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Peritoneal dialysis home visits: A review of timing, frequency and assessment criteria.

Introduction

Peritoneal dialysis (PD) is a type of renal replacement therapy required by patients with end-stage renal disease (ESRD). If eligible patients are trained and supported, they will be able to perform and manage their PD in the comfort of their home environment. Visits by PD nurses to the patient's home serve as an opportunity to observe and assess many aspects of the patient's ability to successfully complete their therapy.

Despite the importance of home visits, there are currently no evidence-based policies or protocols specific to the timing, frequency and assessment criteria for the monitoring and scheduling of these visits. The International Society for Peritoneal Dialysis (ISPD) states that visits by a PD nurse are usually recommended to detect problems with exchange technique, adherence to protocols, and other issues that increase the risk of infection (Szeto et al., 2017).

The ISPD, however, does not provide further guidelines or recommendations for home visit practices.

This paper is a narrative review of literature focussed on PD home visit practices. The review focusses on practices, such as how frequently nurses complete home visits, what is assessed during the visit, and how effective the home visit structure is at managing patients. The aim of this review is to provide evidence-based recommendations for providing PD home visit services.

Method

Search strategy

A search was conducted of the CINAHL, Medline and Pubmed databases. Search terms used in various combinations were: peritoneal dialysis, patient home visits, guidelines, policies or recommendations.

Inclusion criteria

Publications were reviewed if they made recommendations for PD patient home visits and focussed on staff completing home visits, frequency of home visits, or the assessments conducted during visits. Publications were excluded for review if they were published before 2008 or were not in English.

Evidence quality

The Joanna Briggs Institute (JBI) Levels of Evidence for Effectiveness (JBI, 2014) and the National Health and Medical Research Council (NHMRC, 2009) additional levels of evidence were used to critically appraise publications (Tables 1 and 2).

Results

The initial search identified 59 studies. The title and abstract of publications were reviewed for relevance. After inclusion and exclusion criteria were applied, nine publications were identified for review (see Table 3). Based on the JBI criteria, the studies were level 3, 4 or 5 evidence (see Table 4). Using the NHMRC's criteria, six studies were Level IV evidence and 3 received no classification (see Table 5).

Why are home visits needed?

Numerous reasons were cited for performing home visits. These include the benefits of infection prevention, improved therapy compliance, retraining, preservation of residual renal function (RRF) and fostering patient autonomy and empowerment. The trending shift in patient preference for remaining home is also described (Baillie & Lankshear, 2014).

Infection prevention

Although infection prevention is cited as a reason for performing home visits, few studies demonstrated a link between home visits and reduced infection rates. Two which did found home visits reduced the rate of gram-positive peritonitis and patient hospitalisation, leading to improved longevity of PD therapy, and played a pivotal role in preventing infections by helping patients maintain a safe home environment (Kazancioglu et al., 2008; Martino et al., 2014).

Two studies recommend observing the patient's hand washing technique as part of the home visit (Alcaraz et al., 2008; Sayed et al., 2013). Sayed et al., (2013, p. 364) noted that the most commonly neglected steps of hand hygiene were the application of hand disinfectant before disconnection (84% of patients), application of hand disinfectant before connection (78%), avoidance of air drafts (40%) and washing hands with soap and water before the exchange (30%). Assessing the patient or caregiver's daily exit-site care and dressing technique was also recommended (Sayed et al., 2013).

Therapy compliance

For the purpose of the review, PD compliance was defined as "the performance of at least 90% of all prescribed exchanges" (Bernardini & Piraino, 1997, p. 339). One study suggested that home visit programs can improve patient compliance, though the reasons were not clear (Ellis et al., 2010). The ISPD recommends that therapy retraining include the observation and correction of dialysis exchange technique, hand hygiene practices and catheter exit-site care to reduce the risk of developing PD-related infections (Piraino et al., 2011). No other recommendations were made for ensuring therapy compliance.

