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Sx"C  Acriticalpathwayisa_multidisciplinary_Ԁpatientcareplanthatoutlinesthepharmacological  and_nonpharmacological_Ԁtherapies,interventions,andoutcomesexpectedthroughouta   patient'shospitalizationortreatment(13).Itallowsforastandardizedapproachtopatient   managementusingcurrentpractices,scientificevidence,and_benchmarking_,andmaybeused   fordocumentationofinterventionsandoutcomes(4).WedevelopedaCriticalPathwayfor {  thetreatmentofcontinuousambulatoryperitonealdialysis(CAPD)peritonitisinaneffortto g  incorporateevidencebasedliterature,tostandardizetreatment,andtoimplementoncedaily S  _intraperitoneal_Ԁ_aminoglycoside_Ԁdosing(57).Thefollowingreportdescribesourexperience ?  withdevelopment,implementation,andevaluationofacriticalpathwayforthetreatmentof +{  CAPDperitonitis."C݌ g  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S V "    AWXAX#WAW#AWWMaterialsandMethods" ݌   Ќ ,! XX!  #AXXAW2 ##XXXAXt #AXXXX?+ ` hp x X?   Sc`    ?Ixhd$~bp@+pddx bEb V9f  ݌ c Ќ  " ,?+ ` hp x X?  SE"  ACriticalPathwayforthetreatmentofCAPDperitonitisandanaccompanyingpreprinted E Physician'sOrderssheet,basedonthe"PeritonealDialysisRelatedPeritonitisTreatment 1 Recommendations:1996Update"andotherevidencebasedliterature,weredevelopedby  Pharmacyandreviewedbya_multidisciplinary_Ԁteamofmedical,nursing,andpharmacystaff   fromthePeritonealDialysisUnitatSt.Paul'sHospital(_SPH_),Saskatoon,Saskatchewan,  Canada(57).TheCriticalPathwayformindicateswhendiagnostictests,interventions,and  patienteducationaretotakeplaceduringtreatmentdays1Ӏ21and_posttreatment_Ԁfollowup } (seeFigure1).Italsoallowsfordocumentationofoutcomessuchascultureandsensitivity i resultsandpatientreportedsignsandsymptomsofperitonitisandtheirresolution.The U Physician'sOrdersoutlinesempiricanddefinitiveantibiotictherapyforCAPDperitonitisand A includesprovisionforoncedaily_intraperitoneal_Ԁ_aminoglycoside_Ԁdosing."݌ -} Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S l "n  TheCriticalPathwayandPhysician'sOrderswereimplementedinapilotprojectfrom18   Januaryto9April1999.Patientswereeligibleforinclusionintheprojectiftheywereon ! CAPD,iftreatmentwasprovidedonanoutpatientbasis,ifthephysicianapprovedtheuseof " theCriticalPathwayandPhysician'sOrders,andifthepatientwas18yearsofageorolder. # Patientswereexcludedifhospitalizedtypicallywhenperitonitissymptomsdidnotresolve o$ after3daysorwhenthepatient_decompensated_Ԁorrequiredcatheterremoval."n݌ [%  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S&="&!"~  Theperitonealdialysis(_PD_)nursecontactedthephysicianandinitiatedthecriticalpathway &="  whenareportofsuspectedperitonitisfromaneligiblepatientwasreceived.Thecritical ')#! pathwaywastobefollowedforallcareanddocumentation.The_PD_Ԁnursecoordinatedcare ($" bytelephonewithphysicians,patients,andhomecare,andensuredallresponsibilitiesonthe )%# CriticalPathwaywerecompletedanddocumented.ThepreprintedPhysician'sOrderswere *%$ usedbyphysicianstoprescribeempiricantibioticsforpatientspresentingwithasuspected +&% peritonitis.When_PD_Ԁeffluentcultureandsensitivityresultswerereceived,physiciansused u,'& thedefinitiveantibiotictherapysectiontoadjustantibiotictherapy._Tobramycin_Ԁserum a-(' s_`?