California First to Address Dialysis Staffing Problems

Laird Harrison


April 21, 2017

California Bill Triggers Dialysis Staffing Debate

It doesn't take much to kill a patient on hemodialysis. Just overlook a dislodged needle, and a patient can bleed out in a matter of minutes. "When you look on the floor and you see a pile of gelled blood, you know you've got a problem," says Megallan Handford, RN.

As a registered nurse working in busy dialysis clinics, Handford has seen that happen twice—not out of negligence, he says, but because too few staffers were trying to care for too many patients. "It brings on a feeling of guilt, and you question what you're doing."

That's why Handford, who works at a dialysis clinic in Fontana, California, and many of his colleagues are supporting a controversial bill in the California State Senate that would set minimum staffing levels in dialysis clinics.

It would be the first law in the United States to set such limits, though seven other states have set minimum staffing through administrative regulations: Georgia, Maryland, Massachusetts, Oregon, South Carolina, Texas, and Utah, according to an analysis by the Service Employees International Union, the chief backers of the bill.

The California legislation would require a minimum ratio of 1 nurse for every 8 patients, 1 technician for every 3 patients, and 1 social worker for every 75 patients. It would require that dialysis chairs remain empty for 45 minutes between patients. It would also set minimum requirements for inspections and imposes penalties on clinic administrators who fail to meet the new rules. "This legislation will really allow the technicians and nurses to take care of the patients in the way that they're supposed to be taken care of," says Handford.

Not everyone agrees. Some other dialysis professionals warn that the state's clinics could not find enough qualified staff to meet the minimum ratios, forcing them to turn away patients.

"There are a lot of unintended consequences," says nephrologist Bryan Wong, MD, medical director of two dialysis clinics in Northern California. "We cannot hire enough competently trained, certified patient care techs."

The nation's largest dialysis companies, DaVita and Fresenius Medical Care, and some groups of physicians, patients, and nurses have formed a coalition to oppose it. Meanwhile, the American Society of Nephrology and the National Kidney Foundation have so far stayed on the sidelines.

The push for minimum staffing levels comes in response to changes in the industry, Handford says. Fresenius (based in Bad Homburg vor der Höhe, Germany) and DaVita (based in Denver, Colorado) together control 70% of the US dialysis market.

Overwhelmed Staff and Alarming Patient Ratios

Handford, who has worked in clinics run by both companies over the past 15 years, says workloads have sharply increased over that time. When he started, nurses cared for 10 patients each, he says. Then, a few years ago, that number increased to 12. Technicians went from three to four patients each. "We're seeing the results, in poor quality of care and patients dying unnecessarily," says Handford.

He described patients vomiting or passing out while the overworked staff rushes from one to the other. A 45-minute break in between would allow more time to make sure each patient is stable before dismissing them, he says.

"This has been going on for years, and we finally got enough courage to stand up and address the issue," he says. "To do this, we're pushing for unionization as well as a patient ratio bill."

Technicians' wages start at about $13 per hour, and some work 72 hours a week to make ends meet, he says. DaVita and Fresenius nurses start between $25 and $35 an hour, he says, and many could get better wages elsewhere but stay in dialysis because of the deep relationships they form with their patients. "The bill itself is not about helping employees," says Handford. "It's about workers coming together to make sure their patients are getting the quality of care they should be getting."

This has been going on for years, and we finally got enough courage to stand up and address the issue.

He argues that Fresenius and DaVita can easily afford to hire the necessary staff, because Fresenius posted profits of $1.2 billion in 2016 and DaVita posted $880 million.

But dialysis companies might not be able to meet these staffing requirements because not enough techs are passing certification exams, says Dr Wong, who serves on the board of the California Dialysis Council, an industry group. "It's not just a matter of money."

Dialysis Obstacles and Transportation Woes

Adding 45 minutes between patients will extend the length of shifts, he says. But many clinics are already scheduling as many shifts as possible per day, including some that go into the night. And many patients depend on transportation services that aren't available after hours.

Clinics also need the flexibility to accommodate patients who need dialysis under special circumstances, Dr Wong adds. These include patients whose conduits close from clotting. Such patients typically go to vascular access units to get the conduits reopened, then come back for dialysis during a later shift than originally scheduled. Under the proposed law, dialyzing these patients might violate the staffing ratios.

Missing one dialysis session increases an end-stage kidney patient's risk for death by 30%.

And forcing these patients to delay dialysis for a day or more could put them at risk. "Dialysis is not a pleasant experience for patients," he says. "If you throw obstacles in their way, they may not show up for treatment." Missing one dialysis session increases an end-stage kidney patient's risk for death by 30%, Dr Wong says.

