catheter for a suprapubic catheter; consequently PD samples
modality and its complications. For example, shortness of breath
were collected under an incorrect procedure, increasing the risk
(SOB) is the most common and significant complication for
of peritonitis.
haemodialysis patients; whereas peritonitis remains the most
common cause of hospitalisation for peritoneal dialysis (PD) For this reason, it is recognised in our facility that renal
patients (Gadola et al., 2008). physicians need to understand the challenge ED physicians
face and assist in recognising significant symptoms that need
The increasing population of renal dialysis patients has raised the
immediate dialysis intervention, to ensure patient care is
awareness of emergency physicians of the common problems
delivered in a safe and timely manner.
that bring a dialysis patient to ED (Venkat, Kaufmann & Venkat,
2006). However, our internal incident investigation identified PD patients in ED
many incidents associated with peritonitis treatment in the ED A study conducted by Fried, Bernardini, Johnston and Piraino
which has raised the question of how familiar are ED physicians in America (1996) indicated that even though peritonitis is not

Author details: Ginger Chu (RN, MN), Clinical Nurse Consultant, Nephrology Department, Division of Medicine, John Hunter
Hospital, Hunter New England Local Health District, Conjoint Senior Lecturer, University of Newcastle
Correspondence to: Ginger Chu, 1 a Dudley Road, Charlestown, NSW 2290, Australia
Telephone (home & business): (02) 4904 8815 Mobile: 0429 850 453, Facsimile: (02) 4904 8820
Email: ginger.chu@hnehealth.nsw.gov.au

30 Renal Society of Australasia Journal // March 2014 Vol 10 No 1

A defined peritonitis clinical pathway in the emergency department improves outcomes for
peritoneal dialysis patients

often directly linked to patient mortality, some serious pathogens 3. Delay in deciding appropriate antibiotics treatment — with
such as fungal peritonitis or gram-negative bacteria do have a a need for clear steps for diagnosis and treatment. Once the
significant impact on a PD patient's survival. diagnosis is made, evidence has shown intra-peritoneal (IP)
antibiotics to be more superior in treating PD-related peritonitis
Many patients with mild peritonitis can be managed as
over intravenous (IV) antibiotics (Lye, 2004; Wiggins, Craig,
outpatients with antibiotic treatments and adequate support
Johnson & Strippoli, 2010). Therefore, further delays can occur
from the nephrology service; however, for severely ill patients,
hospitalisation or urgent surgical intervention for catheter due to IP antibiotics only being able to be administered by a
removal may be needed to avoid septicaemia (Venkat, Kaufmann trained PD staff. The clinical pathway was developed to address
& Venkat, 2006). Particularly with Staphylococcus aureus infection, all causes of delay and it comprised two parts: the guideline that
delayed treatment can cause peritonitis-related sepsis, which is clearly outlines the required communication channel between
the leading cause of death in patients with peritonitis-related the ED and the renal department, and the flow chart that allows
mortality and majority of patients will require intensive care ED clinicians to categorise patients’ condition, and initiate the
unit (ICU) admission (Fontan, Carmona, Naveiro, Rosales, appropriate management plan (Appendix 1).
Villaverde, & Valdes, 2005). When a dialysis patient requires ICU
Data analysis
intervention, the overall prognosis is usually poorer and mortality
higher compared with a non-dialysis patient requiring ICU The local clinical pathway was implemented at the end of
intervention (Manhes, Heng, Aublet-Cuvelier, Gazuy, Deteix & December 2011, and the data was analysed 12 months after
Souweine, 2005). Therefore, it is imperative for a PD patient to implementation. The report of peritonitis patients who presented
receive adequate treatment in a timely manner to avoid further to ED was firstly summarised by running internal software
complications. using ED diagnosis code of “peritonitis”. The data is further
analysed by reviewing each individual patient’s medical record
Current internal audits in our facility indicated that the time
on digital medical record (DMR) to filter PD-related and non–
taken from the patient presenting at the hospital to receiving
PD related peritonitis. Critically ill patients who required ICU
initial antibiotics for a PD-related peritonitis patient varied
interventions were also excluded from the data, because, for this
between 45 minutes and 1606 minutes (>26 hours); the average
group, stabilising patients haemodynamically is the priority over
time taken to administer initial antibiotics in our facility was 409
peritonitis treatment.
minutes (>6 hours).