/+b|0 h `l-0@E hhzs (#(#                                  (#(#concentrationswereindicatedwhentherapywascontinuedfor_enterococcus_,pseudomonas, $X" andmultipleorganisminfections."~݌ $D # Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S&!3&!  "%  "%%݌̌ ,! XX!  _ ,() Ї  ?+ ` hp x X?" ,?+ ` hp x X?  S.~"&  Followingcompletionofthepilotproject,theCriticalPathwayandPhysician'sOrderswere  evaluatedusingaretrospectivechartreviewandhealthcareprofessional(_HCP_) m questionnaire."& '݌ Y  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S ; " )   AWXAX#WAWZ #AWWResults #AXXAW)##XXXAX)#AXXXXԀ" ))݌  ; Ќ ,! XX!  ?+ ` hp x X?   S R  P+  ?Nxhd$~bp@+pddx bEA b V9 f P++݌̌  " ,?+ ` hp x X?  S7 4 s_g?/+b|0swBR `-2@EYwBR BR , s",  Duringthestudyperiod,therewere21episodesofperitonitisin14patients.TheCritical 7  PathwayorPhysician'sOrderswasusedin13episodes(in11patients).Fiveepisodeswere #s   (#(#                                 -() excludedbecausethepatientwashospitalized.Threeepisodeswereeligibleyetexcluded  becauseneithertheCriticalPathwaynorPhysician'sOrderswasused.Thepreprinted  Physician'sOrderswasusedin100%(13/13)ofeligibleepisodesandtheCriticalPathway  wasusedin77%(10/13)ofeligibleepisodes.B+ ` hp x XB#XXXAXy*#AXXXX",-݌ t Ќ , XX  ?+ ` hp x X?" ,?+ ` hp x X?  S V"5  ThedefinitiveantibiotictherapyfromthePhysician'sOrderswasusedin77%(10/13)of  V episodes.Intwoepisodes,thesuggestedantibiotictherapywasnotusedbecausetheeffluent  B waspositivefor_cephalothin_Ԅresistantcoagulasenegativestaphylococciandtreatmentwith  . _vancomycin_Ԁwasrequired._Vancomycin_Ԁwasnotlistedinthedefinitetherapychoicesfor   treatment,butwasaddedinrevisiontothePhysician'sOrders.Inanothercase,thesuggested   antibiotictherapywasnotusedbecauseaneffluentcultureresultedinnogrowthandcytology    indicatednormalnumbersofwhitebloodcellsandneutrophils."55݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S p  "9  An_HCP_ԀevaluationquestionnairetoevaluatetheCriticalPathwayandPhysician'sOrders  p  wasdistributedto5physiciansand6nursesaffiliatedwiththe_PD_Ԁunitat_SPH_.Ofthese  \  healthprofessionals,only2_nephrologists_Ԁand3nursesfelttheyhad_had_Ԁadequateexperience H  usingtheCriticalPathwayandPhysician'sOrderstocompletethequestionnaire."9A:݌ 4 Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  Sv#s"d=  All_HCP_ԀstronglyagreedoragreedtheformatoftheCriticalPathwayincludingthe v _checkboxes_Ԁanddocumentationsectionswaseasytouseandlogical.All_HCP_Ԁstronglyagreed b oragreedthattheabilitytodirectlydocumentactivities,laboratoryresults,and N communicationwiththepatientontheCriticalPathwayreducedtimeandallowedfor : standardization.InevaluationofthepreprintedPhysician'sOrders,all_HCP_Ԁstronglyagreed &v oragreedthatallsectionswereusefulandtheempiricanddefinitivetherapywasappropriate. b The_HCP_ԀwereaskedtocompareuseoftheCriticalPathwayandpreprintedPhysician's N Orderstotheprevious"peritonitisprotocols"andproceduresutilizedbytheUnit.All(100%) : _HCP_ԀsurveyedindicatedtheypreferredtheCriticalPathwaytopreviousprotocolsbecauseit & resultedintimesavingsandstandardization,andusedevidencebasedtreatment."d==݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  STQ"C   AWXAX#WAW04#AWWDiscussion #AXXAWnD##XXXAXD#AXXXXԀ"C  ; U  ?Uxhd$~bp@+pddx bE b V9 f UU݌̌  " ,?