An initiative to improve effluent culture detection among pediatric patients undergoing peritoneal dialysis through process improvement

Abstract

Background: Peritonitis is a significant cause of morbidity and healthcare cost among pediatric patients undergoing peritoneal dialysis. Culture-negative peritonitis has been associated with an increased risk of technique failure. Known risk factors for culture-negative peritonitis are related to the process of collection and sample processing for culture, but additional studies are needed. A culture detection rate of 16.7% was identified among our patients undergoing peritoneal dialysis, which is below the national benchmark of ≥ 85%. Our primary objective of this quality improvement project was to improve culture detection rates.

Methods: Interventions were developed aimed at standardizing the process of effluent collection and laboratory processing, timely collection and processing of samples, and addressing other modifying risk factors for lack of bacterial growth from culture. These interventions included direct inoculation of effluent into blood culture bottles at bedside and use of an automated blood culture system. Two Plan-Do-Study-Act cycles were completed prior to moving to the sustain phase.

Results: The culture detection rate improved from 16.7% (pre-intervention) to 100% (post-intervention). A decrease in the median process time also occurred from 83 min (pre-intervention) to 53 min (post-intervention). An individual and moving range chart identified a decrease in both the centerline (mean) and upper control limit, indicating that the process became more reliable during the sustain phase.

Conclusions: An improvement in process time and culture positivity rate occurred following standardization of our PD fluid culture process. Future studies should be aimed at the impact of the components of collection and processing methods on the effluent culture yield. A higher resolution version of the Graphical abstract is available as Supplementary information.

Keywords: Culture-negative peritonitis; Pediatric; Quality improvement.

Fig. 1

Individual (A) and moving range (B) charts showing process time for peritoneal dialysis effluent cultures during the pre-intervention (blue), intervention (white), and sustain/post-intervention (green) phases. The intervention for PDSA cycle 1 was the bedside inoculation of effluent into the appropriate containers and placement into our microbial detection system. The intervention for PDSA cycle 2 was the re-education of the main laboratory staff. A decrease in the average process time during the sustain phase likely more accurately reflects time to placement of effluent into optimal growth conditions. A decrease in the upper control limit also occurred during the sustain phase which reflects that the process became more reliable