Association of Dialysis Advocates (ADA) is a newly formed grassroots organization of volunteers dedicated to advocacy for end-stage renal disease (ESRD; permanent kidney failure) patients. Patricia Tate-Harris of Baton Rouge Louisiana, president of ADA, says that “advocacy ensures safe, quality dialysis treatments necessary for patients and their families. Good patient outcomes and cost effective care will always impact a much broader population than the kidney patients ADA serves.”
Harris believes that the growth of the dialysis population will increase the need for education and awareness among patients and the general population, and will intensify ADA’s role. Because ADA’s role is envisioned to empower patients for better outcomes, it also responds to the Center for Medicare and Medicaid Services’ (CMS) guidelines for care. Recently ADA responded to conditions in dialysis facilities. Below are highlights from ADA’s proposal that were shared with me re: “Conditions of Coverage End Stage Renal Disease Facilities” (CMS-3818-P): Proposed Rule.”
Staff qualifications:
ADA proposes that one (1) year of clinical experience and six months of dialysis maintenance is insufficient for the registered nurses responsible for the complex delivery of services in a dialysis unit.
ADA recommends two (2) years of clinical experience and one (1) year of dialysis maintenance, as a minimum. ADA found that there existed a substantial number of deficient practices that led to negative outcomes, and were the direct result of the lack of training, experience, and education of registered nurses in facilities.
Infection control:
Because the number of patients transferring between hospitals, nursing homes, and dialysis units is increasing in age and co-morbid conditions, exposure rates for infection also increases. Protecting in-center patients, as well as the community at large, requires more prescriptive regulation if dialysis facilities are to meet obligations for efficacy.
ADA’s survey results indicated gross noncompliance with basic infection control practices due to the presence of non-prescriptive language. Because dialysis patients can be a reservoir for staph infections, more stringent control is necessary.
Internationally and nationally, healthcare organizations have been addressing infection rates in hospitals, with laws requiring public disclosure. The chronic problem of infections acquired upon entering a facility demands that facilities be held fully accountable to those to whom they deliver care. A large part of that accountability requires that patients be informed of the infection control practices a facility employs, including the hand-washing that remains a number one problem.
Physical environment:
A mechanism for patients to summon staff assistance is needed. Often, during dialysis treatments, patients experience sudden hypotension (lowered blood pressure), bleeding, and other episodes during which they are unable to verbally get the attention of staff. While the dialysis machines have alarms, patients can need attention prior to the sounding of an alarm. Patricia Harris has also said that she would like to see a protocol in place for both patients and staff with regard to alarms.
Patient rights:
Grievance-related education differentiating the mediation authority of ESRD Networks and the enforcement authority of State Survey Agencies is imperative for informed choices in the direction of a grievance. Such is also necessary to expedite action for grievance filings.
Using facility employees to communicate directly with a patient—and/or their family—when problems occur creates a conflict-of-interest and thus, cannot result in unbiased deliberation upon a grievance. Employees necessarily protect the corporation and their personal livelihoods rather than deliver reasonable care if that care has been deemed “unprofitable” by their employer, the dialysis facility. ADA believes that an ombudsman can best serve in the role of an unbiased mediator within the context of a bona-fide patient-provider partnership as envisioned to be the core of patient-centered treatment.
Patient assessment:
Pre-and-post dialysis assessments of patients are vital in addressing adequacy of the treatment. Including:
- Chest auscultation (fluid status, breath sounds, heart rate/rhythm)
- Visual observance (shortness of breath, jugular veins, periorbital edema, extremity edema, pitting edema
- Gastrointestinal evaluation (diarrhea, nausea, vomiting, constipation, pain)
- Access Site Evaluation (redness, swelling, pain, drainage)
- Patient symptoms between treatments (if any)
Patient education:
An education component that employs a Nurse Educator to coordinate planning, oversight, implementation, and evaluation of the education component are necessary for good patient outcomes. Completion of a core educational curriculum based on ability by patients and their family members or representatives lead to greater patient awareness for responsibility for care, better outcomes, and helps constitute bona-fide patient-centered care.
Responsibilities of the Medical Director:
More direct communication between a facility’s Medical Director and a patient’s other physicians decrease the number of preventable negative outcomes, especially those related to compliance and treatment. The clinic manager may act as a representative upon the Medical Director’s request.
Enforcement of ESRD regulations:
The use of a grid, similar to those used for nursing home evaluation—to determine the scope and severity of regulatory noncompliance at dialysis centers—could result in improved care, and provide direction and consequences within the dialysis community. Progressive penalties for noncompliance should include a plan of correction, civil monetary penalties, or termination in order to be effective (in such a highly profitable and portable industry).
Contact ADA:
Patricia Tate-Harris
Association Dialysis Advocates
6344 Silverleaf Avenue
Baton Rouge, LA 70812
(225) 355-5379
.(JavaScript must be enabled to view this email address)
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