Clinics in the state that don't have the support of big companies could suffer even more, warns David Lent, chief executive officer of the Toiyabe Indian Health Project in Bishop, California. The project's dialysis clinic, the only one in the Eastern Sierra Nevada mountain range, serves not only local Indians but the broader community. The Indian Health Service doesn't pay for dialysis, and many patients have no health insurance, so the clinic has to subsidize their care through its general funds, says Lent.

The next nearest dialysis clinic is 3 hours away by car, and it's a particularly difficult trip on snowy days, says Lent. Dialysis itself takes at least 3 hours. And he thinks few people in the sparsely populated area would be willing and able to become dialysis technicians or nurses.

"We'd really have to search to find people who would want to move to our area," says Lent. "If we're going to have quotas in terms of how many nurses and techs you need per patient, that could potentially put us out of business. The people living around us who need dialysis would more than likely have to move."

Dialysis Center Regulations and Ratings

Minimum staffing ratios wouldn't even improve patient care, Dr Wong argues. He points out that the Centers for Medicare & Medicaid Services (CMS) already heavily regulate dialysis clinics, mandating safety procedures, infection control, water quality, and training standards for staff, among other aspects of care.

The coalition opposed to the bill found that CMS in 2015 awarded 47% of California dialysis clinics 4 or 5 stars (its highest ratings) compared with 40% of clinics in all other states and 42% of clinics in those states with regulations setting minimum staff ratios. (The difference between California and all states was statistically significant [P = .007], but the difference between California and states with mandatory staffing ratios was not.)

And analyzing CMS patient surveys, the coalition found that 68.7% of California patients rated their dialysis facilities a 9 on a scale of 0-10, compared with 66.5% nationwide and 63.3% in states with mandated ratios. (These differences were statistically significant [P < 0.001].)

Supporters of the bill counter that these rating systems don't give an accurate comparison of states because some areas of the country have healthier populations than others.

Multiple studies have shown that patients fare worse in hospitals with lower ratios of nurses to patients. For example, a study of European hospitals published in the Lancet in 2014 showed that an increase in a nurse's workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio, 1.068; 95% confidence interval, 1.031-1.106).[1]

It's very difficult to establish a straight-line relationship between the higher mortality rates for dialysis patients in the United States and the manner in which personnel are used to provide that dialysis.

Few studies have examined staffing ratios specifically for dialysis, but a 2008 survey completed by 422 registered nurses belonging to the American Nephrology Nurses Association showed a correlation between a high ratio of patients to nurses, necessary tasks left undone, and adverse events. Compared with nurses caring for fewer than five patients, those with 12 or more patients were 4.09 times more likely to report shortened treatments, 2.63 times more likely to report skipped treatments, and 2.43 times more likely to report patient complaints at least once a week. The results were statistically significant (P < .05).[2]

"Succinctly stated, lower levels of RN staffing have a negative impact on patient care processes in that RNs simply do not have the time to complete their important work," the authors concluded.[2]

In a 2009 study, researchers from the Minneapolis Medical Research Foundation and Fresenius Medical Care included staffing differences in a list of factors that could help explain why mortality rates of US dialysis patients are higher than those in Europe and Japan. Whereas US clinics rely heavily on technicians, "staffing in European countries is predominantly by certified nurses and in Japan exclusively so."[3] Although the gap has narrowed in recent years, 5-year survival in the US is 39%, compared with 41% in Europe and 60% in Japan.[4]

"It's very difficult to establish a straight-line relationship between the higher mortality rates for dialysis patients in the United States and the manner in which personnel are used to provide that dialysis, but it's certainly one area that is a cause of concern," says Robert Bear, MD, a nephrology consultant in Alberta, Canada, who has testified in favor of the legislation.

In Canada, nurses rarely have to care for more than four dialysis patients, he says, and the mortality among dialysis patients there is even lower than in Europe.[5] Dr Bear thinks that running clinics for profit may be the root of the problem with dialysis care in the United States. He cited studies showing that dialysis clinics operated for-profit have higher mortality rates than those operated on a not-for-profit basis.[6]

Increasing staffing ratios might even save money for the healthcare system as a whole by reducing the number of hospitalizations, he says.

"I'm not American; I don't want to sound unduly critical," he says. "But one should look at every aspect of the system and compare it with the systems that exist elsewhere in the developed world and develop a path toward improving patient outcomes and mortality rates."


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