Update April 26, 2017: The Judiciary Committee for the California State Senate has approved Senate bill 349. The bill will now advance to the Senate Appropriations Committee for a hearing in May. 
“It’s like a factory. We put them on and take them off.”

That complaint has been heard from nurses and patient care technicians before in the dialysis field. There is little time to spend with the patient sitting 3 ½ to four hours in the dialysis chair. Turnaround between shifts is tight.

Christine Lubos, 49, a nurse who works in the Los Angeles area for a major dialysis provider, says things have gotten worse since she started in dialysis in 1993. She has seen ratios of one nurse to every 20 patients in a clinic.

“I want to stay in this field until I retire, but things will have to change,” she said.

That’s why she is supporting California state Senate bill 349, the Dialysis Patient Safety Act, introduced by state Senator Ricardo Lara on Feb. 14 and backed by the United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP), to establish staff-to-patient ratios in dialysis clinics.

Read also: Is it possible to reduce hospital admissions through evidence-based clinic staffing? 

The legislation also requires annual licensure for dialysis clinics (versus the current 6-year period) and would set a minimum transition time of 45 minutes between patients at a treatment station.

Staffing ratios for registered nurses would be 1 for every 8 patients; 1:3 for patient care technicians; and 1:75 for social workers.

Hearings are expected to begin in the state Senate in late March or early April, with a floor vote possible by May, according to UNAC/UHCP officials. After that, the bill would go to the state Assembly for a vote.

There are currently more than 50,000 dialysis patients, and almost 500 licensed outpatient dialysis clinics in California, according to state officials.

In the bill, Lara and the union said, “There is broad consensus among medical professionals, academics, and other experts that higher ratios of direct caregiving staff to patients at outpatient dialysis clinics improve patient outcomes, including by reducing the rate at which patients suffer infections or must be hospitalized.

“Current staffing levels in outpatient dialysis clinics in California are inadequate to protect patient health and worker safety, and therefore are presently causing harm to dialysis patients, including unnecessary and avoidable deaths, hospitalizations, infections, and medication errors,” the bill reads. “Other states mandate minimum direct care staffing requirements in order to enhance patient safety and health at outpatient dialysis clinics.”

Opposition to the bill

The California Dialysis Council, an organization of dialysis providers in the state, said it opposes the bill because it would restrict facility flexibility, reduce available treatment shifts, lead to centers closing, and limit access to certain modalities like nocturnal dialysis.

Lubos acknowledges that her provider has recently added nurses to ease the staffing crunch. But she thinks the ratio and the union can help improve her economic status in a state where cost of living increases rarely match what dialysis companies are willing to pay staff.

She says many staff members work two jobs to make ends meet in the Silicon Valley/Los Angeles area. “A union would help me with benefits and a better salary,” said Lubos, who received a 3% pay increase last year.

What other states require

There are only eight states in the U.S. that have staffing ratios for dialysis clinics. Texas was the first. Other states have followed, and include requirements for yearly licensure and/or estimating acuity levels of patients to help determine ratios (see below).  Jeff Rogers, a communications specialist for the United Nurses of California, says a group of dialysis caregivers from the Los Angeles area approached the union “because they felt that patient safety was at risk due to a lack of staffing ratios and high turnover in the industry.

States with staffing ratios or similar requirements

There are only 8 states in the U.S. that have staffing ratios; some include requirements for yearly licensure and/or estimating acuity levels of patients to help determine ratios.

“Caregivers believe the ratios are needed to reduce medical errors, dialysate errors and patient injury,” said Rogers. “The specific ratios we put into the bill are designed to be on par with other states and are based on what dialysis workers consider to be safe and reasonable. They are common sense ratios to protect patients and caregivers.”

Justifying ratios in dialysis clinics

There doesn’t appear to be an established approach to determining a staff to patient ratio for dialysis clinics that would lead to improved outcomes.

But in the article, “Relationships between registered nurse staffing, process of nursing care, and nurse-reported patient outcomes in chronic hemodialysis units,” by Thomas-Hawkins et al., the authors said, “Study findings revealed that high patient-to-RN ratios and increased numbers of tasks left undone by RNs were associated with an increased likelihood of the frequent occurrence of dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints in hemodialysis units.”

Rogers cited other studies that link poor RN staffing to greater risk of hepatitis C exposure among dialysis patients and increased medication errors in both hemodialysis and non-hemodialysis settings. Research shows that places stress on the staff, and that can lead to nurse turnover and burnout.

UNAC/UHCP represents more than 28,000 RNs and other health care professionals, including social workers; optometrists; pharmacists; physical, occupational and speech therapists; case managers; nurse midwives; clinical lab scientists; physician assistants and nurse practitioners, Rogers said.

The union helped win passage of a safe staffing law, which mandates nurse-to-patient ratios in California in the acute hospital setting.

Meeting dialysis clinic staffing requirements

Some dialysis providers are concerned that they could not treat patients if they ended up short on staff.  Likewise, there are questions about whether there are enough nurses to fill the new positions if the staffing ratio gets tougher.

“We have experience with the implementation of California’s safe staffing law for hospitals,” said Rogers. “Employers adjust by having nurses on-call and using per diem nurses.

“Our bill, by giving dialysis nurses and patients the same protections enjoyed by hospital nurses and patients—safe ratios—will help to improve working conditions for caregivers and quality of care for patients. We believe it will create a better employment situation in the industry by making it more attractive to nurses,” he said.