Patients who find themselves on in-center dialysis have the higher rates of hospital admissions than those on peritoneal dialysis.1 These admissions represent a significant financial cost and account for approximately 40% of the total Medicare expenditures for dialysis patients.1

Infection-related hospitalizations have increased 47% since 1993,2 and a single catheter-related bloodstream infection (CRBSI) admission can cost the health care system as much as $80,235.3 Most importantly for patients, infections are the second leading cause of death,4 and the elderly are known to be at an especially high risk of mortality from dialysis-acquired infections.5 Given the frequency of hospitalizations and their consequences, any pragmatic steps that can be taken to reduce admissions will result in improved patient survival and substantial cost savings.

Using evidence and expertise

Evidence–based medicine is a model of decision making that uses a systematic process to integrate the best evidence with clinical expertise and patient values to answer a question about one patient’s plan of care in order to optimize outcomes.6 Absent from prior considerations about ways to reduce hospital admissions among dialysis patients has been the role of evidence-based clinic staffing standards. There is already preliminary evidence on clinic staffing which can serve as a basis for additional research and the eventual establishment such standards.

Read also: Will we see improvements in providing a safer environment for dialysis patients? 

The purpose of this article is to provide: 1) an overview of research on the staffing of nephrologists, patient care technicians (PCT), dietitians, social workers, and nurses which is relevant for hospitalization risk; and 2) to suggest areas where research on staffing is particularly germane for the potential of reducing admissions. As a prelude to this, a brief look is first taken at the historical roots of the longstanding problematic situation with dialysis clinic staffing.

Roots of the problematic situation with dialysis clinic staffing

Staffing in medical care has historically been viewed as a structural measure of quality. Donabedian was the first to propose a framework of assessing quality in medical care consisting of structure-process and outcome.7 In this framework, structure consists of the stable elements that form the basis of the health care system; process consists of the technical and interpersonal components of what is done within the structure, and outcome consists of what happens to the health of the patient.8 Validating the framework, research has linked, for example, inadequate nurse staffing in acute care hospitals with an increased risk of infections,9 mortality,10 medication errors,11 patient falls, 12 and adverse outcomes with nurses themselves (e.g., burnout13 and needlestick injuries14).

Early definitions of adequate staffing’ for dialysis

The subject of dialysis clinic staffing has not been given the same priority, and the roots of this appear to rest with the Centers for Medicare & Medicaid Service (CMS). This began with the original regulations for the End-Stage Renal Disease (ESRD) Program, which describe proper clinic staffing as when “an adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients.”15The basic limitation of this regulatory statement is its vagueness and the fact that the word “adequate” has never been defined, in terms of actual number of personnel relative to patients.

There have had a number of ramifications from this vagueness.

  • Because there are no evidenced-based standards for staffing, it has given dialysis providers freedom in deciding what constitutes an adequate patient-staff ratio. The idiosyncratic and unscientific decision making that has gone on undoubtedly accounts for why in one dialysis chain there might be one dietitian or social worker for every 100 patients, while in another these professionals could have responsibility for 200 patients.16 In extreme examples, recent reports have found some dietitians having responsibility for 240 to 340 patients, divided between 5 facilities17,18 and some social workers trying to cover over 400 patients.19 Similarly with nephrologists, while one physician might have a caseload of 70 patients, another one could have well over 250 patients.20 Within the structure-process- and outcome framework, such wide differences in patient-to-staff ratio are inescapably affecting outcomes. Evidence of this was illustrated in a study of nephrologists which found an association between higher patient caseloads and an increased risk of patient mortality.20
  • ESRD Network Organizations, which are under contract with CMS to oversee care provided to patients and help facilities make quality improvements,21 collect regional data in the areas they serve. The Networks routinely uncover unexplained facility-to-facility variations in patient outcomes,22 but because CMS has not sanctioned staffing via the Conditions for Coverage of the ESRD program as a quality of care issue,23 the Networks have not viewed it within their authority to focus on it in their improvement efforts.

The consequences from this can be illustrated in two areas.

