Design And Application Of A Transitional Care Program For Patients With Early Peritoneal Dialysis

Objective:To design a transitional care program for patients with early peritoneal dialysis,and to investigate the effect of its application in this chronic diseases.Methods:A transitional care team was established and was trained by teaching method and case analysis method. After the training, scores 90 points or more was qualified as a member of transitional care team.The participants should meet the following criteria:(1)The patients with chronic kidney disease(CKD) were hospitalized in the second affiliated hospital of Soochow University from September 2013 to March 2014, and the first peritoneal dialysis catheter was performed. The patients had no physical activity dysfunction and volunteered for the researchers.(2)The exclusion criteria: patients and caregivers are medical stakeholders;(3)Grouping: The patients were randomized divided into two groups of the transitional care group and regular review group, each group with 20 patients. The regular review group performed regular hospital visits, namely phone return visit after discharge from hospital. After discharge, laboratory indicators, 24-hour urine output, the incidence of complications and daily life ability evaluation of each index was collected, at the end of two and six months. These data was compared between the groups.Based on literature review, questionnaire and the practical work experiences, the care content included a return visit by phone, home visit, network platform, and organization of the peritoneal dialysis patient club, naming "123456 plan"(1 means home visits after 1 week of discharged and telephone visit at the end of 1 month afterpatients discharged; 2 means home visit after 2 months of patients discharged,; 3 means telephone visit after 3 days and at the end of 3 months of discharged and; 4 means home visit after 4 months; 5 means telephone visit after 5 months, the transitional care team answer questions in the network platform and accept all kinds of consulting online/video every Friday night; 6 means home visit after 6 months, organization of peritoneal dialysis patient club, and answer questions and accept all kinds of consulting online/video every Saturday night). To inspections or view weather the environment of the peritoneal dialysis room and items placed meet requirements, measuring the patient vital signs, check the tunnel condition, understand patients life self-care ability, physical status, presence of positive signs, answer the questions of the patients and their families at the same time. To eliminate potential complications, improve the self-management consciousness of the patients.Results:1) There were 40 patients entering the study with 20 in each group. No significant difference of gender and age were observed.2) Compared with regular review group, the endogenous creatinine clearance rate and urea clearance index and serum phosphate at the end of 2 months and 6 months were superior in the transitional care group with statistical significance(P < 0.05).There were no statistically significant differences for the blood albumin and hemoglobin at the end of 2 months between two groups as comparison,(P > 0.05). However, at the end of 6 months, the indexes of nutritional status hemoglobin and blood albumin were better in the transitional care group than in the regular review group with statistically significant(P < 0.05).3) As for the incidence of complications, the rate of peritonitis for outpatient service was significantly lower in the transitional care group than in the regular review group(P < 0.05); however, For there was no statistically difference because of tunnel infection and other reasons to go to the outpatient service(P > 0.05).4) Compared GQOLI-74 scores in the end of second and sixth months, the scores were significantly higher in the transitional care group than in the regular review group (P<0.05).Conclusion:1) "123456 plan" was selected as the transitional care model in this study. It can improve the various behavior of the patients, and reflect the comprehensiveness,coordination, continuity and collaborative of care.2) The transitional care helps to improve the effect of dialysis and nutritional status.3) The transitional care helps to improve the patient’s living quality.4) The transitional care helps to reduce the rate of peritonitis of early peritoneal dialysis patients.5) The transitional care helps to improve the hospital’s reputation and improve relations between nurses and patients.