There are threats, then there are threats

Discussions for Patients, Family, and Friends HD For Patients
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[QUOTE=Bill Peckham;11935]

Quote:
Originally Posted by Gus
Its way too complex for someone in our position as citizens to try do do something about but eventually just rely on our scholars, scientists to find a solution which am sure they’re working hard on, as we standby. Of course, the whole world is affected and what do we need to do? Be patient and wait for our scientists to come up with a solution. Its scary of course but we shouldn’t scare the heck out of the rest of the population. Are we trying to cause a panic attack or something?

Gus the http://www.pandemicflu.gov tells you that all US citizens should plan on being able to shelter in place for a week or two. But this advice is for urinators you need dialsis specific information which I find completely lacking.

Do you resupply for home dialysis when you are out of supplies? Always resupplying when you have two weeks of supply left would be smart.

Do you reorder you medications when you have just a month left? That would be smart.

Do include the elements of an emergency renal diet in your normal diet and then restock when you are down to a two week supply? Storing what you eat and eating what you store would be smart." -Bill Peckham

Even though many dialyzors ‘take’ dailysis lying down, it doesn’t mean we have to accept our ‘fate’ that way.

I think that Bill would like us to resign the role of ‘sheople’ and be responsible for ourselves and others regardless of what the ‘scholars’ and ‘learned’ people think or plan…eh?

The nation and world learns by their mistakes and the intense reaction to those mistakes by the sheople, so this situation is not likely to be handled well since as Bill says it’s the first pandemic disease of the ‘dialysis era’.
There will be death and dire consequences all around in the dialysis community when and if this comes about judging from the Katrina crisis and other first time crises. I believe we will see euthanasia as a partial solution should it be dire for the whole country. I do think that many of the dialyzors have faced death often and will not find it as difficult as they think.

Thanks, Bill for trying to prepare individuals to take responsibility for themselves and others. Good luck in trying to ‘move’ the greater community mountain. You’re right, preparation is our best policy. On the west coast where you live, you’ll probably get lots of first hand experience when the ‘first wave’ comes.
A Traveler

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[quote=A Traveler;12025]Thanks, Bill for trying to prepare individuals to take responsibility for themselves and others. Good luck in trying to ‘move’ the greater community mountain. You’re right, preparation is our best policy. On the west coast where you live, you’ll probably get lots of first hand experience when the ‘first wave’ comes.
A Traveler[/quote]
It looks like I will be able to engage on this issue in meat-space. One thing I will try to do is to post about what is being said and what is up for discussion. I think it is very important to have a transparent process - and to report to, if not engage with, the online dialyzor community. I think one of the most important preparations we could create is credible communication channels. There will be a need to translate ideas into action quickly which could be done if there was already an established dialog. A dialog that would lead to a common vocabulary and knowledge base. Every time I think about this another strategy occurs to me that would not cost a lot of money but would be very useful in the event of something as challenging as a highly communicable disease.

I wouldn’t count on anything starting in the area geographically closest to where the current clusters of human cases are being reported. With today’s air travel and mobile society it could start anywhere, and there are Ports of Entry in every state.

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My Name is Jason Snell Its nice to see you here. I have ran into you in the home care at nkc. I was in training breifly for the B BRaun to do Nocturnal,I happened to see you running on the nxstage I was very impressed with the technoligy how is it going for you now?? Dont you think Linda Franklin is great please tell her hi for me. We moved to South Florida we have gone throught 1 home dialysis provider they were a disaster LIFE LINE. I have since stopped my fiances tx with them and we moved on to KIDNEY KARE they are great. We are now back on nocturnal on the baby k it came brand new in the box. Well I just wanted to say your a popular guy hope all is well
Jason Snell

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I’ve registered for the Kidney Community Emergency Response (KCER) Coalition 2007 Summit. It was by posting here that my name was passed on to the coalition doing the disaster planning for the renal community. Here is the summit description:

Emergencies can happen with little or no notice, and each partner from the kidney community plays a critical role in the event of a disaster. FMQAI: The Florida ESRD Network (Network 7) has assumed administrative support lead for coordination of the Kidney Community Emergency Response (KCER) Coalition. The 2007 Summit will focus on testing and refining the national response strategy; raising public awareness of the critical needs of individuals with CKD; promoting and disseminating tools and resources; and planning for a possible flu pandemic. Please register now for the 2007 KCER Summit as we continue the important collaborative work of preparedness and response in the renal community.
They are lumping all emergencies together which I think is a mistake. The timing of this meeting is great - I was already planning on being in DC for other renal industry meetings.