Autonomy and empowerment

Few studies explored the link between home visits and patient autonomy. In one British study, PD patients expressed gratitude towards being able to manage their treatment at home, despite the challenges this can impose (Baillie & Lankshear, 2014). The long-term benefits of this, though, were not clear. Peters (2014) argues that feelings of depression or isolation that may lead to therapy noncompliance can be reduced by vigilant support, contact and monitoring by the PD team, though no evidence was provided for this.

Retraining

The need for retraining patients on the knowledge and skills acquired during pre-dialysis training was emphasised by five studies (Kazancioglu et al., 2008; Martino et al., 2014; Peters, 2014; Piraino et al., 2011; Szeto, 2015). However, despite the ISPD's suggestion that retraining can reduce the risk of peritonitis (Szeto, 2015), there are no evidence-based guidelines or policies that outline a schedule for periodic retraining. Peters (2014) suggests that retraining should occur at regular intervals and after significant events such as infectious episodes, prolonged hospitalisations or when PD staff suspect the patient may be performing unsafe practices.

Staff performing visits

Few studies specified the number of staff required per home visit. Two studies recommended that two PD nurses perform each visit, but reasons for this were not stated (Kazancioglu et al., 2008; Kazancioglu et al., 2008a).

When should visits be performed?

Five of the nine studies made recommendations for when home visits should be performed (Alcaraz et al., 2008; Lo et al., 2008; Martino et al., 2014; Peters, 2014; Sayed et al., 2013). There was little consistency in the literature, though, with recommendations including prior to therapy starting, within the first few weeks of therapy, and after a recent hospitalisation. None of these recommendations were supported by evidence.

Follow-up

There was no consistency in recommendations for the timing of home visits after the initial visit. One study recommended every three months (Martino et al., 2014). Two studies recommended follow-up visits but not a specific interval (Peters, 2014; Sayed et al., 2013). No rationales or evidence were prove for these recommendations.

What should be assessed?

Once the PD nurse is in the patient's home, there are many issues requiring assessment. Those identified in the literature related to the patient's health, the dialysis environment, and the patient's knowledge and skill level, medication management and support system.

Nutrition

Two studies recommended assessing the patient's nutritional status during a home visit (Kazancioglu et al., 2008; Sayed et al., 2013). One PD unit used a questionnaire to assess nutritional status by relying on the patient's ability to recall their daily food intake and the amount of salt added to meals (Kazancioglu et al., 2008). Sayed et al. (2013) discuss the importance of assessing the patient's understanding of their fluid maintenance, so that the patient can modify their fluid intake in the case of fluid overload or depletion.

Personal hygiene

As a part of the patient's overall health and for infection-prevention measures, assessment of the patient's personal hygiene was recommended by three studies (Kazancioglu et al., 2008; Kazancioglu et al., 2008a; Lo et al., 2008). These assessments include asking how frequently the patient bathed and washed their hands (Kazancioglu et al., 2008). One PD unit assessed if the patient had changed their underwear daily, taken a bath and changed the catheter dressing at least twice-weekly, had short, clean fingernails, brushed their teeth daily, and had performed genital cleaning and hair removal (Kazancioglu et al., 2008).

PD records

Most PD units required patients to keep daily records of their PD data, blood pressure and weight, in order to monitor therapy progress. These records are then reviewed by the PD nurse at the home visit. For a patient that is performing continuous ambulatory PD, Kazancioglu et al. (2008) discussed assessment of the patient's dialysis records in further detail including if PD solutions are weighed and ultrafiltration calculated, blood pressure is measured and urine is measured once a week.

Medical equipment

Peters (2014) recommends assessment of the patient's medical equipment at home. Ellis et al. (2010) specify the importance of having a working thermometer and smoke detector. Peters (2014, p.90) also suggests observing the patient operate the equipment in the home with "the distractions, interruptions, and disturbances that are inherent in that environment", in order to ensure its proper usage.

