Looking toward the next 30 years of treating kidney disease


Editor’s note: Nephrology News & Issues is celebrating 30 years of publishing this year. In this series, we are looking to the future. How will treating kidney disease change in the next three decades?

For the first 40 years of the End-Stage Renal Disease (ESRD) Program, the subject of dialysis clinic staffing has been what can be characterized as the “elephant-in-the room.” Everyone seems to be aware of how important sufficient staffing is to patient safety and achieving optimal outcomes, but no one brings up the subject. This has persisted despite staffing being historically recognized as a structural measure of quality in all medical care settings.

The prime illustration of this is the overwhelming evidence linking inadequate staffing in acute care hospitals with increased risks of various adverse patient outcomes, including infections1 and mortality.2 In an article in the June 2016 issue of this publication entitled, “Is it possible to reduce hospital admissions through evidence-based clinic staffing?” I raised questions about whether evidence-based clinic staffing could help reduce the extraordinarily high rate of hospital admissions among in-center patients.3 Quite obviously, for evidence-based staffing to have a chance of becoming a reality, there first needs to be a more open discussion of the subject and especially its ramifications for patients. The following are suggested actions and/or new developments that could help bring staffing more to the forefront and lead to improvements in the next 30 years.

Potential initiatives by the Forum of ESRD Networks

The Forum’s mission is to support and advocate on behalf of the ESRD Networks in order to improve the quality of care delivered to patients.4 As is well known, the Networks routinely uncover unexplained facility-to-facility variations in patient outcomes, including items like infections and mortality. While these variations were first thought to be explained by individual-level patient differences or case-mix factors, the consensus now is that they are due primarily to “center-effects”5-7 from dialysis facilities themselves.

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Notwithstanding that the Centers for Medicare & Medicaid Services (CMS) has not sanctioned a focus on staffing as a means of facilitating improvements in outcomes, the Networks could nonetheless begin to collect national data on the associations found between staffing patterns and various outcomes. A major question of concern is, of course, whether infection rates vary directly with the ratios of patient care technicians (PCT) and nurses to patient. Data collected on this and other critical questions would be extremely valuable if the Forum of ESRD Networks ever decides to advocate with CMS for staffing to be established as a quality of care issue.

Hospital admissions costs

Hospital costs from in-center dialysis patient hospital admissions currently consume 40% of the ESRD budget8 and expenditures are only likely to increase in the future. It is not known to what extent the inability of PCTs to consistently and rigorously adhere to all infection control guidelines is contributing to these admissions. If the findings from multiple studies 9-11 can be generalized to a large number of facilities, the glaring lapses in adherence to guidelines would seem to clearly implicate inadequate staffing as a major culprit. Briefly noting the findings from the most recent investigations, 64% of PCTs failed to scrub catheter hubs with antiseptic following disconnecting blood lines, 85% failed to use antimicrobial ointment in dressing changes; 74% failed to vacate treatment chairs prior to disinfecting them,12 and 46% failed to wash their hands and change gloves in going from one patient station to the next.13 The unending incidence of potentially preventable hospital admissions might eventually compel CMS to establish enforceable upper limits on patient-staff ratios.

Actions by patients themselves

There has been an increasing emphasis on patients as partners in health care safety and of their interest in asking questions and raising concerns.14,15 The “Speak Up” initiative by the Joint Commission presents several brochures that urge patients to pay more attention to the care they receive.16 The latest effort for ESRD patients specifically is led by the Centers for Disease Control and Prevention and called “Making Dialysis Safer for Patients” coalition.17 It is a partnership of health care-related organizations and patient advocacy groups whose primary goal is the prevention of bloodstream infections.

Relevant to the potential benefits from dialysis patients raising more concerns about safety is research showing that, when patients actually ask medical personnel if they have done hand hygiene, it can increase compliance with hand washing by 50%.18 Finally and regarding concerns patients may need to raise about clinic staffing itself, Medicare’s Dialysis Facility Compare website19 has suggested the following questions:

  • How many nurses work on each shift?
  • How many patients does each nurse take care of?
  • How many PCTs work with each nurse?
  • How many patients dose each PCT care for?
  • When is a dietitian in the clinic?
  • How many patients does the dietitian have responsibility for?
  • Does the dietitian see patients at other clinics?
  • When is a social worker at the clinic?
  • How many patients does the social worker have responsibility for?
  • Does the social worker see patients at other clinics?

Dialysis care over the next three decades can produce better outcomes with patient-staff ratios that allow for routine use of universal precautions and patient input into their treatment regimen.


  1. 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
  2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospitalnurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA 2002;288(16):1987-1993
  3. Wolfe WA. Is it possible to reduce hospital admissions through evidence-based clinic staffing? Nephrol News Iss 2016;30(6):26-33
  4. Forum of ESRD Networks. Mission. Retrived from http://www.esrdnetworks.org.
  5. Fink JC, Zhan M, Blahut SA, Soucie M. Measuring the efficacy of a quality improvement program in dialysis adequacy with changes in center effect. J Am Soc Nephrol 2002;13(9):2338-2344
  6. Fink JC, Zhan M, Walker LD, Mullins CD. Center effect in anemia management of dialysis patients. J Am Soc Nephrol 2007;18(2):646-653
  7. Fink JC, Blahut SA, Briglia AE, Gardner JF, Light PD. Effects of center-versus patient-specific factors on variations in dialysis adequacy. J Am Soc Nephrol 2001;12(1):164-169