There are two renal umbrella groups that the Northwest Kidney Centers is a member: Kidney Care Partners and the Kidney Care Coalition. The Kidney Care Partners has been instrumental in getting last Congress’s Kidney Care Quality Improvement Act introduced and cosponsored. The KCP is a broad renal industry group including the big for profit providers (Davita, FMC, etc.) and non-profits (DCI, NKC), manufacturers and drug makers, and non-profit service orgs (MEI, RSN, etc.). The KCC is just the providers so a much smaller group.

On Tuesday I’ll be at a KCC meeting, then Wednesday a KCP meeting, followed by Thursday’s KCER Coalition 2007 Summit. By Friday I shall either be more worried or somewhat heartened. I think both umbrella groups would be appropriate venues for pandemic planning, the most useful planning strategy would be one that included the entire industry (KCP) but the providers should have a special role (KCC) but we’ll need CMS and the renal Networks in order to implement the plan. I think I am very well positioned to provider the dialyzor’s voice.

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Hi Bill,

I’m wondering if there is any update you’re able to give us on that meeting? Did the idea of a flu disaster plan come up? Are the minutes of the meeting posted anywhere for the public?

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I did go to the meeting in Baltimore and one of the results of the meeting was to create a Pandemic Preparedness Response Team (which I believe I am on). Here is the only meeting notes that I could find relating to the Pandemic Preparedness Response Team available online:
404 Error

The meeting confirmed that at this point the renal community is making the mistake of including pandemic planning as part of their larger emergency planning effort. The meeting was mostly an exercise in emergency planning for localized events – a fire destroying a unit, an ice storm impacting a region or a hurricane causing evacuations of a large region. It is good to plan for these events, events that are sure to occur every year to one degree or another.

From the Kidney Community Emergency Response Coalition report (from the July 1, 2006 meeting) on the web here http://www.kidney.org/help/pdf/coalitionFinalReport.pdf
“The new ESRD Network contract, effective July 1, 2006, includes clear responsibilities for every Network in the area of disaster planning and response for ESRD providers, patients, and to CMS.” The Network’s contractual responsibilities include: “In the event of local disasters, ESRD Networks must track and make avail-able to the public the open and closed status of the facilities in the effected area, including specialty services offered; track where patients are receiving services; and coordinate activities, including hosting inclusive, collaborating calls with providers, emergency workers, and other essential persons to ensure coordination and that the needs of individuals with ESRD are being met.”

So it is important for the various ESRD Networks to get together and understand their obligations and figure out what they should be doing in an emergency that is impacting the provision of dialysis in their communities. That’s good, and if there is an earthquake in the Seattle area I hope that this sort of planning will help. It will allow for communication among providers and the coordination of services across the region. However, I do not believe this planning really helps to prepare for a pandemic. A pandemic would impact everyone at the same time and would last much longer than an ice storm or other localized disaster.

I am a bit concerned that there is no sense of urgency around planning at the national level. The current plan is to develop a response over time and perhaps in two years there will be some solid pandemic planning advise. The question we should be asking: Do we have two years?

I don’t know the answer but it is a hell of thing for the renal community to bet on. I hate to feel like I am being alarmist but if you look at the information available but not widely reported, for instance looking at the World Health Organization web site here: http://www.emro.who.int/

New Confirmed Human Case of Avian influenza in Egypt 14 March 2007
(Case number 25)
The national authorities of Egypt have reported a new confirmed human case of avian influenza in Aswan Governorate on the 14th of March 2007. The case is a female 10 years old and she has a history of contact with dead backyard poultry.