The recent statewide “sepsis skills” program, the aim of which Patients
is to reduce preventable harm to patients through improved The total number of PD patients with peritonitis presenting
recognition and management of severe infection and sepsis, through ED in 2011 (12 months prior to the implementation
recommended the first antibiotics should be administered of the clinical pathway) was 34 according to ED diagnosis code,
under 60 minutes (Clinical Excellence Commission, 2013). It of which 23 had PD-related peritonitis. Twelve months after
was, therefore, recognised by our local renal and ED teams that implementing the local clinical pathway in 2012, the numbers
a clinical pathway is needed to reduce the time that a patient of PD-related peritonitis was 14 out of 23 ED diagnosis code of
presenting to ED with peritonitis receives their first dose of patients with peritonitis.
antibiotics.
The time frame for patients receiving the first peritonitis
Development of local clinical pathway treatment in hospital is identified through DMR, and calculated
The clinical pathway was developed by a multidisciplinary team from the time the patient was assessed by the ED physician to
of senior clinicians, clinical nurse consultants and managers from the time the patient received the first dose of antibiotics. The
both the ED and renal departments. The underlying issues were antibiotics could either be administered in ED or on the ward by
discussed between the two teams and the causes of delay were trained PD nurses.
identified as:
Outcomes
1. Delay in notifying ED when an on-call PD nurse refers a
The average time for a PD patient to receive the first antibiotics
patient to present to ED, ED staff were not notified or given
treatment has decreased from 6 hours and 49 mins (409
handover — which also caused delay in triage and notifying the
mins ± SD 360), to 5 hours and 18 minutes (318 mins ± SD
renal unit.
195) 12 months post-implementation. A total of 91 minutes'
2. Delay in sample collection — due to the need to rely on reduction in waiting time was observed only 12 months after the
PD-trained staff from the renal unit. implementation of the local clinical pathway (Graph 1).

Renal Society of Australasia Journal // March 2014 Vol 10 No 1 31

A defined peritonitis clinical pathway in the emergency department improves outcomes for
peritoneal dialysis patients

The International Society for Peritoneal Dialysis (ISPD)

guideline recommends that every organisation should have
a management plan for peritonitis, especially for the initial
presentation and management, to preserve peritoneum
membrane function (ISPD, 2010). Jose et al. (2011) further
emphasise the importance and the need for all PD units to
record infection rates and outcomes to benchmark against
international guidelines. Thus, besides peritonitis protocols, the
author would like to stress the need for a local clinical pathway
to facilitate communication between the ED and the renal
department. The time of administrating the first antibiotic
treatment should also be one of the clinical key indicators that
every PD unit collects, so that good practice can be learned from
Discussion the leading units.