  • Facility-to-facility variations in kidney transplant rates have been known for decades. A recent report alluded to staffing inadequacies as an explanation for lower rates in the southeast region of the U.S.––specifically, a lack time for patient education and referrals to transplant centers.24
  • Variations in hospitalization rates is a second area of concern. The Forum for ESRD Network Organizations has suggested the Networks can have their greatest impact mitigating admissions through quality enhancement efforts related to processes of care.25 However because staffing has not been clearly defined by CMS, the Networks have not focused on it as a means of facilitating improvements. State Health Department surveyors of dialysis facilities would appear to be similarly handicapped because, without staffing standards relative to the number of patients in most states, they have not been able to cite facilities for deviations (only a handful of jurisdictions have mandated staff-patient ratios, with Texas being the most notable16). This might better explain the poor compliance with infection control guidelines frequently uncovered.26

The potential for reducing hospitalizations through evidence-based staffing

Nephrologists

In discussing research on nephrologist staffing that can be used as a basis for the development of evidence-based standards, it is important to note that questions about standards have always centered on the frequency of their face-to-face visits with patients in dialysis facilities. Based on the broad assumption that more frequent visits will improve patient outcomes, CMS changed its physician payment policy in 2004 to incentivize more visits.27 Statistics reveal a dramatic rise in the average number of monthly visits after this policy change, from just 1.52 to 3.13 a month.28 Despite this increase, many unanswered questions remain about the actual impact visits have on patient outcomes, including reducing hospital admissions. For example, the first investigation examining the effects of the increased visits showed they had little clinical value on quality indicators.29 A second inquiry concluded that the heightened visits improved patient compliance with attendance at dialysis sessions, but they were not associated with reduced mortality.30

A cross-over study found that while more frequent nephrologist-patient contact was associated with lower mortality and the better achievement of certain laboratory targets, they were also associated with a lesser chance of being on a transplant waiting list.31  A fourth study discovered that greater nephrologist-patient contacts were associated with a small, but statistically significant reduction in the risk of first hospitalization.32 Results from an investigation involving 26,613 patients suggested that just one additional monthly visit with patients recently discharged from the hospital could reduce the chances of a readmission.33 Finally, a study published last year found that greater frequency of clinic visits was associated with more vascular access procedures, but not prolonged access survival, and only a small reduction in hospitalizations.34

Perhaps a more basic question that evidenced-based research might focus on is whether frequency of clinic visits per se or quality of the nephrologist-patient relationship is the most dominent factor affecting outcomes. Relevant to this question is research showing that for the majority of patients the most important aspect of their medical care is the continuity of being able to see the same doctor.35 Continuity in the relationship is crucial because it is known to increase practitioner’s and the patient knowledge of each other, build trust, and create an overall better context for healing.36

The quality of the nephrologist-patient relationship may be unintentionally undermined in many instances today because, in large nephrology practice groups, there is often an alternating rounding schedule for different doctors to make dialysis clinic visits. In other words, the nephrologist rounding from week-to-week is likely to be different from the one a patient periodically sees during office visits. Such cross-coverage in hospitals has been found to result in errors in judgment by covering physicians, who are unfamiliar with the details of a patient’s situation.37 This type of scheduling with dialysis patients has the potential to create confusion 38 and adversely affect the trust and rapport needed for full cooperation with adherence issues (e.g. fluid restrictions39 and the treatment schedule40) which have implications for hospitalization.

If research determines that quality of the nephrologist-patient relationship is most important factor, it would signal a need for nephrologists to focus on it as a way of improving outcomes. Given the increased emphasis on of pay-for-performance,41 such a finding could also have implications for CMS reimbursement policy, which began to incentivize visits in 2004 as a way of trying to improve outcomes.27 The view has been expressed that in linking clinic visits with monthly capitated payments, CMS created a perverse incentive, which now compels the completion of the fourth monthly visit in order to maximize reimbursements.42 This may be reflected in a recent investigation which found that clinic visits by nephrologists depended more on geographic convenience, rather than the health status of patients.43

 

Patient Care Technicians

PCTs perform 90% of all in-center dialysis treatments today and consequently have the most frequent direct physical contact with patients each week.44 In highlighting the ways evidence-based PCT staffing could potentially reduce the risk of hospitalization, it is useful to look briefly at the array of tasks PCTs are expected to complete within the 30 minutes of what is commonly called “turnover” in dialysis facilities. During this high pressure period,45 PCTs are typically responsible for taking off four patients who have completed a treatment and starting the treatment of four new patients on the next shift. Entailed in this are a subset of additional tasks PCTs are to perform to in order to keep patients safe. Among the most important are guidelines, issued by the Centers for Disease Control and Prevention (CDC),46 which require hand washing and glove changes before and after every patient contact. Being responsible for taking off and putting on 8 patients, this adds up to a minimum of 16 separate hand hygiene/washings and glove changes during turnover.

