Table 1.

Barriers to Urgent-Start PD Implementation

Barriers to Implementation	Solutions
	Nephrologist Level
Inexperience with urgent-start PD	Use PD expertise of nephrology colleagues, professional organizations
Appropriate patient selection	Consensus upon “urgent-start PD” definition to ensure medically appropriate referrals
Financial bias	Introspective evaluation of referral motive
	Operator Level
Inexperience placing PD catheter	Use formalized PD education for operators; evaluate literature regarding PD catheter placement techniques
Timely placement of PD catheter	Do not rely on a single operator, have alternative referral pathways
Agreement on perioperative care	Education on regional standardized care protocols
	Hospital Level
Buy-in from all departments that treat patients with ESRD	Educate staff on importance of urgent-start PD; collaborate on urgent-start PD protocols
Lack of adequate resources or supplies to provide urgent-start PD	Contract with outside acute dialysis provider
Discharge planning	Educate case manager and/or social worker, provide check-lists; provide verbal sign-out to outpatient PD center
	Dialysis Center Level
Dialysis staff buy-in	Engage staff in planning stages and patient selection process
Lack of staff education	Provide regular in-service education
Variability in physician practice patterns	Establish protocols in collaboration with referring physicians
Inadequate resources	Lobby dialysis administration to get more resources (ie, space, gurneys, recumbent chairs, nurses)
Potential for high complication rates	Periodic assessment of pre-established quality metrics and targeted quality improvement measures
	Patient Level
Lack of education	Dedicated time spent by nephrology team to educate patient and family
Unrealistic expectations of modality	Develop and provide dialysis modality education resources
Need for caretaker involvement	Coordinate support services provided by nephrologist, nurse, dietician, and social worker
Psychosocial stress	Early home visit to assess living situation

Abbreviations: ESRD, end-stage renal disease; PD, peritoneal dialysis.