Dialysis stock

Assessing storage of the dialysis stock and ancillary items is recommended by five studies (Alcaraz et al., 2008; Ellis et al., 2010; Kazancioglu et al., 2008; Martino et al., 2014; Peters, 2014). One unit evaluated if PD solutions were kept under non-humid conditions, were not exposed to direct sunlight, within the expiry date, kept in original packaging and if the packages were kept in the dialysis room (Kazancioglu et al., 2008). Peters (2014) recommended assessing for evidence of moisture, vermin, or extreme temperature changes in the storage area.

Home environment

All nine studies stated that holistic assessment of the home environment is paramount to ensure the patient has been able to adapt the environment to facilitate dialysis treatment. One study involving frequent home visits demonstrated the importance of maintaining a safe and convenient home environment for preventing PD-associated infections (Kazancioglu, 2008). Evidence from three studies suggests that a home visit allows for the detection of problems that may impact the safe performance of home therapy and thus the opportunity to either provide appropriate solutions or to make the necessary referrals to the allied health team (Peters, 2014; Sayed et al., 2013; Szeto, 2015).

Dialysis room

Five studies recommend the area the patient is performing PD be examined during the home visit (Alcaraz et al., 2008; Ellis et al., 2010; Kazancioglu et al., 2008; Kazancioglu et al., 2008a; Martino et al., 2014). Two studies recommended assessing how frequently the area was cleaned, and room configuration and ventilation (Kazancioglu et al., 2008, 2008a).

Pets

Pets are recognised as a safety hazard and potential risk factor for PD-related infections (Ellis et al., 2010). Despite this, no study recommended that pets be removed from the home environment or even when therapy is occurring.

Utilities and waste disposal

Three studies recommended assessment of the patient's bathroom and toilet, as this is where the majority of personal hygiene is performed (Ellis et al., 2010; Kazancioglu et al., 2008; Lo et al., 2008). One unit's practice included observing if dialysis fluid was appropriately disposed of (Ellis et al., 2010). Another evaluated if bleach was used to disinfect the toilet after dialysis disposal and if the medical waste was regularly collected by the council (Kazancioglu et al., 2008).

Knowledge and skill

Eight of the nine studies discussed the importance of reviewing the patient's dialysis exchange technique at the home visit (Alcaraz et al., 2008; Ellis et al., 2010; Kazancioglu et al., 2008, 2008a; Martino et al., 2014; Peters, 2014; Sayed et al., 2013; Szeto, 2015). Whilst this was a common recommendation, it was not supported by evidence.

Exchange technique

Seven studies discussed the importance of observing the patient's dialysis exchange or machine set-up technique to ensure that the patient continues to abide by the recommended procedures (Alcaraz et al., 2008; Ellis et al., 2010; Kazancioglu et al., 2008; Martino et al., 2014; Peters, 2014; Sayed et al., 2013; Szeto, 2015). Some argue that "a clean exchange procedure and good connection technique are essential factors in the prevention of peritonitis" (Alcaraz et al., 2008, p. 422). It is also recommended to evaluate the patient's exchange technique after an episode of peritonitis, especially if the cause of the infection was touch contamination (Ellis et al., 2010; Szeto, 2015).

Therapy compliance

Patient compliance with PD therapy is critical for their health. Therefore, two studies recommend that compliance be closely monitored (Martino et al., 2014; Szeto, 2015).

Medications

Four studies recommended a review of the patient's medications during the home visit (Ellis et al., 2010; Kazancioglu et al., 2008; Martino et al., 2014; Peters, 2014). One suggestion was to note the latest prescribed medications on record prior to the home visit and then comparing this with what the patient is actually taking (Ellis et al., 2010). Peters (2014, p. 90) highlighted the importance of not only performing home medication reconciliation, but to also identify if there is a "presence of home or non-traditional therapies", which may negatively impact or cause unsafe interactions with the patient's prescribed medications.