A second task PCTs are required to complete during this period is the cleaning and disinfecting of each treatment station.46 Among the surface areas and items that are supposed to be cleaned and disinfected are treatment chairs, countertops, draw/cupboard handles, controls on television sets, the external surfaces of dialysis machines, scissors, and blood pressure cuffs. This cleaning is critical because it is known that blood-borne pathogens can survive for varying lengths of time on any surface,47,48 and hand contact of PCTs with an inadequately cleaned surface can result in patient-to-patient transmission of infections.49,50

The third and equally critical responsibility PCTs have during turnover is to stringently follow exit site care guidelines required by central venous catheters (CVC). This is important because it is known that bacteria from the skin tends to migrate and colonize around the hubs of CVCs, making it the most common cause of CRBSIs.51 Using chlorhexidine 2% with 70% alcohol as the preferred antiseptic,52 a compilation of guidelines issued by the CDC’s “Scrub-the-Hub-Protocol”53 and the National Kidney Foundation 54 call for PCTs to rigorously adhere to the following steps:

Perform hand hygiene and don new gloves and mask before beginning

Apply antiseptic solution in a circular motion to skin working outwards from CVC exit site

Cover an area 10 cm in diameter

Reapply antiseptic to skin twice, but allow to dry before doing so

Clean CVC connection 10 cm up catheter

Vigorously scrub CVC hub and caps before opening to connect blood lines

Studies have looked at the ability of PCTs to consistently adhere to all the safety standards required during turnover and found a very high frequency of lapses, which might explain the continually escalating CRBSI rates.2 Regarding the stringent care required by CVCs, a just published 2015 investigation discovered that 64% of PCTs failed to scrub CVC hubs with antiseptic following disconnecting blood lines; 55% failed to scrub external CVC hubs(caps) at the initiation of a treatment; and 85% failed to use antimicrobial ointment in dressing changes.55 As to lapses with cleaning and disinfecting, this same investigation found that 82% of PCTs failed to disinfect non-disposable items returned to the common area; 74% failed to vacate treatment chairs prior to disinfecting; and 59% failed to disinfect surfaces per recommendation of manufacturers.55

Turning to lapses with hand hygiene guidelines, one study discovered that 46% of PCTs failed to wash their hands and change gloves in going from one patient care station to the next; 44% did not wash their hands and change gloves before giving intravenous medications, and 40% failed to do hand hygiene and change gloves prior to putting patients on to begin a treatment.56 These findings are reinforced by a more recent inquiry which found that hand hygiene was less than 33% in more than 75% of dialysis patients .57

Support for the potential of evidence-based PCT staffing to substantially decrease CRBSIs comes from investigations showing that when staff have the actual time to rigorously adhere to all safety standards, infections can be dramatically reduced. For example, very low CRBSIs and catheter survival (around 1 year) were found to be achievable in infants and children on dialysis, when staff had the time to “adhere to a strict catheter management protocol”58 Data from the 17 dialysis facilities that participated in Collaborative Prevention Effort led by the CDC, similarly revealed that when staff have time to meticulously adhere to  protocols it can result in a 32% reduction in overall bloodstream infections and a 54% reduction in vascular access-related infections.59  There is also the case report on a dialysis patient who used a CVC for 3 years and nine months without single episode of CRBSI, because safety guidelines were consistently adhered to.60      

Further illustrating its critical importance, research has discovered that when hospital personnel have time to adhere to all safety guidelines, CRBSIs can be similarly decreased. For example, a 66% reduction of CRBSIs was achieved and maintained in the intensive care unit (ICU) when nurses had the time to meticulously follow guidelines.61 A 76% drop in bloodstream infections in a neonatal ICU was found to be associated with more registered nursing hours.62 Some investigators have gone so far as to suggest CRBSIs can actually be eliminated in surgical ICUs if staff have the opportunity to rigorously adhere to all safety standards.63 Finally in a recent review of research it was estimated that 70% of CRBSIs are preventable, if staff are able to stringently follow CDC guidelines.64

Dietitians

It is well established that protein energy malnutrition (PEM) is associated with increased morbidity and mortality risk in dialysis patients.65 There is controversy surrounding the impact interventions by dietitians can have on PEM. This is because of the many factors that can contribute to PEM (i.e. inflammation,66 metabolic acidosis,67 the catabolic effects of dialysis itself,68 co-morbidities like diabetes and cardiovascular disease69 and increased age70). The growing consensus seems to be that when PEM is primarily the byproduct of inadequate nutritional intake, dietitians can have the greatest impact facilitating improvements, as measured by serum albumin values.71 For example, counseling by dietitians has shown it can increase serum levels 0.07 g/dl per month and with some patients in the 12-month study going from a low 2.9 level to a much healthier 3.9 level.72 Relevant to their potential to reduce hospitalizations, “intensive nutritional counseling”  by dietitians in Right Start project was credited with being instrumental in helping to decrease the risk of admissions.73  There are also the results of a retrospective study of 77,205 dialysis patients which concluded that a 0.2 g/dl increase in serum albumin, facilitated by dietitians is associated with a 28% reduction in risk of hospitalization, while an increase of more than 0.4 g/dl is associated with a 41% decreased risk.74 The investigators when on to suggest that a 0.2 g/dl overall increase in albumin concentrations could result in 6000 hospitalizations being adverted, and save Medicare $36 million.74  Finally an earlier investigation simply concluded that when dietitians have more than 30 minutes per patient per week for counseling, the risk for a hospital admission is significantly reduced.75