This brings up the total number of confirmed human cases of avian influenza in Egypt to 25 with 13 deaths.
So this year there have been 25 confirmed cases of human avian influenza in Egypt with a case fatality rate above 50% . And it’s not just Egypt – other headlines this month: South Korea records seventh outbreak; Bird Flu Strikes Hanoi, Over 1,000 Chickens Culled; Bird flu erupts in Vietnam south; total 5 provinces infected; Bird flu found in 6 more areas of Afghanistan; Laos teenager dies from bird flu; Indonesian Villagers Hide Birds And Spread Flu; Myanmar takes preventive measures against bird flu; Southern China is epicenter of bird flu, U.S. researchers find; Suspicious bird flu deaths in Tehran’s Pardisan Park; World experts in Kuwait as more bird flu cases detected .

At the KERC Summit I did talk to someone from the CDC but I was unsatisfied with her answers to my questions. For instance I wanted clarification of what the CDC planning scenario envisions as a severe pandemic Attack Rate – “If the attack rate is 30% what exactly does that mean?” and “Why did the CDC planning scale imagine a 2% case fatality rate as a worse case scenario when the current CFR is above 50%?” These questions begged specific answers but her answers were vague and contradicted published informnation. So I didn’t really learn anything new at the Summit and what discussion there was about a pandemic was not very sophisticated.

I guess I am worried that this particular threat is not being taken seriously enough. I think the Northwest Kidney Centers is light years ahead of any other effort I am aware of but I do not understand why the rest of the community is not taking similar preparation measures.

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From what I heard on NPR, a pandemic wouldn’t necessarily impact everyone at the same time…exactly. The expert described a series of “waves” each lasting about 6 weeks in any one area and then moving on. He thought (wish I could recall who it was!) that there would be local quarantines that might last 4-6 weeks at a time.

Of course, with air travel, there could be multiple focal points at any one time in any given community–and the larger a metro area, the more likely that scenario would be. So, they could all combine into one giant, quarantine mess…

(Case number 25)
The national authorities of Egypt have reported a new confirmed human case of avian influenza in Aswan Governorate on the 14th of March 2007. The case is a female 10 years old and she has a history of contact with dead backyard poultry.

I think this last (in bold) is key–yes, humans are getting this flu now, directly from birds. Since most (if not all) flu every year comes from birds, this isn’t unusual. The unanswered question is whether this can jump from person to person–and if so, when might that happen?

I think you’re right to urge planning and hope you’re successful in engaging the community on this issue. It would be much better to spend time thinking through what might happen and figuring out what to do about it than wishing we had done so after the fact…

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The exact timing would vary from one locale to another but my understanding of waves is that when a novel virus “pops” it will impact communities in waves over a period of two or so years but each wave will be impacting communities at about the same moment in time.

This is based on the 1918 experience when waves of pandemic washed across the country over a period from 1918 to 1920. Right now all the talk is about the first wave because it is hoped that by the time the second wave begins there will be a vaccine; there is no way to have a vaccine for the first wave because you have to wait until the virus presents before you can create the vaccine. It may be that a wave would start in one community a few weeks before it starts in another community but for most intents it will be happening everywhere at the same time.

I think it is pretty clear that human to human to human transmission has occurred but it has not yet been sustained. There are several issues with clusters like the one(s) in Egypt. The first is that every time a human gets the virus H5N1 it is like spinning a roulette wheel – there is another chance for the virus to recombine into a version that can spread easily among humans.

This is why I think it is one hell of a bet that the renal community is making – one of these times a virus will recombine and the spread will begin – there is no way to know if it has happened; right now there could be a person on an airplane with a version of the virus that could spread easily. There are several obvious scenarios that could happen that would result it the virus popping in a geographically dispersed way; by the time we knew it was happening it would be too late.