Family and support

Two studies recommended assessing the type of family or social support the patient has (Ellis et al., 2010; Peters, 2014). This might include the patient's social network or community support (Peters, 2014).

Discussion

Nine publications that focussed on the characteristics of PD home visits were reviewed. This literature is heavily characterised by case studies, recommendations and expert opinion, but with little overall consensus or evidence-based guidelines for PD home visit practices. The Joanna Briggs Institute rates this literature as Grade B evidence. The NHMRC rates the literature as Level D, which must be applied with caution. Despite the lack of high-level evidence literature to support the practice of PD patient home visits, the JBI (2013, p. 212) argues that health professionals should consider the "opinion of experts and the views of experienced clinicians and their professional bodies as valid forms of evidence for practice, especially when some intervention or activity is required in practice, even if no evidence from research exists".

The literature makes many recommendations when visiting PD patients at home. These include assessing the patient's therapy technique and support network. If the primary purpose of a home visit is to keep the patient at home and out of the hospital setting, then such visits are clearly worthwhile, despite limited evidence to support this. An example of the benefits of PD home visits is in reducing infections. The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) maintains data on PD-related peritonitis episodes in Australia (ANZDATA, 2016). The 2015 ANZDATA report (2016) showed a considerable overall drop in peritonitis rates in recent years. Despite this drop, peritonitis was the most common cause of technique failure in Australia in 2015 (ANZDATA, 2016). The ISPD (2016) guidelines for the prevention and treatment of peritonitis support home visit services by the PD unit, describing the practice as being "useful in detecting problems with exchange technique, adherence to protocols, and other environmental and behaviour issues which increase the risk of peritonitis" (Kam-Tao Li et al., 2016, p. 3).

Endeavouring to address the varying factors that contribute to PD-related infections can be challenging and at times difficult for PD units. During the home visit, assessment of the dialysis environment, retraining the patient and family/carers, and assessment of patient knowledge and technique may contribute to reducing the risk of PD-related infections. Furthermore, noncompliance with performing all of the prescribed PD exchanges can be attributed to adverse health outcomes, increased rates of transfer to haemodialysis and increased hospital admissions (Bernardini et al., 2000). Russo et al. (2006) argue that patient adherence to the procedural technique and prescribed treatment is crucial for the prevention of adverse complications.

A home visit creates an opportunity to reinforce the importance of completing all prescribed exchanges and allows the nurse to identify patients who are non-compliant. The home visit also provides an opportunity for the PD nurse to assess the patient's support network, community safety, and family dynamics within their own environment (Peters, 2014). It creates the opportunity to have a conversation with the patient and family about any cultural, religious or family-specific practices that may have an impact on the patient's ability to perform the prescribed PD exchanges (Peters, 2014). The PD nurse could then work out a routine that is tailored to the patient's lifestyle, as "failure to work within the patient's value system is a recipe for failure and can lead to unsafe practices" (Peters, 2014, p. 89). Finally, the physical and emotional health of the patient can also be assessed. Any concerns that require multidisciplinary intervention can then be referred to the appropriate services.

Conclusion

Home visits to patients performing PD are conducted for a variety of reasons, as identified in the literature. There are many recommendations for performing these visits, but the literature is characterised by weak forms of evidence. This review highlights the need for further research using rigorous designs to determine the impact that home visit services have on PD patients' health outcomes and how these visits should best be performed.

References

Alcaraz, M., Brzostowicz, M., & Moran, J. (2008). Decreasing peritonitis infection rates. Nephrology Nursing Journal, 35(4), 421-423. Retrieved from http://search.proquest.com.ez.library.latrobe.edu.au/docview/216534305?OpenUrlRefId=info:xri/sid:primo&accountid=12001

ANZDATA. (2016). 38th Report, Chapter 5: Peritoneal Dialysis. Retrieved from Australia and New Zealand Dialysis and Transplant: http://www.anzdata.org.au/anzdata/AnzdataReport/38thReport/c05_anzdata_peritoneal_v1.0_20160421_web.pdf

Baillie, J., & Lankshear, A. (2014). Patient and family perspectives on peritoneal dialysis at home: findings from an ethnographic study. Journal of Clinical Nursing, 24(1-2).