Given the potential impact dietitians can have in decreasing hospital admissions, research on evidence-based standards might logically focus on the time required for these professionals to provide the optimal help patients need. Research is needed because of the diminishing opportunity dietitians have for face-to-face time with patients. For example, due to the two-fold increase in the number of dialysis patients with diabetes, it was estimated that the time dietitians have available has been reduced by 50%.76 The higher documentation required by the newest Condition for Coverage has been identified as another major factor which has taken time away from patients.77 It was recently observed by a group of nephrologists that, “most if not all of the dietitians’ time is spent on mineral and bone disorder.”78 Two recent national surveys 17,18 have reinforced evidence that the imposition of  additional administrative responsibilities on dietitians is limiting their ability to provide intensive nutritional counseling, especially about patients’ need to increase their protein intake, which is rated by dietitians (88.5%) as the highest priority.18 Finally, but typically overlooked there are the high patient-to-dietitians ratios, which inherently limit the amount of help individual patients are able to get with nutritional issues.16

A second area that evidence-based dietitian staffing research might focus is the time required for nutrition intervention with patients recently discharged from the hospital. This is important not only because of the increased emphasis on avoiding hospital admissions,79 but also readmissions, defined as reentering the hospital within 30 days of a discharge.80 It is known that re-stabilizing a patient following a hospitalization requires an intense effort.81 The concerted involvement of dietitians is critical because nutrition  rapidly declines during a hospital stay.82 Close monitoring of patients’ nutritional status after discharge,  and early detection of the first signs of malnutrition can potentially reverse the spiral of malnutrition, which is more difficult to treat when severe.83 Research has found that following a hospital stay today many patients never regain a stable nutritional status, and die prematurely.82

 

Social workers

Largely overlooked in the quest of finding ways to reduce hospital admissions is the potential role social workers can play in several areas. First, missed and shortened dialysis are known to increase patients’ chances for an admission84 and research has demonstrated that when social workers have enough time for interventions. they can help improve adherence.85 Secondly, depression which occurs in as many as 44% to 78% of all new dialysis patients86 and is known to be an independent risk for hospitalization.87 Multiple studies have demonstrated that when social workers have enough time for psychotherapeutic interventions they can be effective in lessening the symptoms of depression88 and by implications the associated morbidity risks. Thirdly there is the chronic problem of patients not adhering to their fluid restrictions, which is also known to be a major risk for hospitalization.89 Research has similarly demonstrated that when these professionals have time for the necessary patient involvement, adherence in this area can likewise be improved.90

In order to maximize social workers’ role in reducing hospital admissions, evidence-based staffing research is first needed to establish baselines on the percentage of patients who might be struggling in silence because needed help with depression, adherence to fluid restrictions, and treatment schedule is not sufficiently available. With reports showing that up to 80% of patients are not able to consistently adhere to their fluid restrictions91 and missed/ shortened treatments remain a pervasive problem,84 the unmet psychosocial needs of this population could be substantial. Depending on the priority that stakeholders give to harnessing the contributions of all disciplines in the reduction of hospital admissions, there may be a need to increase the number of social workers.

Nurses

The American Nephrology Nurses Association recognizes that adequate staffing is critical to quality of care.92 The most important finding from research on nurse staffing having immediate relevance for increasing patients’ risk of hospitalization, is that the fact that the majority are not able to consistently adhere to guidelines for hand hygiene. One investigation found that 59.2% of nurses did not wash their hands and do glove changes going from one dialysis patient station to the other; 57% failed to do hand hygiene before administering intravenous medications; and 45.8% did not wash their hand and do glove changes before putting patients on to begin a treatment.53 A second inquiry discovered  that dialysis nurses washed their hands only 35.6% of the time after patient contact and  13.8% of the time before patient contact.93 Inadequate staffing is implicated in these lapses because it is known that understaffing, by increasing patient workload, decreases the frequency of hand washing and duration, thus favoring the transmission of pathogens.94 One of the major goals of evidence-based staffing research would be to determine the threshold in nurse workload, where there is a diminished ability to strictly adhere to hand hygiene standards.

