It’s Time to Stop Dialysis Staffing by the Numbers

This blog post was made by Gale Schulke, RN, CDN on June 8th, 2017.
It’s Time to Stop Dialysis Staffing by the Numbers

By Gale Golden Schulke

I have been thinking a lot about staffing ratios since the staffing bill hit the California legislature. (Although I am not the manager for an in-center program, I am still concerned about ratios in the dialysis clinics, including home clinics.) In the process I also gave a lot of thought to our social workers. I agree with the legislation that the ratios need to be addressed, but not in the way they are trying to address them.

In my home clinics, I have about 100 patients. I have had the nurses rate them on acuity 1-3 (1 being few or no issues and 3 being most acute). The idea originally was to distribute the patient load a little more evenly. I have found, however, that the acuity rating does more. It gives me a heads up as to who may be at the higher risk for dropping out of the program and who needs the most support, especially starting out in a home modality. If a nurse is given 10 patients rated at 3, his or her ability to take care of the remaining patients diminishes—and, before you know it, you have even more 3’s. These are the patients we need to address at our IDT meeting. They are also the patients that I, as a manager, should be assisting with. Clinic managers need to do more than sit behind a desk filling out paperwork. We need to be actively involved with patient care to understand the needs of our staff and of our patients. (This is also an argument for RNs as managers).

Acuity staffing also works very well to address in-center issues. For RNs, there could be a pod of higher acuity patients, or if the entire clinic is in an area where the acuity level is high, it makes sense to staff RNs at 1:8, and CCHTs at 1:3. It does not make sense in an area or at a clinic with an overall lower acuity to staff that way. I have always felt 1:13 is too intense anywhere. However, 1:11 or 1:10 allows the nurse to pre-assess fluidly. (With the overall lowering of the catheter rate in dialysis clinics, catheters are becoming less of an issue, and acuity is not as high as it once was with 10 catheters on a shift of 24 patients).

The acuity rating corresponds very closely with the amount of time the social worker is spending with a patient, as well. When dealing with the caseload of a social worker, numbers do not work. What matters is how “in need” are those patients. A ratio of 1:120 patients can look very different from clinic to clinic. In one clinic, that could be a very unrealistic patient load. If the SW is dealing with a large number of poor people requiring a lot of assistance with services, their ratio should be much lower than the ratio of a social worker in another clinic where the acuity is much lower with a relatively high number of self sufficient people. The availability of the Social Worker should be taken into consideration as well. If a clinic with the high acuity ratio only has a social worker available 3 days a week because of the numbers, and s/he is being asked to pick up a load somewhere else, that does not make any sense. That social worker may well need to be available at that high acuity clinic full-time, even if he/she has only 80 - 90 patients.

It is time for us to stop looking at our patients as merely numbers for staffing. We need to move into a model for registered nurses, certified hemodialysis technicians, social workers, and dietitians that looks more at the realistic needs of the patients. People are not numbers on a piece of paper. They are human beings who are looking to us to supply high quality care. We cannot do that as long as we are looking at a strictly numerical system of staffing our clinics. I really encourage the dialysis companies to develop staffing tools that are based upon acuity and need, not merely the number of people.

Comments

  • John agar

    Jun 10, 3:00 AM

    Excellent summary, Gayle.

    In Australia, with rare exceptions which relate to historical anomalies, all facility dialysis is delivered by Grade 1, fully certified and trained nurses, not technicians or other less trained staff. Many dialysis nurses - indeed now almost all - have higher degree training in renal nursing and have renal certification.

    I answered a question on this back in about 2009 at the old message boards - and I don't think things have altered greatly since. I can check for you when I return to my office in early July after the next three weeks during which I will be on leave.

    The URL to this discussion at the HDC message boards is:

    http://forums.homedialysis.org/archive/index.php/t-3484.html

    I hope that link works for you.

    John

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  • Cathy

    Jun 9, 8:09 PM

    Great ideas I just moved a 28 station unit to the Pod concept with appointment times. 15-30 minutes between patients. 45 minutes between shifts. Pct/LPN 4:1 with RN 9:1 in addition ,2 Nurse managers one on unit. One in office.
    I like your acuity idea. Will share it with the nurses next week. Thanks

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  • Beverly Stetten

    Jun 9, 7:39 PM

    It is so about time. My husband is now in home dialysis. When he was in center , he was so sick.

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  • Gracie Castro

    Jun 9, 1:04 PM

    I totally agree! I have been on dislysis for over 21 yrs. two of them on peritoneal. Since I first started in 1997 the quality healthcare in dialysis clinics have totally gone down not better. The dietitian and Social worker had more time to spend with patients. Even Clinic Managers had more time to connect wit patients. Staff have been expected to connect more patients and rush patients to be connected. In the last several months in our clinic there has been a wider time space to connect patients. It's better for staff and patients. I am now seeing many of the stafff being physically injured on the job with hurt shoulders, hands and backs. Several of the staff in my clinic are out having surgeries, recovering and missing work to care for their injuries or still working injured while taking care of their own healthcare. I believe this is happening nationally. Is this their rewards after years of dedication to their work? The patients have to deal with stressed out staff. We definitely need a change in the dialysis clinics. I'm in California and a dialysis clinic ratio Bill has passed the Senate and now it will go to the Assembly. If this passes I'm hoping it will change for the staff and patients healthcare. CKF Chronic Kidney Failure is a challenging and complex demanding disease. Whatever positive improvements are made it can help the well being of the patients to live a better quality of life. Thank you Gale for this article.

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  • Lynda Kauffroth

    Jun 9, 11:43 AM

    I heartily agree that acuity needs to be considered when staffing. That's a daily concern especially in the Acute setting. Now, any ideas as how to get that across to the managers who make the decisions besides giving examples of the actual time it takes to care for more than two at a time? The degree of throughness, assessment, critical thinking skills, foresight, intervention. They are listening but not hearing. Dodging " bullets" QD is time consuming and the recipe for poor staff morale.

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