Infection-related hospitalizations have increased 47% since 1993,2 and a single catheter-related bloodstream infection (CRBSI) admission can cost the health care system as much as $80,235.3 Most importantly for patients, infections are the second leading cause of death,4 and the elderly are known to be at an especially high risk of mortality from dialysis-acquired infections.5 Given the frequency of hospitalizations and their consequences, any pragmatic steps that can be taken to reduce admissions will result in improved patient survival and substantial cost savings.
Using evidence and expertise
Evidence–based medicine is a model of decision making that uses a systematic process to integrate the best evidence with clinical expertise and patient values to answer a question about one patient’s plan of care in order to optimize outcomes.6 Absent from prior considerations about ways to reduce hospital admissions among dialysis patients has been the role of evidence-based clinic staffing standards. There is already preliminary evidence on clinic staffing which can serve as a basis for additional research and the eventual establishment such standards.
The purpose of this article is to provide: 1) an overview of research on the staffing of nephrologists, patient care technicians (PCT), dietitians, social workers, and nurses which is relevant for hospitalization risk; and 2) to suggest areas where research on staffing is particularly germane for the potential of reducing admissions. As a prelude to this, a brief look is first taken at the historical roots of the longstanding problematic situation with dialysis clinic staffing.
Roots of the problematic situation with dialysis clinic staffing
Staffing in medical care has historically been viewed as a structural measure of quality. Donabedian was the first to propose a framework of assessing quality in medical care consisting of structure-process and outcome.7In this framework, structure consists of the stable elements that form the basis of the health care system; process consists of the technical and interpersonal components of what is done within the structure, and outcome consists of what happens to the health of the patient.8 Validating the framework, research has linked, for example, inadequate nurse staffing in acute care hospitals with an increased risk of infections,9 mortality,10medication errors,11 patient falls, 12 and adverse outcomes with nurses themselves (e.g., burnout13 and needlestick injuries14).
Early definitions of adequate staffing’ for dialysis
The subject of dialysis clinic staffing has not been given the same priority, and the roots of this appear to rest with the Centers for Medicare & Medicaid Service (CMS). This began with the original regulations for the End-Stage Renal Disease (ESRD) Program, which describe proper clinic staffing as when “an adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients.”15The basic limitation of this regulatory statement is its vagueness and the fact that the word “adequate” has never been defined, in terms of actual number of personnel relative to patients.
There have had a number of ramifications from this vagueness.
- Because there are no evidenced-based standards for staffing, it has given dialysis providers freedom in deciding what constitutes an adequate patient-staff ratio. The idiosyncratic and unscientific decision making that has gone on undoubtedly accounts for why in one dialysis chain there might be one dietitian or social worker for every 100 patients, while in another these professionals could have responsibility for 200 patients.16 In extreme examples, recent reports have found some dietitians having responsibility for 240 to 340 patients, divided between 5 facilities17,18 and some social workers trying to cover over 400 patients.19 Similarly with nephrologists, while one physician might have a caseload of 70 patients, another one could have well over 250 patients.20 Within the structure-process- and outcome framework, such wide differences in patient-to-staff ratio are inescapably affecting outcomes. Evidence of this was illustrated in a study of nephrologists which found an association between higher patient caseloads and an increased risk of patient mortality.20
- ESRD Network Organizations, which are under contract with CMS to oversee care provided to patients and help facilities make quality improvements,21 collect regional data in the areas they serve. The Networks routinely uncover unexplained facility-to-facility variations in patient outcomes,22 but because CMS has not sanctioned staffing via the Conditions for Coverage of the ESRD program as a quality of care issue,23 the Networks have not viewed it within their authority to focus on it in their improvement efforts.
The consequences from this can be illustrated in two areas.