Discussion

Over the more than 40  year history of the ESRD program, several initiatives to reduce morbidity and mortality risk have been made, including the development of the National Kidney Foundation’s Kidney Disease Kidney Disease Outcome Quality Initiative,95 Fistula First Initiative96 and most recently the Quality Incentive Program.97 Absent from these initiatives has been any explicit consideration of the pragmatic role sufficient staffing plays in their actual implementation. This is perhaps best illustrated in the K/DOQI Clinical Practice Guidelines for Nutrition,98 where surveys have found that the majority of dietitians are not able to fully implement the intensive nutritional counseling guideline 99 and also the recommended frequency and method for diet assessment,18 both because of inadequate staffing.

Conclusion

Focusing on the extraordinarily high hospital admission rate among in-center dialysis patients, this article provides an overview of how insufficient staffing can contribute an adverse outcome, and simultaneously the way evidence-based staffing could potentially mitigate the problem. The most compelling evidence highlighted would appear to be the way inadequacies in nurse and PCT staffing are probably limiting these professionals’ ability to comply with guidelines, issued to keep patients safe.

References

  1. S. Renal Data System: USRDS 2015. USRDS Annual Data Report. Atlas of End-Stage Renal Disease & End-Stage Renal Disease in the United States 2015. Bethesda, MD, National Institute of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, 2015
  2. Centers for Disease Control and Prevention. Introduction to the CDC Dialysis Collaborative. Retreived from www.cdc.gov/dialysis/collaborative.
  3. Bakke CK. Clinical and cost effectiveness of guidelines to prevent intravascular catheter-related infections in patients on hemodialysis. Nephrol Nurs J 2010;37(6):601-616
  4. Karkar A, Mandin B, 1Dammang ML. Infection control in hemodialysis units: a quick access to essential elements. Saudi J Kidney Dis Transpl 2014;25(3):496-519
  5. Dalrymple LS, Mu Y, Romano PS et al. Outcomes of Infection-related hospitalizations in Medicare beneficiaries receiving in-center hemodialysis. Am J Kidney Dis 2015;65(5):754-762
  6. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Hayes RB. Evidence-Based Medicine: How To Practice and Teach EBM. Edinburgh, NK, Churchill Livingstone, 2000
  7. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund 1966;44:166-203
  8. Himmelfarb J, Pereira BJG, Wesson DE, Smederg PC & Henrich WL. Payment for quality in End-Stage Renal Disease. J Am Soc Nephrol 2004;15:3263-3269
  9. Stone PW, Pogorzelska M, Kunches L & Hirschhorn LR. Hospital staffing and healthcare-associated infections: a systematic review of the literature. Clin Infect Dis 2008;47:937-944
  10. Aiken LH, Clarke SP, Sloane DM, Sochalski J & Silber JH. Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA 2002;288(16):1987-1993
  11. Stratton KM, Blegen MA, Pepper G & Vaughn T. Reporting of medication errors by pediatric nurses. J Pediatr Nurs 2004;19(6):385-392
  12. Dunton N, Gajewski B, Taunton RL & Moore J. Nurse staffing and patient falls in acute care hospital units. Nurs Outlook 2004;52(1):53-59
  13. Thomas-Hawkins C, Denno M, Currier H & Wick G. Staff nurses’ perception of the work environment in freestanding hemodialysis facilities. Nephrol Nurs J 2003;30(2):169-178
  14. Patrician PA, Pryor E, Fridman M et al. Needlestick injuries among nursing staff: association with shift-level staffing. Am J Infect Control 2011;39(6):477-482
  15. Department of Health, Education and Welfare (HEW). Renal Disease: Implementation of Coverage of Suppliers of End-Stage Services. Fed Regist 1976;41(108):22510-22512
  16. Wolfe WA. Adequacy of Dialysis Clinic Staffing and Quality of Care: A Review of Evidence and Areas of needed Research. Am J Kidney Dis 2011;58(2):166-176
  17. Hand RK, Steiber A & Burrows J. Renal dietitians lack of time and resources to follow the NKF KDOQI guidelines for frequency and method of diet assessment: results of a survey. J Ren Nutr 2013;23(6):445-449
  18. Hand RK & Burrows JD. Renal dietitians’ perceptions of roles and responsibilities in outpatient dialysis facilities. J Ren Nutr 2015;25(5):404-411
