We at DialysisEthics.org have decided to push for Standards of Care here in Colorado. The following is what has resulted after a meeting back in June with Davita representatives to discuss conditions in dialysis that left many unanswered questions (in attendance were: two representatives from Davita, Colorado State Representative John Kefalas, Della from DialysisEthics.org, and myself). Also we have contacted Northwest Kidney Centers and received information on patient/staff ratios, Dr. John Agar from Home Dialysis Central has provided information, and we have been in contact with DCI.
The following has resulted after the above inquiries and years of watching the goings-on in dialysis. This list is a wish-list that can be added to, subtracted from, revised, and definitely commented on. It could result in a Colorado state bill, but State Representative John Kefalas hasn’t committed to anything - however, he is very aware and interested in this. (link is provided at end of post to flyer in pdf form)
Possible Standards of Care in Colorado
A group of us have been working on possible Standards of Care here in Colorado for several months. The following are 5 items we have come up with for better care in dialysis. To add items, comment on the following items (either in favor or not), or to seek more information email can be sent to the following people:
Main contacts:
Chris Schwab, DialysisEthics.org: chriss.deo.ceo@gmail.com
Front Range Kidney Patient Association: gp134b@yahoo.com
Alternate contact: (John has asked that the “Main Contacts” filter most emails and contacts, however if something is better directed to him he can be contacted)
Colorado State Representative John Kefalas: john.kefalas.house@state.co.us ph. 303-866-4569 (office), 970-221-1135 (home)
1) Increased time on dialysis
How:
Run pump speeds between 300 and 325 ml/min - as they do in Australia. Increase time on dialysis and keep standardized Kt/V the same. And possibly use HDP to figure dialysis adequacy:
HDP: http://www.therenalnetwork.org/qi/resources/HDP.pdf
Dr. John Agar and discussion on pump speeds and time on dialysis: http://forums.homedialysis.org/showthread.php/2961-Hdp
Why:
"Disappearance of postdialysis fatigue, better dialysis adequacy, a higher removal of middle and large molecules, a reduction of phosphate binders, improvement of status nutritional, and an important reduction of cardiovascular risk factors " http://www.ncbi.nlm.nih.gov/pubmed/12787423
“Just as speed on the road kills, so it does in hemodialysis.” Dr. Carl Kjellstrand, http://www.dialysisethics2.org/index.php/Our-Concerns/dr-carl-kjellstrand.html
“Japan, Europe, Australia and New Zealand have long recognized the survival benefits of longer, slower and gentler dialysis compared to our American style violent sessions.” Peter Laird, MD: http://www.billpeckham.com/from_the_sharp_end_of_the/2010/10/do-we-need-to-abandon-high-ultrafiltration-rates-in-america.html%20
2) Standardized Patient/Staff ratios:
Standard community dialysis units in Colorado would have a 40/60 percent ratio of nurses to techs. Units with Special Care patients and those with 12 or less patients would have a 50/50 percent ratio of nurses to techs. The ratio of staff to patients would be 1/3. (Numbers obtained from Northwest Kidney Centers and Arlene Mullin, former dialysis tech and a founder of DialysisEthics)
3) Reuse would be abolished
Why: &nb sp;
- “Dialysis in freestanding facilities reprocessing dialyzers with peracetic/acetic acid may be associated with worse survival than dialysis in free-standing facilities not reprocessing dialyzers” Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia 19104-6021, USA. http://www.dialysisethics2.org/forum/index.php?topic=58.0
- Human error with reuse hasn’t been eliminated after years of trying to get it right: "In April, however, Price’s routine at Pikes Peak Dialysis Center went awry when he was mistakenly hooked up to a reusable filter, a dialyzer, that belonged to another patient — a person who had a virulent bacterial infection commonly known as MRSA. Price’s health was probably not in danger, his doctors say, and giving one person’s dialyzer to another patient is a mistake that doesn’t happen often at Colorado dialysis centers.
But it happened to Price, and it happened in February at a sister clinic when a patient was given a dialyzer belonging to someone infected with Hepatitis C. (Hepatitis C and AIDS are not killed by current sterilization techniques) " Colorado Springs Gazette, http://www.gazette.com/articles/dialysis-102290-three-mix.html
4) Blood Transfusions are to be done in a Hospital, NOT in a dialysis clinic
From Roberta Mikles RN, QualitySafePatientCare:
- The reality is such that the RNs barely have time to conduct their usual work load, and with the added necessary observation, etc required during a transfusion, the result might be a dialysis technician, unqualified to do such, will be monitoring a patient, or even, perhaps, administering such, even though this is prohibited. Also, most units do not have a sufficient number of RNs. 2) The Nurse Practice Act, in various states, clearly identifies responsibilities, of Registered Nurses.
- The storage of blood, e.g. temperature of refrigerators — >this is a concern considering, when reviewing refrigerator temperatures in surveys, this is a cited deficiency.
- Administering transfusions in a dialysis unit is a very potentially dangerous situation. If a patient has an adverse reaction, which can mean the difference between life and death, that requires immediate intervention, this might not happen, and if it does, it might not be successful e.g. saving a patient’s life.
5) Non-compete agreements would be abolished.
Monopolies are normally bad. Doctors and nurses are a limited resource and should be free to move to other companies, as is just about everybody else in our society.
“The mud began to fly last year when the second-largest group of Denver kidney doctors, called nephrologists, ended their exclusive affiliation with DaVita and partnered with a Massachusetts dialysis company entering the Denver market.” http://www.denverpost.com/firstinthepost/ci_12830453
“That might explain why a company (DaVita) that treats about 114,000 patients nationally is pursuing unspecified damages from six physicians in Colorado Springs who treat roughly 400.” http://www.gazette.com/articles/davita-57449-dialysis-doctors.html#ixzz1YsZOgkWx