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Redesigning peritoneal dialysis catheter exit-site classification.

Practice consistency through technique standardization has been driving peritoneal dialysis (PD) practice at our 32-bed acute general medicine and nephrology (22 acute general medicine and 10 nephrology beds) in-patient unit at Sunnybrook Health Sciences Centre, a teaching hospital in Toronto, Ontario. With funding from the Ontario Ministry of Health and Long-Term Care Late Career Nurse Initiative (LCNI) * we undertook and completed a knowledge translation to practice initiative that focused on the implementation of an ISPD recommendation (Piraino et al., 2005) to integrate exit-site classification methodology into practice. This 2010-11 LCNI initiative was implemented by two experienced nurses under the direction of the unit's Advanced Practice Nurse (APN) and is a continuation of a previous 2009-10 LCNI initiative to support advanced competence in peritoneal dialysis.

We set out to complete the 2010-11 LCNI initiative with these three goals/ objectives in mind:

1. To establish best practice in documentation of PD exit site.

2. To ensure standardization of practice in classifying PD exit sites.

3. To simplify the practice of PD exit-site classification such that it is understandable and easy to apply by nurses and also patients.

The initiative took 240 hours and was implemented in three phases:

Phase 1: Conducted a needs assessment to determine the level of satisfaction with the current method of documenting the condition of PD exit sites,

Phase 2: Designed training materials and practice tools to support exit-site classification, and

Phase 3: Implemented exit-site classification. * The Late Career Nurse Initiative (LCNI) is a funding program established to create alternative, less physically demanding role alternatives for RNs 55 years of age or older to utilize their knowledge, experience and skills without loss of work hours or income.

Phase 1: Needs assessment

We learned from focus group discussions with unit staff that there had been an attempt by the previous APN to introduce exit-site classification. Overall, nurses agreed with the concept of exit-site classification, but felt it would "take too long to carry out" and that it "depends on how experienced the nurse was".

Our two LCNI nurses reviewed documentation on all PD patients for the month of January 2010 and found that 100% (3/3) of exit-site documentation audited (pre-study) used the descriptor "D&I" (to mean "dry and intact") to describe the PD exit site.

We considered that the use of the descriptor "D&I" was inadequate for the purposes of exit-site classification, as it was not consistent with College of Nurses of Ontario documentation standards or what was recommended by the current literature. We, therefore, concluded that PD exit sites were poorly documented and a change in practice was needed.

Based on the findings from this documentation audit, our unit APN proposed a business case to redesign our existing PD documentation record to include a page for PD exit-site classification.

Phase 2: Development of training materials and practice tools

Exit-site classification methodology first introduced in 1966 (Twardowski & Prowant, 1996) is the basis for the Exit Site Infection (ESI) Scoring System (Piraino et al., 2005) presented in the 2005 ISPD Guidelines.

The APN used the ESI Scoring System as the basis for a pocket tool that our nurses could refer to when performing PD exitsite care. In the context of three key criteria (simple, useful, understandable), we redesigned the one-page documentation form used to record daily PD treatments, converting it to a four-page/two-sided documentation form. The first three pages were available to record PD treatments. The single "cell" on the old one-page form used to describe the exit site as "D&I" was replaced with a one-page risk assessment checklist on page 4 of the new form.

The idea of marrying a checklist with risk assessment came from the APN's observation of a daily skin assessment screening tool used throughout our hospital to assess a patient's risk for pressure ulcers. Instead of the parameters of "sensory perception, friction, pressure, moisture, nutrition", we would assess parameters of "swelling, crust, redness, pain, drainage". Paralleling the process used to assess skin risk, we could score each exitsite parameter using Twardowski's ESI Scoring methodology. The key difference in our unit's approach to the traditional exit-site classification methodology is that nurses are not asked to classify the exit site. Instead, the tool focuses on "monitoring" (versus diagnosing) and requires the nurse to total the individual ESI scores to compute "risk" and apply a predetermined set of interventions to mitigate the risk.

Nurses had expressed concerns that the process was time consuming and subjective and, so, simplicity was essential to the design of the new form to ensure timeliness of completion. The concept of a checklist was appealing because nurses would not have to "spin their wheels" trying to memorize or spend time thinking about which descriptors to use if they were already on a preprinted a template. Using risk totals to drive nursing interventions structured by a decision-tree algorithm provided nurses with a pragmatic (useful) tool for daily use and guaranteed consistency of language (understandable).