  19. Merighi JR, Brown T & Bruder K. Caseloads and salaries of nephrology social workers by state, ESRD Network snd National Kidney Foundation Region: Summary findings for 2007 and 2010. J Nephrol Soc Work 2010;34:9-51
  20. Harley KT, Streja E, Rhee CM, Molnar MZ, Kovesdy CP, Amin AN & Kalantar-Zadeh K. Nephrologist caseload and hemodialysis patient survival in an urban cohort. J Am Soc Nephrol 2013;24(10):1678-1687
  21. Wish JB & Meyer KB. ESRD Networks: Past, Present and Challenges in the Future. Clin J Am Soc Nephrol 2012;7:1907-1914
  22. Tangri N, Moorthi R, Tighiouhart H, Meter KB & Miskulin DC. Variation in fistula use across dialysis facilities: Is it explained by case mix? Clin J Am Soc Nephrol 2010;5(2):307-313
  23. Centers for Medicare and Medicaid Programs. Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule 42 CFR Parts 405, 410, 413 et al.73. Fed Regist 2008;20369. Retrived from gpo.gov/fdsys/pkg/FR-2008- 04-15/htm1/08-1102.htm
  24. Patzer RK, Plaantinga L, Krisher J & Pastan SO. Dialysis facility network factors associated with loe kidney transplantation rates among United States facilities. Kidney transplant access in the southeast: view from the bottom. Am J Transplant 2014;14:1562-1572
  25. Networks air sharp response to proposed restructuring. Nephrol News Iss 2010;24(3):12
  26. Garrick R, Kliger A & Stefanchik B. Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety. Clin J Am Soc Nephrol 2012;7(4):680-688
  27. Department of Health and Human Services (DHHS). Centers for Medicare and Medicaid Services (CMS) Program: Revisions to payment policies under the physician fee schedule for calendar year 2004. Final Rule with comment period. Fed Regist 2003;68:63195-63395
  28. Upchurch LC. Changes to the nephrology monthly capitation payment in the USA. Perit Dial Int 2004;24:521-525
  29. Mentari EK, DeOreo PB, O’Connor AS, Love TE, Ricanati ES & Sehgal AR. Changes in Medicare reimbursement and patient-nephrologist visits, quality of care and health-related quality of life. Am J Kidney Dis 2005;46(4):621-627
  30. Plantinga LC, Fink NE, Sadler JH et al. Frequency of patient-physician contact and patient outcomes in hemodialysis care. J Am Soc Nephrol 2004;15:210-218
  31. Plantinga LC, Jaar BG, Fink NE et al. Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets. Int J Qual Health Care 2005;17(2):115-121
  32. Slinin Y, Guo H et al. Association of provider-patient visit frequency and patient outcomes in hemodialysis. J Am Soc Nephrol 2012;23(9):1560-1567
  33. Erickson KF, Winkelmayer WC, Cherton GM & Bhattacharya J. Physician visits and 30-day hospital readmission in patients receiving hemodialysis. J Am Soc Nephrol 2014;25(9):2079-2087
  34. Erickson KF, Mell MW, Winkelmayer WC, Chertow GM & Bhattrcharya J Provider visit frequency and vascular access intervention in hemodialysis. Clin J Am Soc Nephrol 2015;10(2):269-277
  35. Smith CH, Armstrong D. Comparision of criteria derived by government and patients for evaluating practitioners services. BMJ 1989;299(6697):494-496
  36. Hjortdahl P. Continuity of care-going out of style? British J Gen Pract 2001; 699-700
  37. Petersen LA, Brennan TA, O’Neil AC, Cook EF & Lee TH. Does house staff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med  1994;121:866-872
  38. Bleyer A J. Prevention of sudden cardiac death in dialysis patients: a nephrologist’s perspective. Dial Transplant 2008;37(4):124-129
  39. Pace RC. Fluid management in patients on hemodialysis. Nephrol Nurs J 2007;34(5):557-559
  40. Fulop TM, Ulysal A, Lengvarsky Z, Szarvas T, Ballard K & Dossabhoy NR. Regional differences in nonadherence to dialysis among southern dialysis patients: a comparative cross-sectional study. Am J Med Sci 2010;339(6):516-518
  41. Himmelfarb J, Pereira BJG, Wesson DF, Smedberg PC & Henrich WL. Payment for Quality in End-Stage Renal Disease. J Am Soc Nephrol 2004;15: 3263-3269.
  42. Mehrotra R, Shaffer RN & Molitoris BA. Implications of a nephrology workforce shortage for dialysis patient care. Semin Dial 2011;24(3):275-277
  43. Erickson KF, Tan KB, Winkelmayer WC, Chertow GM & Bhattacharya J. Variation in nephrologist visits to patients in hemodialysis across dialysis facilities and geographic locations. Clin J Am Soc Nephrol 2013;8:1-8
  44. Ellingson LL. The poetics of professionalism among dialysis technicians. Health Commun 2011;26(1):1-12