+ ` hp x X?  S } "V  AXAX#AT#ATheauthorsacknowledgethefollowingcontributorstothisproject:Dr.Judy_Klassen_,_Joann_Ԁ_Merkley_,Audrey   Millar,Jane_Dutchak_,June_Rivard_,andDr.JeffTaylor.#AXXA䐩W##XXXAXW#AXXXXԀ"VzW݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S&v #   "Z  MichelleEdwards1 &v  _Piera_ԀT._Calissi_*2 b  JoanneE.Kappel3"Z[݌ N  Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  S=  "]  DepartmentofPharmaceuticalServices1   RoyalUniversityHospital | DepartmentofPharmaceuticalServices2 h DepartmentofMedicine3 T St.Paul'sHospital @ Saskatoon,Saskatchewan,Canada"]]݌ ,| Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  Sk  "F`  *email:4YZ   5  /  calissip@sdh.sk.ca6aZaG   7"KaӀ"F``݌  Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  STQ"b   AWXAX#WAWY#AWWReferences #AXXAWc##XXXAXc#AXXXXԀ"bSc݌ T Ќ ,! XX!  ?+ ` hp x X?   S^   e  ?[xhd$~bp@+pddx bEb V9_f  e`e݌̌   W(03] A XAX#  AId#A  ""  X<( ` hp x X<  SM  X?+4 4` hp x X? #AXX Af##XXXAXg#AXXXXHg2.3  Ԁ  _Ireson_ԀCL.Criticalpathways:effectivenessinachievingpatientoutcomes.J_Nurs_ԀAdm  1997;27:1623.Hgh݌   Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S"n!  X?+4 4` hp x X?j2.3  Ԁ  ShaneR.Takethefirststeponthecriticalpathway.AmJHealth_Syst_ԀPharm1995; "n 52:10513.jk݌  #Z Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S$I$  X?+4 4` hp x X?m2.3  Ԁ  Kirk_JK_,MichaelKA,_Markowsky_Ԁ_SJ_,_Restino_Ԁ_MR_,_Zarowitz_ԀBJ.Criticalpathways:the $ timeishereforpharmacistinvolvement._Pharmacotherapy_1996;16:72333.mn݌ %  Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S'j"&"  X?+4 4` hp x X?tq2.3  Ԁ  _Ibarra_ԀV,_Titler_ԀMG,_Reiter_ԀRC.Issuesinthedevelopmentandimplementationof 'j" clinicalpathways._AACN_Ԁ_Clin_ԀIssues1996;7:43647.tqyr݌ (V# Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S)$E)$  X?+4 4` hp x X?t2.3  Ԁ  KeaneWF,AlexanderSR,BailieGR,BoeschotenE,_Gokal_ԀR,_Gopler_ԀTA,etal. )$ Peritonealdialysisrelatedperitonitistreatmentrecommendations:1996update._Perit_ *% DialInt1996;16:55773.tu݌ p+&  Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S-R(,'  X?+4 4` hp x X?x2.3  Ԁ  BernardiniJ,PirainoB,_Holley_ԀJ,JohnstonJR,LutesR.Arandomizedtrialof -R(! Staphylococcusaureusprophylaxisinperitonealdialysispatients:_mupirocin_Ԁcalcium ->)" ointment2%appliedtotheexitsiteversuscyclicoral_rifampin_.AmJKidneyDis  1996;27:695700.xy݌  Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S.~+  X?+4 4` hp x X?|2.3  Ԁ  _Thodis_ԀE,_Bhaskaran_ԀS,_Pasadakis_ԀP,_Bargman_ԀJM,VasSI,OreopoulosDG.Decreasein .~ StaphylococcusaureusexitsiteinfectionsandperitonitisinCAPDpatientsbylocal j applicationof_mupirocin_Ԁointmentatthecatheterexitsite._Perit_ԀDialInt1998;  V 18:26170.|}݌  B Ќ $ X4, X$   &  ?+ ` hp x X?) A XAX  S 1   ,  ?+ ` hp x X?)c  a_Tekin_Ԁ_Akpolat_,_Mahmut_Ԁ_Yavuz_,_Cengiz_Ԁ_Utas_,_ etin_Ԁ_Ozener_,_Neslihan_Ԁ_Seyrek_,_Emin_Ԁ_Yilmaz_,_Fevzi_Ԁ_Ersoy_,_Taner_ԀCamsari,_Rezzan_Ԁ_Ataman_,   _Semra_Ԁ_Bozfakioglu_,_Fehmi_ԀAkcicek,_Oktay_Ԁ_Karatan_.)c݌ " r Ќ AXX A  S  ,B+ ` hp x XB#XXXAXh#'1