• 1.

    United States Renal Data System. 2021 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2021. https://adr.usrds.org/2021

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  • 2.

    Fotheringham J, et al. Rationale and design for SHAREHD: a quality improvement collaborative to scale up shared haemodialysis care for patients on centre based haemodialysis. BMC Nephrol 2017; 18:335. doi: 10.1186/s12882-017-0748-

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COVID-19 and the Future of Outpatient Dialysis

Karen Blum
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With infectious agents, such as monkeypox and Candida auris, emerging in the wake of peak pandemic, the Great Resignation, supply chain difficulties, and lingering sadness over the loss of patients or family members to COVID-19, it's no surprise that the health care and dialysis industries have had significant challenges, said Jeffrey Hymes, MD, executive vice president, global head of Clinical Scientific Affairs at Fresenius Medical Care North America. Hymes spoke during the Kidney Week 2022 Clinical Practice Session, A Look in the Crystal Ball: COVID-19 and the Future of Outpatient Dialysis. He offered some tips to stimulate a turnaround.

“We've had our own wave of early retirement, attraction of our staff to other careers that are less challenging, perhaps viewed as being less risky or demanding,” said Hymes, who is also chief medical officer for care delivery at Fresenius.

In his presentation, Dialysis Facility Staffing in the Wake of COVID-19, Hymes noted that new hires are experiencing less face-to-face mentoring from existing health care staff already stretched to its limits, and there is increased complexity in caring for dialysis patients. “The cliché is that people can go and flip burgers for about the same money that they can be a dialysis technician,” he said.

In previous years, non-US-born nurses were a source of labor for dialysis centers, he continued. However, now, there are increasing requirements for these nurses to stay within their home countries, which are also experiencing turnover in health care. Nursing costs are rising as well, with some nurses being recruited out of dialysis centers to agencies for “hourly rates that are really unsustainable,” Hymes said, sometimes reaching rates similar to reimbursement for dialysis treatment. Having a traditional nurse and an agency nurse working side by side for unequal pay can “drive dissatisfaction, disaffection, and resignation,” he said.

Together, these elements can result in patients feeling forced to choose conservative care if being treated by staff who are less experienced and are under less supervision, Hymes said, which could increase the potential for adverse events. Additionally, he said, “It's so valuable for a patient who's on insulin or hemodialysis to get educated by a nurse about transplant and home dialysis. How can they do that when they're running as fast as they can bound up in PPE [personal protective equipment]?” Meanwhile, dialysis providers are seeing delayed or reduced admissions, resulting in financial losses.

There are four possible avenues that could help mitigate these risks, he said.

  1. Trends in end stage kidney disease (ESKD). For the first time in years, the number of incident ESKD patients has fallen, according to the 2021 US Renal Data System Annual Data Report (1). This could be reflective of increased mortality among late-stage 4/early-stage 5 patients, as well as the inability of patients with chronic kidney disease (CKD) to have had appropriate referrals during the worst of the pandemic, Hymes said. It is possible that a focus on home therapies and transplantation will somewhat ease the burden in the clinics, he said. However, this requires that nurses and physicians have additional skills and are competent in training in peritoneal dialysis and home dialysis and in caring for patients following post-acute care stays in transplant centers. Furthermore, assigning the healthiest patients to home dialysis means that those in the clinics will be sicker.

  2. Therapeutic choices. Home dialysis offers an opportunity to stretch nurses and nursing hours, said Hymes. Studies have shown that involving patients in shared care or self-care can reduce the burden on nurses (2). There also is excitement in the field about the impact of sodium glucose co-transporter 2 inhibitors, aldosterone antagonists, glucagon-like peptide 1 agonists, and other agents that can have a favorable effect on cardiovascular health and slow the progression of ESKD, potentially resulting in fewer patients with kidney diseases or healthier patients in the future.

  3. Staff training and deployment. Retaining employees is not only about money but also ensuring they feel safe, adequately trained, and well treated by supervisors, Hymes said. Lengthening training and mentorship periods and limiting the number of patients for whom a new staff member oversees care can have positive effects, he said. Personality profiling is important to identify a good fit, as is having a career path that offers staff opportunities to advance. Virtual training can be used to allow staff to learn to handle complications, such as severe hemorrhage or cardiac arrest.

    Another example of employment satisfaction is expanding the scope of practice and allowing patient-care technicians and licensed practical nurses to practice at the top of their licenses. This could look like a few patient-care technicians serving patients on a 1:1 basis, with a nurse rounding to check on them and being available as needed, or providing supervision via video monitoring.

  4. Technology. There are several technologies that also could help, Hymes said. These include programs to optimize schedules that ensure robust nurse and patient-care technician staffing when the clinic is most busy and less staffing when it is not. Centralized “control tower” programs can allow patient-care technicians to keep an eye on several patients at once from one location, for example, viewing computer monitors tracking vital signs. Technologies in development may allow for better blood volume monitoring, which could improve safety and reduce nursing time.

Additionally, continuous monitoring of blood pressure, pulse, and other vital signs used in other specialties has “huge potential” for dialysis centers, Hymes said, including monitoring of disease progression. Furthermore, ultrasound, artificial intelligence, and robotic programs can be used to guide needle placement, potentially increasing patient satisfaction and reducing damage to arteriovenous fistulas.

References

  • 1.

    United States Renal Data System. 2021 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2021. https://adr.usrds.org/2021

    • Search Google Scholar
    • Export Citation
  • 2.

    Fotheringham J, et al. Rationale and design for SHAREHD: a quality improvement collaborative to scale up shared haemodialysis care for patients on centre based haemodialysis. BMC Nephrol 2017; 18:335. doi: 10.1186/s12882-017-0748-

    • Search Google Scholar
    • Export Citation
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