The other issue with clusters in Egypt or Indonesia is how well do you suppose we know what is going on in these regions? People in the slums of Cairo or Jakarta are use to living and dying in their homes, they do not, as a matter of course, seek medical treatment. And there are a number of very strong incentives for governments to under report cases – human bird flu cases decreased in Vietnam at the same time as “respiratory distress” cases increased. Like I say it is a hell of a bet the renal community is making. It could turn out alright, maybe the powers that be do know what is going on in the Nile delta or the Jakarta shanty towns. But I rather doubt it.

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Maybe I should just stop reading these articles

Five million Egyptians keep chicken and ducks in their homes and backyards, providing an essential source of food and income.

Women feed their birds by chewing corn and blowing it into their mouths, a tradition that dates back to the days of the Pharaohs.

These households will be difficult to regulate.

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Women feed their birds by chewing corn and blowing it into their mouths, a tradition that dates back to the days of the Pharaohs.

Yuck! That could certainly explain some of the bird-to-human transmission in Egypt.

This is why I think it is one hell of a bet that the renal community is making – one of these times a virus will recombine and the spread will begin – there is no way to know if it has happened; right now there could be a person on an airplane with a version of the virus that could spread easily. There are several obvious scenarios that could happen that would result it the virus popping in a geographically dispersed way; by the time we knew it was happening it would be too late.

This is unfortunately all too true.

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Get Informed. Be Prepared.
U.S. Department of Health and Human Services, May 2006

“While the Federal Government will use all resources at its disposal to prepare for and respond to an influenza pandemic, it cannot do the job alone. This effort requires the full participation of and coordination by all levels of government and all segments of society… perhaps most important, addressing the challenge will require active participation by individual citizens in each community across our Nation.”
George W. Bush, President
[I]United States of America

[/I] “Pandemics are global in nature, but their impact is local. When the next pandemic strikes, as it surely will, it is likely to touch the lives of every individual, family, and community. Our task is to make sure that when this happens, we will be a Nation prepared.”
Michael O. Leavitt, Secretary
U.S.[I] Department of Health and Human Services

[/I] http://www.pandemicflu.gov/plan/individual/familyguide.html
The US government’s pandemic preparedness Guide for Individuals and Families specifically instructs dialyzors: If you receive ongoing medical care such as dialysis, chemotherapy, or other therapies, talk with your health care provider about plans to continue care during a pandemic.

Therefore it is our job to initiate the conversation. Here is what I think should be done if we were suddenly faced with a pandemic emergency based on the information that is currently available. If there was a pandemic in the next two years providers would have to make decisions in the absence of clear guidance from the CDC, CMS or the Renal Networks. In two years time the renal community should be able to provide guidance on a mitigation strategy but until that happens this is what I think should happen at the unit level.

Normal operations at Dialysis Unit X:
18 stations, three patient shifts/day, 108 patients, all patients dialyze for 4 hours 3 days a week. Normal hours are 6AM to 11PM: M,T,W,Th,F,S. Staff to patient ratio: 1 to 3. Stations turn every 5 hours. First on of first shift is 6:30 AM. Last on of third shift 18:00.

First shift ons from 6:30 to 8:00; offs from 10:30 to 12:00
Second shift ons from 11:30 to 13:00; offs from 15:30 to 17:00
Third shift ons from 16:30 to 18:00; offs from 20:30 to 22:00

FTEs = 18 (Normal operations require the equivalent of eighteen full time employees)

Event:

CDC has declared a category five pandemic:[ul]
[li]Avian influenza is spreading locally[/li][li]Schools are closed[/li][li]Projected duration 12 weeks.[/ul]Nine staff are available/willing/need to work: 50% operational capacity[/li]
Projected operation utilizing pandemic mitigation strategy providing minimum dialysis dose: strategy provides 66% of dialysis dose provided under normal operations.

18 stations, two patient shifts/day, 108 patients, all patients dialyze for 6 hours 2 days a week. Hours are 5:00 to 24:00. Staff to patient ratio: 1 to 6. First shift begins at 6:00 all first shift patients have left unit by 14:30. Second shift begins at 15:00 all second shift patients have left unit by 23:00.