- Facility-to-facility variations in kidney transplant rates have been known for decades. A recent report alluded to staffing inadequacies as an explanation for lower rates in the southeast region of the U.S.––specifically, a lack time for patient education and referrals to transplant centers.24
- Variations in hospitalization rates is a second area of concern. The Forum for ESRD Network Organizations has suggested the Networks can have their greatest impact mitigating admissions through quality enhancement efforts related to processes of care.25 However because staffing has not been clearly defined by CMS, the Networks have not focused on it as a means of facilitating improvements. State Health Department surveyors of dialysis facilities would appear to be similarly handicapped because, without staffing standards relative to the number of patients in most states, they have not been able to cite facilities for deviations (only a handful of jurisdictions have mandated staff-patient ratios, with Texas being the most notable16). This might better explain the poor compliance with infection control guidelines frequently uncovered.26
The potential for reducing hospitalizations through evidence-based staffing
Nephrologists
In discussing research on nephrologist staffing that can be used as a basis for the development of evidence-based standards, it is important to note that questions about standards have always centered on the frequency of their face-to-face visits with patients in dialysis facilities. Based on the broad assumption that more frequent visits will improve patient outcomes, CMS changed its physician payment policy in 2004 to incentivize more visits.27 Statistics reveal a dramatic rise in the average number of monthly visits after this policy change, from just 1.52 to 3.13 a month.28 Despite this increase, many unanswered questions remain about the actual impact visits have on patient outcomes, including reducing hospital admissions. For example, the first investigation examining the effects of the increased visits showed they had little clinical value on quality indicators.29 A second inquiry concluded that the heightened visits improved patient compliance with attendance at dialysis sessions, but they were not associated with reduced mortality.30
A cross-over study found that while more frequent nephrologist-patient contact was associated with lower mortality and the better achievement of certain laboratory targets, they were also associated with a lesser chance of being on a transplant waiting list.31 A fourth study discovered that greater nephrologist-patient contacts were associated with a small, but statistically significant reduction in the risk of first hospitalization.32Results from an investigation involving 26,613 patients suggested that just one additional monthly visit with patients recently discharged from the hospital could reduce the chances of a readmission.33 Finally, a study published last year found that greater frequency of clinic visits was associated with more vascular access procedures, but not prolonged access survival, and only a small reduction in hospitalizations.34
Perhaps a more basic question that evidenced-based research might focus on is whether frequency of clinic visits per se or quality of the nephrologist-patient relationship is the most dominent factor affecting outcomes. Relevant to this question is research showing that for the majority of patients the most important aspect of their medical care is the continuity of being able to see the same doctor.35 Continuity in the relationship is crucial because it is known to increase practitioner’s and the patient knowledge of each other, build trust, and create an overall better context for healing.36
The quality of the nephrologist-patient relationship may be unintentionally undermined in many instances today because, in large nephrology practice groups, there is often an alternating rounding schedule for different doctors to make dialysis clinic visits. In other words, the nephrologist rounding from week-to-week is likely to be different from the one a patient periodically sees during office visits. Such cross-coverage in hospitals has been found to result in errors in judgment by covering physicians, who are unfamiliar with the details of a patient’s situation.37 This type of scheduling with dialysis patients has the potential to create confusion 38 and adversely affect the trust and rapport needed for full cooperation with adherence issues (e.g. fluid restrictions39 and the treatment schedule40) which have implications for hospitalization.
If research determines that quality of the nephrologist-patient relationship is most important factor, it would signal a need for nephrologists to focus on it as a way of improving outcomes. Given the increased emphasis on of pay-for-performance,41 such a finding could also have implications for CMS reimbursement policy, which began to incentivize visits in 2004 as a way of trying to improve outcomes.27 The view has been expressed that in linking clinic visits with monthly capitated payments, CMS created a perverse incentive, which now compels the completion of the fourth monthly visit in order to maximize reimbursements.42 This may be reflected in a recent investigation which found that clinic visits by nephrologists depended more on geographic convenience, rather than the health status of patients.43
Patient Care Technicians
PCTs perform 90% of all in-center dialysis treatments today and consequently have the most frequent direct physical contact with patients each week.44 In highlighting the ways evidence-based PCT staffing could potentially reduce the risk of hospitalization, it is useful to look briefly at the array of tasks PCTs are expected to complete within the 30 minutes of what is commonly called “turnover” in dialysis facilities. During this high pressure period,45 PCTs are typically responsible for taking off four patients who have completed a treatment and starting the treatment of four new patients on the next shift. Entailed in this are a subset of additional tasks PCTs are to perform to in order to keep patients safe. Among the most important are guidelines, issued by the Centers for Disease Control and Prevention (CDC),46 which require hand washing and glove changes before and after every patient contact. Being responsible for taking off and putting on 8 patients, this adds up to a minimum of 16 separate hand hygiene/washings and glove changes during turnover.
A second task PCTs are required to complete during this period is the cleaning and disinfecting of each treatment station.46 Among the surface areas and items that are supposed to be cleaned and disinfected are treatment chairs, countertops, draw/cupboard handles, controls on television sets, the external surfaces of dialysis machines, scissors, and blood pressure cuffs. This cleaning is critical because it is known that blood-borne pathogens can survive for varying lengths of time on any surface,47,48 and hand contact of PCTs with an inadequately cleaned surface can result in patient-to-patient transmission of infections.49,50
The third and equally critical responsibility PCTs have during turnover is to stringently follow exit site care guidelines required by central venous catheters (CVC). This is important because it is known that bacteria from the skin tends to migrate and colonize around the hubs of CVCs, making it the most common cause of CRBSIs.51 Using chlorhexidine 2% with 70% alcohol as the preferred antiseptic,52 a compilation of guidelines issued by the CDC’s “Scrub-the-Hub-Protocol”53 and the National Kidney Foundation 54 call for PCTs to rigorously adhere to the following steps:
Perform hand hygiene and don new gloves and mask before beginning
Apply antiseptic solution in a circular motion to skin working outwards from CVC exit site
Cover an area 10 cm in diameter
Reapply antiseptic to skin twice, but allow to dry before doing so
Clean CVC connection 10 cm up catheter
Vigorously scrub CVC hub and caps before opening to connect blood lines
Studies have looked at the ability of PCTs to consistently adhere to all the safety standards required during turnover and found a very high frequency of lapses, which might explain the continually escalating CRBSI rates.2 Regarding the stringent care required by CVCs, a just published 2015 investigation discovered that 64% of PCTs failed to scrub CVC hubs with antiseptic following disconnecting blood lines; 55% failed to scrub external CVC hubs(caps) at the initiation of a treatment; and 85% failed to use antimicrobial ointment in dressing changes.55 As to lapses with cleaning and disinfecting, this same investigation found that 82% of PCTs failed to disinfect non-disposable items returned to the common area; 74% failed to vacate treatment chairs prior to disinfecting; and 59% failed to disinfect surfaces per recommendation of manufacturers.55
Turning to lapses with hand hygiene guidelines, one study discovered that 46% of PCTs failed to wash their hands and change gloves in going from one patient care station to the next; 44% did not wash their hands and change gloves before giving intravenous medications, and 40% failed to do hand hygiene and change gloves prior to putting patients on to begin a treatment.56 These findings are reinforced by a more recent inquiry which found that hand hygiene was less than 33% in more than 75% of dialysis patients .57
Support for the potential of evidence-based PCT staffing to substantially decrease CRBSIs comes from investigations showing that when staff have the actual time to rigorously adhere to all safety standards, infections can be dramatically reduced. For example, very low CRBSIs and catheter survival (around 1 year) were found to be achievable in infants and children on dialysis, when staff had the time to “adhere to a strict catheter management protocol”58 Data from the 17 dialysis facilities that participated in Collaborative Prevention Effort led by the CDC, similarly revealed that when staff have time to meticulously adhere to protocols it can result in a 32% reduction in overall bloodstream infections and a 54% reduction in vascular access-related infections.59 There is also the case report on a dialysis patient who used a CVC for 3 years and nine months without single episode of CRBSI, because safety guidelines were consistently adhered to.60
Further illustrating its critical importance, research has discovered that when hospital personnel have time to adhere to all safety guidelines, CRBSIs can be similarly decreased. For example, a 66% reduction of CRBSIs was achieved and maintained in the intensive care unit (ICU) when nurses had the time to meticulously follow guidelines.61 A 76% drop in bloodstream infections in a neonatal ICU was found to be associated with more registered nursing hours.62 Some investigators have gone so far as to suggest CRBSIs can actually be eliminated in surgical ICUs if staff have the opportunity to rigorously adhere to all safety standards.63 Finally in a recent review of research it was estimated that 70% of CRBSIs are preventable, if staff are able to stringently follow CDC guidelines.64
Dietitians
It is well established that protein energy malnutrition (PEM) is associated with increased morbidity and mortality risk in dialysis patients.65 There is controversy surrounding the impact interventions by dietitians can have on PEM. This is because of the many factors that can contribute to PEM (i.e. inflammation,66 metabolic acidosis,67 the catabolic effects of dialysis itself,68 co-morbidities like diabetes and cardiovascular disease69 and increased age70). The growing consensus seems to be that when PEM is primarily the byproduct of inadequate nutritional intake, dietitians can have the greatest impact facilitating improvements, as measured by serum albumin values.71 For example, counseling by dietitians has shown it can increase serum levels 0.07 g/dl per month and with some patients in the 12-month study going from a low 2.9 level to a much healthier 3.9 level.72Relevant to their potential to reduce hospitalizations, “intensive nutritional counseling” by dietitians in Right Start project was credited with being instrumental in helping to decrease the risk of admissions.73 There are also the results of a retrospective study of 77,205 dialysis patients which concluded that a 0.2 g/dl increase in serum albumin, facilitated by dietitians is associated with a 28% reduction in risk of hospitalization, while an increase of more than 0.4 g/dl is associated with a 41% decreased risk.74 The investigators when on to suggest that a 0.2 g/dl overall increase in albumin concentrations could result in 6000 hospitalizations being adverted, and save Medicare $36 million.74 Finally an earlier investigation simply concluded that when dietitians have more than 30 minutes per patient per week for counseling, the risk for a hospital admission is significantly reduced.75
