Título

HIGH-FREQUENCY, DISTINCTIVE STAFFING & OUTCOMES: IMPROVING THE DIALYSIS EXPERIENCE

Introdução

Frequent dialysis has consistently improved patient outcomes. Professional staffing of dialysis affects patient care quality and safety. In Brazil there is a requirement for a physician to be present in each dialysis unit, whereas nursing staff is predominantly by technicians. We have set up a 24-stations in-center short daily hemodialysis (SDHD) program whose all day long care is provided by two on-site nephrologists, certified nurses, renal dietitians and psycologists with fulltime dedication. This report outlines the impact of 10 years of combining daily hemodialysis with selected clinical staffing on patient outcomes.

Material e Método

Nephrologist schedule, patient to staff ratios, adverse events rates (hypotension, medication errors, patient falls), vascular access profile (type, infection rates), patient compliance (missed treatment rate), hospitalization (admissions and days per patient-year [pp-y]), cumulative survival and kidney transplantation rates were assessed in 200 consecutive unselected private-insured patients (122M/78F; mean age 58.0±18.5 yrs, 18-96) receiving in-center SDHD (6-7 times/wk; lasting 115.4±11.2 min, 90-180; ultrapure dialysate and single-use high-flux dialyzer).

Resultados

From June 2009 to May 2019 four out 5 nephrologists shared equitable schedule 7 days/week, each one prescribing up to 24 patients in 2 parallel and 2 sequential 6-hour workday. In 2009 we stopped hiring technicians and moved to 100% nurses staffing, reaching now 21 fulltime certified nurses (up to 3:1 ratio). Additionaly, 2 dietitians and 2 psycologists assist 80 prevalent patients (40:1 ratios). In 2018 symptomatic hypotension occurred in 3% of 20,035 dialysis treatments, medication errors in 17 occasions (none critical) and no patients fell in the unit. Over the 10-year study period, arteriovenous fistula was used in 53% and tunneled catheter in 47% of patients, with bacteremia rate of 0.27 and 0.50 events per 1,000 patient- and catheter-days, respectively. Missed treatment rate was 1.49% or 4.6 days pp-y. Hospitalization rate was 0.4 admissions pp-y or 2.9 days pp-y. Five-year survival rate was 64% and average kidney transplantation rate was 7.5%. Duplicating nephrologist presence and replacing all technicians with certified nurses doubled labor costs, largely offset by higher productivity (five 2-hour shifts a day) and longer dialysis vintage.

Discussão e Conclusões

This intensive dialysis modality delivered by a first-rate clinical staffing represents an unparalleled approach toward an optimal treatment.

Palavras Chave

Daily Hemodialysis, Economic Analysis, Patient Experience