Bernardini, J., & Piraino, B. (1997). Measuring compliance with prescribed exchanges in CAPD and CCPD patients. Peritoneal Dialysis International, 17(4), 338-342.

Bernardini, J., Nagy, M., & Piraino, B. (2000). Pattern of noncompliance with dialysis exchanges in peritoneal dialysis patients. American Journal of Kidney Diseases, 35(6), 1104-1110.

Ellis, E. N., Blaszak, C., Wright, S., & Van Lierop, A. (2010). Effectiveness of home visits to pediatric peritoneal dialysis patients. Peritoneal Dialysis International, 32(4), 419-423.

Joanna Briggs Institute (JBI). (2013). New JBI Grades of Recommendation. Retrieved from Joanna Briggs Institute: http://joannabriggs.org/assets/docs/approach/JBI-grades-of-recommendation_2014.pdf

Joanna Briggs Institute (JBI). (2014). New JBI Levels of Evidence. Retrieved from Joanna Briggs Institute: http://joannabriggs.org/assets/docs/approach/JBI-Levels-of-evidence_2014.pdf

Kazancioglu, R., Ozturk, S., Ekiz, S., Yucel, L., & Dogan, S. (2008). Can using a questionnaire for assessment of home visits to peritoneal dialysis patients make a difference to the treatment outcome? Journal of Renal Care, 34(2), 59-63.

Kam-Tao Li, P., Szeto, C., Piraino, B., de Arteaga, J., Fan, S., Figueiredo, A. E.,... Johnson, D. (2016). ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Journal of the International Society for Peritoneal Dialysis, 36(5), 481-508.

Kazancioglu, R., Ozturk, S., Yucel, L., Guvenc, S., Ekiz, S., & Dogan, S. (2008a). Importance of home visits in peritoneal dialysis. Dialysis & Transplantation, 37(4), 132-136.

Lo, W., Kwan, T, Ho, Y, Lee, M., Cheng, Y., Ng, S., & Chu, W. L. (2008). Preparing patients for peritoneal dialysis. Peritoneal Dialysis International, 28(S3), S69-71.

Martino, F., Adibelli, Z., Mason, G., Nayak, A., Ariyanon, W., Rettore, E.,... Ronco, C. (2014). Home visit program improves technique survival in peritoneal dialysis. Blood Purification, 37(4), 286-290.

Peters, A. (2014). Safety issues in home dialysis. Nephrology Nursing Journal, 41(1), 89-92.

Piraino, B., Bernardini, J., Brown, E., Figueiredo, A., Johnson, D., Lye, W.,... Szeto, C. (2011). ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Peritoneal Dialysis International, 31(6), 614-630.

Sayed, S. A., Abu-Aisha, H., Ahmed, M. E., & Elamin, S. (2013). Effect of the patient's knowledge on peritonitis rates in peritoneal dialysis. Peritoneal Dialysis International, 33(4), 362-366.

Szeto, C. (2015). Peritoneal dialysis-related infection in the older population. Peritoneal Dialysis International, 35(6), 659-662.

Szeto, C., Li, P., Johnson, D., Bernardini, J., Dong, J, Figueiredo, A., Ito, Y., Kazancioglu, R., Moraes, T., Esch, S., & Brown, E. (2017). ISPD catheter-related infection recommendations: 2017 update. Peritoneal Dialysis International, 37, 141-154.