Given the potential impact dietitians can have in decreasing hospital admissions, research on evidence-based standards might logically focus on the time required for these professionals to provide the optimal help patients need. Research is needed because of the diminishing opportunity dietitians have for face-to-face time with patients. For example, due to the two-fold increase in the number of dialysis patients with diabetes, it was estimated that the time dietitians have available has been reduced by 50%.76 The higher documentation required by the newest Condition for Coverage has been identified as another major factor which has taken time away from patients.77 It was recently observed by a group of nephrologists that, “most if not all of the dietitians’ time is spent on mineral and bone disorder.”78 Two recent national surveys 17,18 have reinforced evidence that the imposition of additional administrative responsibilities on dietitians is limiting their ability to provide intensive nutritional counseling, especially about patients’ need to increase their protein intake, which is rated by dietitians (88.5%) as the highest priority.18 Finally, but typically overlooked there are the high patient-to-dietitians ratios, which inherently limit the amount of help individual patients are able to get with nutritional issues.16
A second area that evidence-based dietitian staffing research might focus is the time required for nutrition intervention with patients recently discharged from the hospital. This is important not only because of the increased emphasis on avoiding hospital admissions,79 but also readmissions, defined as reentering the hospital within 30 days of a discharge.80 It is known that re-stabilizing a patient following a hospitalization requires an intense effort.81 The concerted involvement of dietitians is critical because nutrition rapidly declines during a hospital stay.82 Close monitoring of patients’ nutritional status after discharge, and early detection of the first signs of malnutrition can potentially reverse the spiral of malnutrition, which is more difficult to treat when severe.83 Research has found that following a hospital stay today many patients never regain a stable nutritional status, and die prematurely.82
Social workers
Largely overlooked in the quest of finding ways to reduce hospital admissions is the potential role social workers can play in several areas. First, missed and shortened dialysis are known to increase patients’ chances for an admission84 and research has demonstrated that when social workers have enough time for interventions. they can help improve adherence.85 Secondly, depression which occurs in as many as 44% to 78% of all new dialysis patients86 and is known to be an independent risk for hospitalization.87 Multiple studies have demonstrated that when social workers have enough time for psychotherapeutic interventions they can be effective in lessening the symptoms of depression88 and by implications the associated morbidity risks. Thirdly there is the chronic problem of patients not adhering to their fluid restrictions, which is also known to be a major risk for hospitalization.89 Research has similarly demonstrated that when these professionals have time for the necessary patient involvement, adherence in this area can likewise be improved.90
In order to maximize social workers’ role in reducing hospital admissions, evidence-based staffing research is first needed to establish baselines on the percentage of patients who might be struggling in silence because needed help with depression, adherence to fluid restrictions, and treatment schedule is not sufficiently available. With reports showing that up to 80% of patients are not able to consistently adhere to their fluid restrictions91 and missed/ shortened treatments remain a pervasive problem,84 the unmet psychosocial needs of this population could be substantial. Depending on the priority that stakeholders give to harnessing the contributions of all disciplines in the reduction of hospital admissions, there may be a need to increase the number of social workers.
Nurses
The American Nephrology Nurses Association recognizes that adequate staffing is critical to quality of care.92The most important finding from research on nurse staffing having immediate relevance for increasing patients’ risk of hospitalization, is that the fact that the majority are not able to consistently adhere to guidelines for hand hygiene. One investigation found that 59.2% of nurses did not wash their hands and do glove changes going from one dialysis patient station to the other; 57% failed to do hand hygiene before administering intravenous medications; and 45.8% did not wash their hand and do glove changes before putting patients on to begin a treatment.53 A second inquiry discovered that dialysis nurses washed their hands only 35.6% of the time after patient contact and 13.8% of the time before patient contact.93 Inadequate staffing is implicated in these lapses because it is known that understaffing, by increasing patient workload, decreases the frequency of hand washing and duration, thus favoring the transmission of pathogens.94 One of the major goals of evidence-based staffing research would be to determine the threshold in nurse workload, where there is a diminished ability to strictly adhere to hand hygiene standards.
Discussion
Over the more than 40 year history of the ESRD program, several initiatives to reduce morbidity and mortality risk have been made, including the development of the National Kidney Foundation’s Kidney Disease Kidney Disease Outcome Quality Initiative,95 Fistula First Initiative96 and most recently the Quality Incentive Program.97 Absent from these initiatives has been any explicit consideration of the pragmatic role sufficient staffing plays in their actual implementation. This is perhaps best illustrated in the K/DOQI Clinical Practice Guidelines for Nutrition,98 where surveys have found that the majority of dietitians are not able to fully implement the intensive nutritional counseling guideline 99 and also the recommended frequency and method for diet assessment,18 both because of inadequate staffing.
Conclusion
Focusing on the extraordinarily high hospital admission rate among in-center dialysis patients, this article provides an overview of how insufficient staffing can contribute an adverse outcome, and simultaneously the way evidence-based staffing could potentially mitigate the problem. The most compelling evidence highlighted would appear to be the way inadequacies in nurse and PCT staffing are probably limiting these professionals’ ability to comply with guidelines, issued to keep patients safe.
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