Infection remains the major leading cause of death for both PD Future research should have an emphasis on the effect of
and haemodialysis patients (ANZDATA, 2012). While catheter- delayed treatment in peritonitis and patients’ mortality, as there
Discussion
related infection is emphasised in literature for haemodialysis is currently a lack of evidence in this field. Like the peritonitis
patients, peritonitis
Infection remains should
the major be cause
leading treated like catheter-related
of death for both peritoneal dialysis and rate, there should be a minimum acceptable time for a peritonitis
infection with a sense of urgency to avoid unnecessary hospital patient to receive their first antibiotics treatment for all units to
haemodialysis patients (ANZDATA 2012). While catheter-related infection is
admission and severe septicaemia. A study conducted by Aslam, benchmark their data against.
emphasised in literature for haemodialysis patients, peritonitis should be treated like
Bernardini, Fried, Burr and Piraino in 2006 found that PD and
catheter-related infection with a sense of urgency to avoid unnecessary hospital Conclusion
haemodialysis patients had a similar infection rate; therefore, it
isadmission
importantand severe septicaemia. A study conducted by Aslam, Bernardini, Fried,
for nephrology clinicians to monitor peritonitis Peritonitis can be a life-threatening condition if it is not
treatment as key
Burr and Piraino clinical
in 2006 foundindicators, justdialysis
that peritoneal as theyandwould for
haemodialysis patients managed in a timely manner. Despite limitations, this project
catheter-related infection. has shown the possibility of how a local clinical pathway can
had a similar infection rate, therefore it is important for nephrology clinicians to
facilitate effective communication between the ED and the renal
monitor peritonitis treatment as a key clinical indicators the same as catheter- related
The data collected thus far shows the effectiveness of the clinical department, thereby reducing the time taken for a PD-related
pathway
infection. in reducing time taken to administer the first antibiotic peritonitis patient presenting to ED receiving their first dose of
treatment for peritonitis patients presenting to ED in our local antibiotics. This project has also highlighted the need for each
facility. Despite the limitation of this analysis including a small hospital to collect the average time taken for peritonitis patients
number of patients, the possibility("of introducing a “sepsis kill” to receive their first antibiotics treatment, so the practice can be
"
program in ED and short monitoring period, this will be the benchmarked and improved.
ongoing direction for the author's team to work on to evaluate
the sustainability of the clinical pathway. Acknowledgments
The author would like to thank the nursing staff, managers
In terms of patient outcomes, the length of hospital stay was and educators from John Hunter Hospital Nephrology ward
analysed to compare patient groups in 2011 and 2012. Even and emergency department, and Wansey community dialysis
though the retrospective chart audit did not show a significant home training centre for their contribution to the successful
difference in length of hospital stay between the two groups (8 implementation of this project, especially Ms Carmel Peek
days vs 7 days), it did show a significant decrease in number of (former service manager/Division of Medicine), Kristy Barnes
patients who required ED intervention and hospital admission. (NUM), Jennifer Cousin (PD Nurse), Diana Williamson (ED
Prior to implementing the clinical pathway, there were 23 CNC), Dr Conrad Loten (ED physician) and Dr Alastair Gillies
peritonitis patients who required ED intervention and hospital (Director of Nephrology) for their support and involvement in
admission. Twelve months post-implementation of the clinical this project.
pathway, there were only 14 ED presentations and three out of
*Staff who prearranged patients to present to ED should contact
14 were successfully managed/discharged from the ED without
ED NUM (#xxxx) and nephrology in charge nurse
needing hospital admission. This result has demonstrated that
(#xxxx) to avoid unnecessary waiting time and admission.
with good communication and prompt management between
ED and the renal department, peritonitis can be managed more *Renal in charge nurse is to be contacted by ED to facilitate bed
efficiently, which means less need for ED service and hospital allocation by liaising with ED NUM and bed manager once the
beds. decision for admission is made.

32 Renal Society of Australasia Journal // March 2014 Vol 10 No 1

A defined peritonitis clinical
*Staff who pathway in the emergency
to ED shoulddepartment improves outcomes for
Appendix 1: Flow chart for management of patients with PD presenting to xx hospital ED

prearranged patients to present contact ED NUM (#xxxx)

peritoneal dialysis patients
and Nephrology
admission.
in charge nurse (#xxxx) to avoid unnecessary waiting time and

*Renal in charge nurse is to be contacted by ED to facilitate bed allocation by liaising

with ED NUM and bed manager once the decision for admission is made.
Appendix 1: Flow chart for management
Triage Clinically unstable Manage in ED but still consider the
of patients with PD presenting to following treatment options
John Hunter Hospital ED  
Clinically stable
 

PD related clinical presentation Non-PD related clinical presentation

Catheter Issues
Suspected Peritonitis
• Leaking catheter Patients with PD
• Abdominal pain
• Broken catheter catheters presenting
• Redness around
• Catheter extension catheter exit site to ED with non –
line/or cap dislodge
• Nausea/vomiting & peritoneal dialysis
• Non-functioning diarrhoea related issues,
catheter
• Cloudy peritoneal such as head injury,
or
dialysis fluid chest pain, or
• Peritoneum issues
• Temperature greater trauma etc.  
than 37ºC
e.g. blood in effluent
or suspected • WCC >100 with 50%
abdominal leak or more neutrophils
(assessment to be • General feeling of
performed by a renal being unwell 1. Follow normal ED
nurse)   triage / admission
  process
Contact Nephrologist 2. Contact in-charge
renal nurse to attend
peritoneal dialysis.
Contact in-
charge ward
renal nurse
1. Chart IP antibiotics as
recommended (see
appendix 2 for local
Ward in charge nurse will
peritonitis protocol)
perform assessment and  
communicate with the on- 2. Complete pathology forms
call Nephrologist re: for PD specimen (M/C/S,  
treatment plan and Gram stain & WCC)
possible discharge or  
3. Contact renal nurse to
admission
implement peritonitis
protocol

10  
  W., Tranaeus, A.,Voss, D., Walker,
Jose, M. D., Johnson, D. W., Mudge, D.
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