Trish Buena RN, BN/BPH, MN, Clinical Nurse Specialist Alfred Health Peritoneal Dialysis Unit, Melbourne, VIC, Australia

Peter Tregaskis RN, BN Alfred Health Peritoneal Dialysis Nurse Practitioner/Coordinator, Melbourne, VIC, Australia

Malcolm Elliott RN, PhD Senior Lecturer, Monash Nursing & Midwifery, Monash University, VIC, Australia

Correspondence to: Trish Buena RN, BN/BPH, MN, Clinical Nurse Specialist Alfred Health Peritoneal Dialysis Unit, Melbourne, VIC, Australia Email m.buena@alfred.org.au

Submitted: 7 November 2017, Accepted: 4 June 2018
Table 1: JBI levels of evidence for effectiveness

    Level                                           Number

Observational          3.b--Systematic review         1
--analytic designs     of comparable cohort and
                       other lower study designs
                       3.d--Case-controlled study     1
                       3.e--Observational study       1
                       without a control group
Observational          4.b--Cross-sectional study     2
--Descriptive designs  4.c--Case series               2
Expert opinion and     5.b--Expert consensus          1
Bench research         5.c--Single expert opinion     1
                                             Total    9

Table 2: NHMRC levels of evidence

Level  Intervention

I      Systematic review of level II studies
II     Randomised controlled trial
III-1  Pseudorandomised controlled trial
III-2  Comparative study with concurrent controls
III-3  Comparative study without concurrent controls
IV     Case series with either post-test or pre-test/post-test
       outcomes

Table 3: Reviewed studies

Authors           JBI level                   NHMRC level

Szeto (2015)      3.b--systematic review of   No classification:
                  comparable cohort studies   systematic review of
                  and other lower study       comparable cohort studies
                  designs                     and other lower study
                                              designs
Martino et al.    3.d--case-controlled        III-3: case-controlled
(2014),           study                       study
Italy
Peters (2014)     5.c--single expert opinion  No classification: single
                                              expert opinion
Sayed et al.      4.c--case series            IV--case series
(2013),
Sudan
Ellis et al.      4.b--Cross-sectional        IV: A cross-sectional
(2012), USA       study                       study
Alcaraz et al.    4.c--case series            IV--case series
(2008)
Kazancioglu et    4.b--Cross-sectional        IV: A cross-sectional
al. (2008),       study                       study
Turkey
Kazancioglu et    3.e--observational study    IV: Case series with
al. (2008a),      without a control group     post-test outcomes
Turkey
Lo et al. (2008)  5.b--expert consensus       No classification: expert
                                              consensus

Authors           Sample population      Number of      Frequency of
                                         staff present  home visit
                                         at visit

Szeto (2015)      Not applicable         Not specified  Not specified
Martino et al.    188 PD adult patients  Not specified  Every three
(2014),                                                 months
Italy                                                   Additional visit
                                                        if medically
                                                        suggested
Peters (2014)     Not applicable         Not specified  Early visit ASAP
                                                        Periodic visits
                                                        Recently
                                                        hospitalised
Sayed et al.      50 adult PD patients   Not specified  Start of home
(2013),                                                 dialysis
Sudan                                                   Regular
                                                        intervals, no
                                                        specified time
                                                        frame
Ellis et al.      22 paediatric PD       Not specified  Not specified
(2012), USA       patients from 1 PD
                  unit
Alcaraz et al.    52 Adult PD patients   Not specified  Within first
(2008)                                                  week after start
                                                        of home dialysis
Kazancioglu et    32 adult PD patients   2 nurses       Not specified
al. (2008),       from 1 PD unit
Turkey
Kazancioglu et    32 adult PD patients   2 nurses       Not specified
al. (2008a),
Turkey
Lo et al. (2008)  Not defined            Not specified  Pre-dialysis
                                                        (for some
                                                        patients)