Three staff work entire day – 18 hour shift. Staff are designated Work Group (WG) A, B & C.[ul]
[li]MWF first shift patients are now M/Th first shift staffed by WG_A.[/li][li]MWF second shift patients are now M/Th second shift staffed by WG_A[/li][li]TThS first shift patients are now T/F first shift staffed by WG_B[/li][li]TThS second shift patients are now T/F second shift staffed by WG_B[/li][li]MWF third shift patients are now W/S first shift staffed by WG_C[/li][li]TThS third shift patients are now W/S second shift staffed by WG_C[/ul]Patients and staff should call in every day, at specified time, to touch base, report any symptoms so that exposure or spread can be tracked and changes to schedule can be accommodated.[/li]
Pandemic Influenza Mitigation Benefits of strategy:
Resource conservation – strategy conserves supplies and transportation resources. Limits spread of illness if one member of shift is infectious prior to onset of symptoms because patient to patient contact limited. Of six patient groups and three staff groups contact among groups is limited. Worker commute reduced to twice/week (two 19 hour shifts). Patient transportation reduced by a third. Continuity of care – same staff caring for patient group.

Issues to Resolve

Availability/use of anti-virals?
If member of patient household has flu what should be done?
If patient presents with symptoms what should be done?
If patient is confirmed with symptoms what should be done?
How should other non-pharmaceutical interventions be used? e.g. masks, humidifiers, etc?
Transportation issues?

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Interesting thoughts, Bill. Besides FTE’s at the dialysis center and patients, though, there is also transportation. You have to wonder what will happen to folks who live in nursing homes or those who need paratransit or other ride services to get to & from dialysis in centers.

Are there any data to suggest that a twice weekly 6-hour schedule would work? It would clearly be better than nothing, but the fluid removal targets & rates would change so much that staff would really need to THINK about each person’s treatment–and time for thought would likely be in very sort supply.

I’m not saying I have anything better to offer–at least what you’ve suggested is a plan that folks could get started with.

Ensuring that everyone who needs to be in contact with others has the appropriate antivirals would also be important.

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The comparison is to some other reduced dose schedule not to the dose under normal operations. By maintaining the total number of hours on the machine per week this schedule offers the chance for lower UFRs than a schedule that cut treatment length while maintaining frequency.

Transportation would be the biggest barrier to the provision of dialysis and I do list it under “Issues to Resolve”. By cutting frequency from three days a week to two days a week this pandemic mitigation strategy solves 33% of the transportation challenge - but those two trips a week still present the most difficult challenge. I think we could come up with strategies to help with transportation but a coherent strategy will take time to develop so we’re back to “Everything will be fine as long as it doesn’t happen.”

34

Oops–I’d missed those “issues to resolve.” I wonder how the Feds are planning to handle things like gas stations and who counts as “essential” personnel who would be able to out on the streets if there really are quarantines. Clearly medical staff would be in this group, but how do you “prove” you’re on dialysis to someone who doesn’t know anything about it? Show a vascular access? (Maybe). Presumably gas stations would need to stay open, even if there were quarantines. You’d hope that utilities (water, electricity, natural gas) would continue to operate as usual…

Delivery of home dialysis supplies is also a question mark. You’d think that truckers would be “essential,” since they move goods like food, gasoline, and dialysis supplies from place to place.

The emergency plans always seem to call for people storing 4-6 weeks worth of food, though–and preferably not having to cook it. Hmmm. So, even the day-to-day non-dialysis logistics look pretty dicey if a pandemic were to come to pass. Folks getting only 2 days of in-center treatment (although a longer, better treatment) would probably need a fair amount of help with daily living tasks. Few people have the ability to buy & store that much food, and if folks ran out, it could get pretty ugly pretty quickly.

35

I’m not sure about two 19 hour shits for staff. Studies with medical personnel in hospitals have shown that long work hours contribute to medical errors. Here are a couple of others posisbilities.

