Standards of Care in Colorado

We at 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, 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,
Front Range Kidney Patient Association:
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: ph. 303-866-4569 (office), 970-221-1135 (home)

1) Increased time on dialysis
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:
Dr. John Agar and discussion on pump speeds and time on dialysis:
"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 "
“Just as speed on the road kills, so it does in hemodialysis.” Dr. Carl Kjellstrand,
“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:

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;

  1. “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.
  2. 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,

4) Blood Transfusions are to be done in a Hospital, NOT in a dialysis clinic
From Roberta Mikles RN, QualitySafePatientCare:

  1. 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.
  2. 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.
  3. 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.”
“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.”


A retired dialysis nurse I know looked over the proposed Standards of Care and mentioned it looked like they are coming along nicely. She did mention however that Fresenius hadn’t done transfusions for quite a while (15 years or so). May have to find out if they are starting up again. I’ve contacted Roberta Mikles from QualitySafePatientCare about it.

There should be little need to do blood transfusions in dialysis patients who do not have another condition necessitating them. Anemia can be managed by providing enough dialysis to avoid early destruction of red blood cells, making sure that patients’ iron stores are sufficient, and providing sufficient erythropoiesis stimulating agents (Epogen, Aranesp) to maintain hemoglobin in the acceptable range. If hemoglobin remains low in spite of supplementation with iron and ESAs, it would be important to assess the patient for other conditions that may be leading to ESA resistance, which may include such things as inflammation, malignancy, aluminum toxicity, etc. The FDA recommended that ESAs be started when hemoglobin is less than 10 and that the dose be reduced or ESAs stopped when hemoglobin approaches 11.

We have been concerned that dialysis clinics could be starting to refer patients to hospitals for transfusions or provide transfusions for which they would get paid separately by Medicare when they would have to provide Epogen or Aranesp under the new bundle of services and not get paid separately for it. Blood transfusions raise antibody levels which could jeopardize patients’ ability to get a transplant or make it take longer to get one. Also, if more dialysis patients are transfused instead of giving drugs that treat anemia, it could risk our scarce blood supply.

Sure hope so! Guess we are worried too if the clinics had a financial incentive to do blood transfusions, they might do more than necessary - I’m remembering the epo scandal: