#58: Improving the Peritoneal Dialysis Program in a Pediatric hospital in Honduras Using Six Sigma Methodology
Authors: Molina Sara Eloisa Rivera , Quiroz Claudia Romero , Acosta Dilcia Sauceda 
Published: March 2021

Abstract

Background
Peritoneal dialysis (PD) is the most common method of renal replacement therapy (RRT) in pediatric patients in Honduras. It has improved survival and quality of life. Unfortunately, there are complications associated with the use of PD catheters, 85% of which, are of infectious origin. These infections carry a high burden of morbidity and mortality, lengthen hospital stays, and increase costs and are a motive for transfer to hemodialysis. Hospital María Especialidades Pediátricas (HMEP) is a pediatric hospital caring for patients with chronic kidney disease in Honduras, PD has been offered as a method for RRT since September 2014.

Methods
In HMEP, monitoring of PD infection rates through active surveillance began December 1, 2017, as the first step (define and measure) toward the improvement of the PD Program based on Six Sigma methodology. A case of peritonitis was diagnosed when at least 2 of the following 3 criteria were met: (1) Clinical signs or symptoms of peritonitis (cloudy effluent or abdominal pain with fever or vomiting); (2) Altered peritoneal fluid cell count (after a dwell time of 2 hours: a WBC above 100 cells/mm3 in an uncentrifuged sample, with at least 50% neutrophils; or any WBC count with at least 50% neutrophils if the dwell time was less than 2 hours); (3) Positive peritoneal fluid culture. Patient data, risk factors for infection, causative organisms, and event outcomes were recorded. We present the main results of the analysis phase of all peritonitis cases using descriptive statistics.

Results
From December 1, 2017, through November 30, 2019, 79 patients required PD, representing 8931 catheter-days; and 30 peritonitis episodes occurred among 28 individuals (35%). The peritonitis rate during the 2-year surveillance period was 1.2 infections per patient-years (ideally: &lt;0.67). Twenty-seven (90%) of cases were classified as healthcare associated since these patients underwent PD 3 times a week in the hospital and the catheter was only manipulated by medical staff; the other patients received dialysis at home. The median time from catheter placement to the event was 27 days (5–383 days). All patients had clinical signs or symptoms of peritonitis. Peritoneal fluid cell count results were available for 29 infections, all of which reported altered results. Peritoneal fluid cultures were positive in only 12 events (40%); 6 (50%) reported Gram-negative organisms, 5 (41%) reported Gram-positive and 1 reported Aspergillus spp. Nonfermentative Gram-negative bacteria (Pseudomonas aeruginosa and Acinetobacter lwoffii) were the most common organisms identified; Staphylococcus epidermidis was the most common Gram-positive. Ten events (33%) required removal and replacement of the catheter due to the infection, 6 (20%) required permanent transfer to hemodialysis; 2 (7.1%) patients experienced a relapse. Two (7.1%) died due to infection.

Conclusions
Implementing Six Sigma methodology allowed us to improve our PD Program by objectively quantifying the magnitude of the problem and identifying risk factors. This supported the infection prevention and control team with the implementation and improvement of preventive measures: change in hand hygiene products (from triclosan to chlorhexidine), increasing hand hygiene compliance, improving connection/disconnection procedure, PD catheter insertion, and maintenance, empowerment of caregivers.