  45. Association for Professions in Infection Control. Guide to the Elimination of Infections in Hemodialysis. Retrived from apic.org.
  46. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infection among hemodialysis patients. MMWR 2001;50(RR-5):1-43
  47. Kramer A, Schwebke I & Kampf C. How long do nosocomial pathogens persist on inanimate surfaces? BMC Infect Dis 2006;6(1):130
  48. Otter JA, Yezli S & French GL. The role played by contaminated surfaces in the transmission of nosocmial pathogens. Infect Control Hosp Epidemiol 2011;32(7):687-699
  49. Nguyen DB, Gutowski J, Ghiselli M et al. A large outbreak of hepatitis C virus infections in a hemodialysis clinic. Infect Control Hosp Epidemol 2016;37(2):125-133
  50. Morgan DJ, Rogawski E, Thom JA et al. Transfer of multidrug-resistant bacteria to healthcare workers gloves and gowns after patient contact increases with environmental contamination. Crit Care Med 2012;40(4):1045-1051
  51. Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med 2004;30:62-67
  52. Momoz O, Pieroni L. Lawrence C et al. Prospective, randomized trail of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Crit Care Med 1996;24:1818-1823
  53. Centers for Disease Control. Hemodialysis central venous catheter scrub-the-hub-protocol. Retrived from cdc.gov/dialysis/PDFs/collaborative./
  54. National Kidney Foundation.Vascular Access 2006 Work Group. Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 2006;48(Suppl 1):S176-S247
  55. Chenoweth CE, Hines SC, Hall KK et al. Variation in infection prevention practices in dialysis facilities: Results from the National Opportunity to Improve Infection Control in ESRD (End-Stage Renal Disease) Project. Infect Control Hosp Epidemiol 2015;36(7):802-806
  56. Shimokura G, Weber DJ, Miller WC, Wurtzel H & Alter MJ. Factors associated with personal protection equipment use and hand hygiene among hemodialysis staff. Am J Infect Control 2006;34:100-107
  57. Shimokura G, Chai F, Weber DJ et al. Patient care practices associated with an increased prevalence of hepatitis C virus infection among chronic hemodialysis patients. Infect Control Hosp Epidemiol 2011;32:415-424
  58. Eisenstein I, Tarabeih M, Magen D et al. Low infection rates and prolonged survival times of hemodialysis catheters in infants and children. Clin J Am Soc Nephrol 2011;6(4):793-798
  59. Patel Pr, Yi SH, Booth S et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013;62(2):322-330
  60. Hill KE, Barbara J, Thorburnt L & Torpey K. The long-term use of a tunneled central venous catheter for haemodialysis. Ren Soc Aus J 2013;9(3):126-128
  61. Pronovost PJ, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006;355(26):2725-2732
  62. Cimiotti JP, Haas J, Saiman L & Larson EL Impact of staffing on bloodstream infections in the neonatal intensive care unit. Arch Pediatr Adolesc Med 2006;160(8):832-836
  63. Berenholtz SM, Pronovost PJ, Lipsett PA et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014-2020
  64. Umscheid CA, Mitchell MD, Doshi JA et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32(2):101-114
  65. Leavey SF, Strawderman RL, Jones CA, Port FK, & Held PJ. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998;31(6):997-1006
  66. Stenvinkel P, Heimburger O, Lindhelm B, Kaysen GA, Bergstrom J. Are there two types of malnutrition in chronic renal failure? Evidence for relationship between malnutrition, inflammation, and atherosclerosis (Mia Syndrome). Nephrol Dial Transplant 2000;15:953-960
  67. Szeto CC, Chow KM. Metabolic acidosis and malnutrition in dialysis patients. Semin Dial 2004;17:371-376
  68. Bergstrom J. Why are dialysis patients malnourished? Am J Kidney Dis 1995;26:229-241
  69. Kalantar-Zadeh K, Block G, McAllister CJ, Humphreys MH & Kopple JD. Appetite and inflammation, nutrition and clinical outcome in hemodialysis patients. Am J Clin Nutr 2004;80(2):299-307
  70. Maruyama Y, Lindholm B & Stenvinkel P. Inflammation and oxidation stress in ESRD-the role of myeloperoxidale. J Nephrol 2004(Suppl 8):S72-S76
  71. Kuhlmann MK & Levin NW. Interaction between nutrition and inflammation in hemodialysis patients. Contrib Nephrol 2005;149:200-207
  72. Alpele L & Baily JL. Nutrition counseling impacts serum albumin levels. J Ren Nutr 2004;14(3):143-148
