After a long drought in growth and scant activity among its faithful, peritoneal dialysis is starting to come into its own as a viable treatment modality for dialysis. Because of the gradual rise in PD usage amidst the relative paucity of experience and knowledge, many articles are being published in professional trade journals and talks given at conferences covering a wide range of PD topics.
However, these articles and talks do not address three core, underlying issues on which I believe a successful PD program must focus, with the ultimate motivation being the patient’s welfare, not a provider’s financial gain. If these three core essentials are not rigorously pursued, patient well-being will be mediocre, the PD professionals will get discouraged, and the entire PD program will stagnate, at best, and probably fail.

1. Commitment

Commitment is a series of continuing decisions by everyone involved in the PD program, at every level, focusing on patient well-being. Currently, per the 2013 USRDS Annual Data Report (2011 data), PD as a percent of prevalent dialysis patients ranges from a dismal 7.4% in the United States to an admirable 75% in Hong Kong. For facilities in the United States and other countries to grow PD to a more acceptable percentage, nephrologists, nurses, and surgeons must take active steps to commit to the success of the program.

Nephrologists need to make every effort to learn how to offer quality PD to their patients, starting with insisting on more training in their nephrology fellowships, where currently 57% offer less than 10 PD patient experiences. The result is predictable enough: nephrologists start practice with incomplete, at best, and certainly inadequate, knowledge of PD and all advantages it offers to the patient––medically, socially, financially, and life-style. Likewise, the PD nurses must commit to the PD program since they are the primary caregivers who will motivate the patients to succeed in their own patient-focused treatment.

Surgeons also need to commit to focusing on patient well-being. Since they implant about 85% of all PD catheters, they need to recognize that the catheter is the first step in a critical life-support system, and therefore, the type of catheter, as well as how, where, and when it is implanted are all critical. Equally important is to recognize and preemptively take appropriate actions to deal with catheter twisting, kinking, catheter angulation through the rectus muscle, coil location, adhesions, omentum, and exit-site location. If the catheter fails, PD cannot be done. Their commitment is vital.

2. Persistence in offering excellent care

Persistence is commitment to patient welfare for the long-haul––tenacity to write and follow the procedures and policies needed for a strong PD program, and to amend as needed. Persistence is absolutely essential to achieve excellence. There are a number of published, proven standards of excellence in PD from professional and commercial sources. But following these Best Practices is not sufficient. Persistence means to always strive to exceed national standards, and to surpass patient expectations. The ongoing push for patient well-being will be fatiguing, and without persistence, it cannot be achieved.

Excellence will be achieved if the entire staff persists in paying attention to all the small details involved in PD that make a difference in the standard of care. This includes, for example, following all the steps in the pre- and post PD catheter implantation follow-up care, as defined in the written policies and procedures.

3. Insistence on using best practices, techniques, and tools

Insistence by the team on a systematic, precise, and thorough reproducible method of evaluating patients before PD begins and throughout the entire treatment is critical to the success of the PD program. Penetrating, evaluative questions about patient life style, expectations, home care, cognitive skills, mechanical skills, cooperativeness, and responsibilities must be continually measured and re-evaluated to discern if the goal of patient wellness is being achieved.

Insistence on the best access procedure that produces consistently good results is critical. If a catheter is implanted poorly, it will fail sooner rather than later. If it is placed using the best demonstrated practices, it will succeed. Implantation options include interventional radiology, peritoneoscopy, and some forms of laparoscopy. Research these and insist on the one that results in long-term technique survival, which will also improve the patient’s quality of life.

Insistence on the best catheter means not only evaluating its physical properties, but also matching the catheter size, shape, and style to the individual patient. One catheter cannot fit all patients. Even the location of the best implantation site as well as the optimum tunnel track and exit site makes a difference in catheter complications and survival rates. There is only one proven objective way to determine these criteria––use of a brand-specific stencil.

Conclusion
 

While these three core issues are distinct and need to be carefully reviewed, the reality is that they are all inter-related. Insistence on a quality catheter without commitment means that the wrong catheter may be implanted. Persistence to excellence while taking short cuts or not doing all the steps well will compromise results. Without commitment, when there are difficult situations, the patients suffer, and the PD program stagnates or fails.

By contrast, adherence to these core issues––commitment, persistence, and insistence––is essential for patient well-being. Then your PD program will be medically, ethically, socially, financially, and personally successful.