Authors (including presenting author) :
Kwan WS(1), Lau LW(1), Chan SK(1), Wong KL(1), Cheng PPP(2), Lok WP(2),
Chan SKV(2)
Affiliation :
(1)Community Nursing Service,(2) Department of Medical, Yan Chai Hospital
Introduction :
According to Hong Kong Renal Registry (2018), 4397 renal patients under Continuous Ambulatory Peritoneal Dialysis (CAPD) were cared by themselves or carers in the community. Newly trained CAPD patients are the most high-risk group with CAPD complications due to the highly skillful procedures, and environmental changes from hospital to community. In Yan Chai Hospital (YCH), Community Nursing Service (CNS) and Renal Team collaborated to enhance the clinical support of CAPD patients.
Objectives :
(1) Empower patients / carers on CAPD care and promote their quality of life in community; (2) reduce the prevalence of CAPD related complications; (3) facilitate the discharge plan of CAPD cases
Methodology :
A workgroup was formed in July 2016 to organize a series of CAPD care support in community. Community Nurses (CNs) and renal nurses had jointly visited aged homes to review the competence of CAPD care for support the discharge planning to patients. In November 2018, the program was extended to newly trained CAPD patients at home setting. Meanwhile, Workflow of CAPD Care Training Program from Hospital to Community” for guiding patient journey and “Assessment of Patient on CAPD Form” for standardized care were established. After CNS assessment, the case would have been clinical handover to Renal Team for discussion. Patient would have follow-up by CNS and/or further training in Renal Centre.
Result & Outcome :
In 2017 – 2020, total 169 participants from 35 aged homes (90%) attended the seminar and workshop to enhance their knowledge and skills of CAPD care. The pre & post test results were improved 40% (from 46 to 65 marks). A list of 15 competent aged homes was consolidated in 2017; total 21 aged homes were qualified till now. Renal team and CNS jointly on-site assessed those aged homes regularly that maintained 71-85% compliance rate. The extended program was started in March 2019, total 45 patients were assessed their home environment, CAPD technique, knowledge and Tenckhoff care at home; among 5 cases needed to review their CAPD care for further care management. The program had demonstrated a strong collaborative approach between Renal Team and CNS of YCH in enhancing the healthcare quality in community.