  73. Wingard RL, Pupim LB, Krishnan M, Shintan A, Ikizler TA & Hakim RM. Early intervention improves mortality and hospitalization rates in incident hemodialysis patients. Clin J Am Soc Nephrol 2007;2:1170-1175
  74. Lacson E Jr., Ikizler A, Lazarus M, Teng M & Hakim RM. Potential impact of nutritional intervention in End-Stage Renal Disease hospitalization, death and treatment costs. J Ren Nutr 2007;17(6):363-371
  75. Kelly MP, Gettel S, Meltzer GC et al. Nutrition and demographic data related to the hospitalization of hemodialysis patients. CRN Q. 1987;2:16
  76. Daines MM, Wilkins K, Cheney C. Comparison of 1983 and 1992 renal dietitian staffing levels with patient morbidity and mortality. J Ren Nutr 1996;6:94-102
  77. Karalis M. Renal Nutrition Update: How to make the new Conditions for Coverage work in your dialysis clinic[on line]. Nephr Online. 2009;4. Retrived from www.nephronline.com/articleprint.asp?print=18indexxId=152
  78. Ikizler TA, Franch HA, Kalandar-Zadeh K, Ter Wee OM, Wanner C. Time to revisir the role of renal dietitians in the dialysis unit. J Ren Nutr 2014;24:58-60
  79. Hakim RM, Collins AJ. Reducing avoidable rehospitalization in ESRD: a shared accountability J Am Soc Nephrol 2014;25(9):1891-1893
  80. Plantinga LC & Jaat BG. Preventing repeat hospitalizations in dialysis patients: a call for action. Kidney Int 2009;76:249-251
  81. Castner D. Management of patients on hemodialysis before, during and after hospitalization: challenges and suggestions for improvements. Nephrol Nurs J 2011;38(4):319-330
  82. Kelly MP, Knight MA, Torres M, Migliore V & SDC-RD Scientific Support. The nutritional cost of hospitalization and time needed to achieve nutritional resiliency for hospital patients. J Ren Nutr 1994;4(4):183-191
  83. Fouque D & Guebre-Egziabher F. An update on nutrition in chronic kidney disease Int Urol Nephrol 2007;39:239=246
  84. Obialo C, Zager PG, Mayers OB & Hunt WC. Relationships of clinic size, geographic region and race/ethnicity to the frequency of missed/shortened dialysis treatments. J Nephrol 2014;27:425-430
  85. Cabness J, Miller C, Martina K. Mastering hemodialysis to reverse patterns of missed and shortened treatments. J Nephrol Soc Work 2007;27:45-51
  86. Watnick S, Kirwin P, Mahnensmith R, & Concato The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 2003;41(1):105-110
  87. Hedayati SS, Minhajuddin AT, Afshar M, Toto RD, Trivedi MH & Rush AJ. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization or death. JAMA 2010;303(19):1946-1953
  88. Johnstone S. Depression management for hemodialysis patients: Using DIPPS data to further guide nephrology social work intervention. J Nephrol Soc Work 2007;26:18-31
  89. Shotan A, Dacca S, Shochat M, Kazatsker M, Blondheim DS & Meisel S. Fluid overload contributing to heart failure. Nephrol Dial Transplant 2005;20(Suppl 17): vil24-vil27
  90. Johnstone SL, Li NC & Demaline J. The expansion of a social work behavioral health program: Helping dialysis patients manage fluid craving. Nephrol News Issues 2015;29(1):30-35
  91. White RB. Adherence to the dialysis prescription: partnering with patients for improved outcomes.Nephrol Nurs J 2004;31(4):432-435
  92. American Nephrology Nurses’ Association (ANNA). Position Statement; Nuse Staffing Model. Retrived from www.annanurse.org/download/
    reference/health/position/nursestaffingmodel.pdf
  93. Arenas MD, Sanchez-Paya J, Barrit G et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant 2005;20(6):1164-1171
  94. Pitt D, Mourouga P, Pernger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:100-107
  95. National Kidney Foundation KDOQI Clinical practice guidelines and clinical practice recommendations for 2006 update: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006;48:S1-S322
  96. AV Fistula First Breakthrough Coalition. National Vascular Access Improvement Initiative (NVAII). Retrived from fistulafirst.org
  97. Centers for Medicare & Medicaid Services CMS, HHS.Medicare Program; End-Stage Renal Disease Prospective System, and Quality Incentive Program. Final Rule. Fed Regist 2015;80(215):68967-9077
  98. NKF KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Am J Kidney Dis 2000;35(Suppl 2):S1-S140

99 Burrowes JD, Russell GB, Rocco MV. Multiple factors affect renal dietitians’ use the NKF-K