#1
Perhaps one way to address the personnel issue is to start working now to encourage more clinics to teach patients how to do self-care. This way capable patients can do their own care whether they’re in a clinic or at home. That would mean that clinics could have staffing ratios that required fewer personnel to take care of patients who couldn’t do their own treatment and to be available as needed for self-care patients. If a clinic offers self-care in-center, it does not need to have separate certification to do this. However, I would expect that surveyors would want to know that a facility that offered self-care had policies and procedures and qualified personnel as required for clinics that teach patients to do self-care at home. It seems to me that the clinic could be reimbursed for training patients to do self-care (additional $20/treatment), but this would be something to ask the fiscal intermediary about. Patients who chose to learn how to do self-care in-center dialysis get Medicare sooner – Day 1 of the month dialysis starts if they start a training program before Day 1 of the third full month of dialysis.

#2
CMS also has a way in emergency situations of designating a location as a “special purpose dialysis facility.” As I understand it, this could apply to a hospital. It can also apply to a nursing home that hadn’t previously chosen to be certified to offer chronic dialysis onsite. Perhaps they could have trained dialysis staff go to those settings rather than trying to transport residents to a dialysis facility. There would need to be dialysis equipment that wouldn’t require a lot of facility modification and that could be used on multiple patients – like the NxStage System One. Down the road, the Renal Solutions’ Allient might be another option. Then someone would need to figure out if for staffing purposes it would be better to offer shorter more frequent treatments or longer treatments 2-3 days a week per patient. Keeping a patient in his/her room and moving from patient to patient should reduce the risks of infection that getting out in public on shared transportation assuming the staff follow standard infection control policies and procedures.

Here’s how special purpose renal dialysis facilities are defined in the current ESRD regulations:

Special purpose renal dialysis facility.
A renal dialysis facility which is approved under § 405.2164 to furnish dialysis at special locations on a shortterm basis to a group of dialysis patients otherwise unable to obtain treatment in the geographical area. The special locations must be either special rehabilitative (including vacation) locations serving ESRD patients temporarily residing there, or locations in need of ESRD facilities under emergency circumstances.

And the criteria they must meet:

§ 405.2164 Conditions for coverage of special purpose renal dialysis facilities.
(a) A special purpose renal dialysis facility must comply with all conditions for coverage for renal dialysis facilities specified in §§ 405.2130 through 405.2164, with the exception of §§ 405.2134, and 405.2137 that relate to participation in the network activities and patient long-term programs.
(b) A special purpose renal dialysis facility must consult with a patient’s physician to assure that care provided in the special purpose dialysis facility is consistent with the patient’s longterm program and patient care plan required under § 405.2137.
© The period of approval for a special purpose renal dialysis facility may not exceed 8 calendar months in any calendar year.
(d) A special purpose renal dialysis facility may provide services only to those patients who would otherwise be unable to obtain treatments in the geographical areas served by the facility.
[48 FR 21283, May 11, 1983, as amended at 51 FR 30362, Aug. 26, 1986]

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I agree Beth, self-care and home dialysis are important elements of any mitigation strategy. Beyond self-care I think looking to dialyzors for help operating the unit should be part of the solution but to operationalize a dialyzor militia takes time and what I am concerned about is the lack of planning for what to do if this happens before we are ready. My mitigation strategy could be operationalized tomorrow if, god forbid, it was needed.

I think a 19 hour shift has to be judged in the light of the alternatives. If transportations was not a limiting issue it would be straight forward to break my mitigation staffing strategy into four 10 hour sifts and still keep shifts of workers and patients from mingling. The key would be to prevent a single person from infecting an entire operation in one fell swoop. If transportation rose to become a confining resource then a 19 hour shift cuts the transportation problem in half. There would be secondary issues that come from extended shifts but I think they would be less significant then the problems that would come from maintaining the eight hour work day.

The preparations for hospital surge capacity – flu wards – include provisions for staff to be quartered. The thinking is that staff would not want to go home and risk bringing infection into the household. Would that be true for dialysis unit staff? Would we see staff moving in with each other rather than commuting between family and work?

I don’t think bringing dialysis to the people is a viable option. I think our pandemic strategy must require fewer resources not more resources. If only half the normal staff were available it would require compromising dose to create a bridge to the resumption of normal operations. The current Policies and Procedures in our industry can a bridge a disruption lasting days – through diet. I think we have to think about creating bridges that can span a disruption of weeks.