Phase 3: Implementation of exit-site classification

The result was a change in practice that resulted in technique standardization on the unit, high staff satisfaction scores and, most importantly, positive patient outcomes. In addition to all nursing staff, the nephrology nurse practitioner, staff nephrologists, and the hospital forms committee were engaged in the change process.

Concurrent with the rollout of the new documentation tool was the delivery of a training program to all nurses performing peritoneal dialysis. The training program comprised a pocket tool, a six-minute training video, a game and an exit-site classification demonstration on a real patient.

The implementation of the final documentation tool was preceded by emails to everyone involved in the change process requesting feedback on the proposed revisions to the documentation form and focus group sessions with nursing staff. The revised Daily PD record with space added for RNs to document the condition of the PD catheter exit site has been approved by the hospital forms committee and is now being used on our unit.

Implications for future nursing practice and patient education

PD exit-site classification is a well-known methodology used to diagnose exit-site infections, but it has had limited usefulness for nurses practising at the bedside. An alternative application for the methodology is to embed the concepts in a screening tool that is tied to a decision algorithm. The screening tool, when used by nurses at the bedside, has the following benefits:


* Early detection of possible complications or infection by nursing staff

* Enables practice consistency and continuity of care between nurses (strengthens transfer of accountability)

* Provides data to support evidencebased research on exit-site infection prevention.

The tools developed from this initiative have only been used on nurses, but may also have broader applications such as a self-care education tool for outpatients on home dialysis. Potential benefits of using the screening tool by patients at home would parallel benefits for nurses at the bedside:

* Early detection of possible complications or infection by patient

* Enable practice consistency and continuity of care between nurse and patient (strengthens therapeutic nurse-patient relationship)

* Provides data to support evidencebased research on exit-site infection prevention.


Practice consistency in classifying peritoneal dialysis (PD) catheter exit sites promotes the standardization of technique throughout a hospital, and enhances prevention and monitoring of exit-site infections. It also reduces the risk of peritonitis. To achieve practice consistency, nephrology nurses responsible for carrying out PD in a hospital environment must have appropriate training and tools to support best practice in PD exitsite classification.

Practice consistency requires re-education of nursing staff and is achievable with the use of simple and pragmatic training and practice tools.

We developed an innovative and valuable screening tool and hope that other dialysis units will adopt the training methods and tool we developed. Since the implementation of the exit-site pocket tool and roll-out of the new documentation tool there is:

* Improved monitoring of PD exit sites by nurses

* 100% of documentation completed using the re-designed PD exit site classification tool

* No hospital-acquired PD exit-site infections post-implementation

* Improved transfer of accountability related to PD exit-site classification

* Documentation to support useful, objective data on which to base treatment decisions

* Simplification of the task of PD exitsite classification

* Enhanced patient awareness of PD exit-site care

* Available qualitative and quantitative data for trending PD exit-site conditions

* Increased staff satisfaction.

All nurses interviewed to date (10/26 unit PD nurses) including the nephrology nurse practitioner expressed satisfaction with the new tool rating it on average, "10 out of 10" on: simplicity, usefulness, and understandability (post-study).

* The Late Career Nurse Initiative (LCNI) is a funding program established to create alternative, less physically demanding role alternatives for RNs 55 years of age or older to utilize their knowledge, experience and skills without loss of work hours or income.


Piraino, B. et al. (2005). ISPD guidelines/ recommendations: Peritoneal dialysisrelated infections recommendations: 2005 update. Peritoneal Dialysis international, 25, 107-131.

Twardowski, Z.J., & Prowant, B. (1996). Classification of normal and diseased exit sites. Peritoneal Dialysis International, 16 (Suppl. 3),

Address correspondence to: Patsy Cho, RN, MScN, Advanced Practice Nurse, Nephrology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Office E206b, Toronto, ON M4N 3M5. Email:

Department Editor: Eleanor Ravenscroft, RN, PhD, CNeph(C)

By Patsy Cho, RN, MScN, Emelie Exconde, RN, Virginia Sulit, RN, Gillian Brunier, RN(EC), MScN, CNeph(C), Araceli Espiritu, RN, Elena Taruc, RN, and Shirley Drayton, RN, BA
COPYRIGHT 2012 Canadian Association of Nephrology Nurses & Technologists
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Article Details
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Title Annotation:Practice corner
Author:Cho, Patsy; Exconde, Emelie; Suli, Virginia; Brunier, Gillian; Espiritu, Araceli; Taruc, Elena; Dray
Publication:CANNT Journal
Geographic Code:1CANA
Date:Jan 1, 2012
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