Peritonitis is the most serious complication of peritoneal dialysis, with 57 percent of infected patients requiring hospitalization at a price tag of $21,646 per hospitalization. Preventing peritonitis prevents these costly hospital stays, allows patients to continue home-based dialysis and normal school and family activities, and avoids transitioning patients to hemodialysis. Much of pediatric nephrologist Alicia Neu's work has been devoted to improving outcomes in children with end-stage kidney disease, or ESRD. She is currently one of the lead faculty on the Standardizing Care to improve Outcomes in Pediatric ESRD (SCOPE). Part of the Children's Hospital Association's Quality Transformation Network, SCOPE focuses on increasing implementation of recommended peritoneal dialysis catheter practices to reduce the risk of peritonitis.

So, how do you approach the goal of preventing peritonitis?

Because pediatric kidney disease is a relatively rare condition, large collaborative studies are required to collect enough data to accurately describe existing care and to identify areas in which care can be improved. One such effort, the North American Pediatric Renal Trials and Collaborative Studies, or NAPRTCS, has collected information on thousands of children on dialysis. This and other international efforts have allowed the development of practice guidelines aimed at reducing the risk for peritonitis. Unfortunately, it is unclear how frequently these guidelines are implemented. SCOPE seeks to increase implementation of these recommended care practices in an effort to reduce peritoneal dialysis catheter related infections. Currently there are 29 pediatric nephrology centers around the country participating and more than 700 children on peritoneal dialysis have been enrolled.

How does it work?

SCOPE uses quality improvement methodology to increase use of recommended practices. Central to this process is monitoring what we're actually doing with or to the patient. Every single time a catheter goes into a patient, we monitor whether or not the best care practices are followed. Did the surgeon give an antibiotic at the right time? Did he put the right kind of catheter in? Every time we train a patient to do dialysis at home, we ask whether or not very specific steps for hand washing or performing the dialysis procedure were included in that training. And every time we see the patient for a clinic visit, we monitor whether those steps are reviewed with the patient. We ask the provider, did you review hand washing with the patient? Did you review the aseptic technique used to do the dialysis procedure? We also monitor every infection that occurs.

What have you found?

Overall compliance with those best practices has improved-from less than 10 percent to 70 to 80 percent. Also, we've seen more than a 30 percent drop in our infection rates. Because most children who get peritonitis have to be hospitalized, we know we've reduced hospitalizations, too. The idea is that by increasing the implementation of these recommended practices, we're reducing the infection rates. But we're also looking further to see if there are particular care practices that are more closely associated with infection than others.

So in effect your goal is to change best practices?

We're really looking to define best care practices. We hope to develop what people should do and really impact what happens to any person on peritoneal dialysis.

##