37

With the nursing shortage, there are a number of hospitals that offer three 12-hour shifts/week for full-time pay. But I’m not aware of situations where anyone works more than 12 hours. Even medical school training has cut back, in many cases, because interns who were working 24 hour shifts were making fatal errors. Many dialysis staff have family at home who rely on them (young children, etc.), and won’t be able to be available for that long. And, working such long shifts would also reduce immunity among those doing it, making them more susceptible to the flu.

[QUOTE=Bill Peckham;13028] Normal operations at Dialysis Unit X:
18 stations, three patient shifts/day, 108 patients, all patients dialyze for 4 hours 3 days a week. Normal hours are 6AM to 11PM: M,T,W,Th,F,S. Staff to patient ratio: 1 to 3. Stations turn every 5 hours. [/QUOTE]
I’m not a dialysis administrator, but this doesn’t seem very efficient–mainly because there are so few staff to help patients get on the machines (and most patients can’t help themselves).

What if, as a strategy, centers started by:
1.) Teaching all able patients to self-cannulate. This could be started now, and made into an expectation–“It’s your arm, and you will be best at putting needles in. We’ll teach you how.” This strategy would have the side benefits of empowering patients and reducing vascular access errors and hospital stays. Some patients would decide to go home, once clearing the cannulation hurdle.

2.) Teaching one lesson per week about how to set up the machine Techs could do this as they set up the machine for each patient, so it wouldn’t take a lot of extra time. The goal is to keep track of which patients appear to be “getting it” well enough to start taking on some role of their own.

3.) Including interested patients in regular technician training classes. Again–this is no major additional effort, since the classes would be held anyway, but could lead to more knowledgeable patients in the center who could help themselves–and possibly other patients as well.

4.) Offer small group training for home dialysis. Get as many patients out of the centers as possible so they can be more self-sufficient in the event of a pandemic. This obviously has all the side benefits of home therapy besides.

Just some thoughts…

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[quote=Dori Schatell;13039]

[quote=Bill Peckham;13028]
Normal operations at Dialysis Unit X:
18 stations, three patient shifts/day, 108 patients, all patients dialyze for 4 hours 3 days a week. Normal hours are 6AM to 11PM: M,T,W,Th,F,S. Staff to patient ratio: 1 to 3. Stations turn every 5 hours. [/quote]
I’m not a dialysis administrator, but this doesn’t seem very efficient–mainly because there are so few staff to help patients get on the machines (and most patients can’t help themselves).[/quote]

Can you outline the details of a more efficient operation? A higher patient/staff ratio I assume. Are shorter runs more efficient too?

I think it is important to have multiple time horizons. What would you do if it happened tomorrow? What would you put in place if you knew it would happen in 24 months? In 60 months? The renal community seems to be only working with extended time horizons. It’s a bet - nothing will happen for months/years/never.

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If there are 18 chairs & 3 staff (as in your scenario), none of the patients can help themselves at all, and all 3 staff put people on, then it would take an hour to put everyone on, even if it only took 10 minutes per person. (18 x 10 = 180 = 3 hours divided by 3 staff).

But if half of the people can put in their own needles, take and record their own vitals, set their machines, etc., it would only take 30 minutes to get everyone on. That’s what I meant by inefficient. Longer runs do make sense for the lower staffing ratios you suggested–since people would have many fewer symptoms and crashes running for 6 hours, it shouldn’t be a problem to have half as many staff (this is what nocturnal in-center hemo programs do, and it works). Shorter runs = more symptoms & crashes = need for more staff. So, that wouldn’t help any with the emergency scenario.

Also, potentially patients who could put themselves on might be able to help others get on the machine. Then, maybe a center could run (with 6-hour treatments) with even more of a skeleton crew–2 staff? One RN, one tech.

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Hey, a new CDC-approved vaccine!
http://my.earthlink.net/article/hea?guid=20070417/46244640_3ca6_15526200704171539450101.