Authors           Assessment criteria at home visit

Szeto (2015)      Dialysis environment
                  --home environment
                  Knowledge and skill
                  --exchange technique
Martino et al.    Dialysis environment
(2014),           --exchange room
Italy             --dialysis stock storage
                  Knowledge and skill
                  --exchange technique
                  --dialysis compliance
                  Medications
Peters (2014)     Dialysis environment
                  --housing situations
                  --water services
                  --cleanliness
                  --adequate lighting
                  --hand washing facility--paper towels for drying
                  hands
                  --presence of ceiling or room fans, windows
                  --presence of pets
                  --dialysis stock storage
                  --physical environment
                  --safety hazards
                  Knowledge and skill
                  --exchange technique
                  Patient health
                  --equipment
                  Medications
                  Family and support
                  --patient's community
                  --social support network
                  --family functioning
Sayed et al.      Dialysis environment
(2013),           --home environment
Sudan             Knowledge and skill
                  --exchange technique
                  --hand washing
                  --exit site care
                  --fluid maintenance
                  Patient health
                  --nutrition
Ellis et al.      Dialysis environment
(2012), USA       --home environment
                  --exchange room
                  --disposal of dialysis waste
                  --dialysis stock storage
                  --presence of pets
                  Knowledge and skill
                  --exchange technique--if patient had episode of
                  peritonitis the preceding year
                  Patient health
                  --dialysis records
                  --medical equipment: blood pressure, weigh scales,
                  thermometer
                  --state of dialysis machine
                  Medications
                  --correct dose, within date, storage
                  Family and support
                  --type of surrounding community (urban, city, rural)
                  --type of living quarters--single family home,
                  apartment, trailer
Alcaraz et al.    Dialysis environment
(2008)            --exchange room
                  --dialysis stock storage
                  Knowledge and skill
                  --solution warming procedure
                  --exchange technique
                  --hand washing technique
Kazancioglu et    Dialysis environment
al. (2008),       --exchange room
Turkey            --home environment
                  --dialysis waste disposal
                  --condition of bathroom and/or toilet
                  --dialysis stock storage
                  Knowledge and skill
                  --exchange technique
                  --treatment details
                  Patient health
                  --personal hygiene
                  --dialysis records
                  --patient's socio-economic status
Kazancioglu et    Dialysis environment
al. (2008a),      --exchange room
Turkey            Knowledge and skill
                  --peritonitis prevention knowledge
                  --infections prevention knowledge
                  Patient health
                  --nutrition
                  --constipation
                  --personal hygiene
                  Medications
Lo et al. (2008)  Dialysis environment
                  --home environment
                  --home habits
                  --hand washing and showering facilities

Table 4: JBI levels of evidence for effectiveness

Level

1 Experimental designs        1a Systematic review of
                              randomised controlled trials (RCTs)
                              1b Systematic review of RCTs and
                              other study designs
                              1c RCT
                              1d Pseudo-RCTs
2 Quasi-experimental designs  2a Systematic review of quasi-experimental
                              designs
                              2b Systematic review of quasi-experimental
                              designs and other
                              lower study designs
                              2c Quasi-experimental
                              prospectively controlled study
                              2d Pre-test/post-test or historic
                              /retrospective control group study
3 Observational--analytic     3a Systematic review of
designs                       comparable cohort
                              3b Systematic review of
                              comparable cohort and other
                              lower study designs
                              3c Cohort study with control group
                              3d Case-controlled study
                              3e Observational study without a
                              control group
4 Observational               4a Systematic reviews of
--descriptive studies         descriptive studies
                              4b Cross-sectional study
                              4c Case series
                              4d Case study
5 Expert opinion and          5a Systematic review of expert
bench research                opinion
                              5b Expert consensus
                              5c Bench research/single expert
                              opinion

Table 5: Study ranking using NHMRC levels of evidence

Level              Intervention         Number
                                        6
IV                 Case series with
                   either post-test or
                   pre-test/post-test
                   outcomes
No classification                       3
                                 Total  9
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Author:Buena, Trish; Tregaskis, Peter; Elliott, Malcolm
Publication:Renal Society of Australasia Journal
Date:Jul 1, 2018
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