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When Needles Dislodge, Dialysis Can Turn Deadly

Medicare rules do not require dialysis clinics to tell outside authorities about lapses in patient safety, even if they result in injuries or deaths. One model: The Department of Veterans Affairs, which has adopted mandatory reporting of accidents and near-misses to save lives.

Cathleen Sharkey holds a frame of photographs of her mother, Barbara Scott, whose bloodline became disconnected during a dialysis treatment at Dutchess Dialysis Center. Scott never fully recovered and died shortly after of heart failure. (Dan Nguyen/ProPublica)

Barbara Scott relied on dialysis to do what her damaged kidneys could not. Three times a week, a machine pumped her blood out of her body, pushed it through a specialized filter, then returned it cleansed of waste. The bright crimson circuit kept the 73-year-old retired bookkeeper alive.

Until it nearly killed her.

Partway through Scott's treatment on Dec. 28, 2005, the tube feeding blood back into her became dislodged. A temporary employee at her storefront clinic in Poughkeepsie, N.Y., hadn't taped the tube in place properly, and the facility didn't follow safety rules requiring the connection to remain visible, regulators later determined.

A family photo of Barbara Scott. Scott's bloodline became disconnected during one of her dialysis treatments. Scott never fully recovered and died soon after. (Photo courtesy of Cathleen Sharkey)

A family photo of Barbara Scott. Scott's bloodline became disconnected during one of her dialysis treatments. Scott never fully recovered and died soon after. (Photo courtesy of Cathleen Sharkey)

As Scott rested under a blanket, more than a quarter of her blood pooled beneath her and spilled onto the floor instead of flowing back into her system. She barely managed to call for help before losing consciousness.

Dialysis patients die or are hospitalized every year as a result of catastrophic hemorrhages during treatment, a ProPublica review of regulatory and court records has found. In dozens of cases in which patients suffered such harm, government inspection records show, regulators later cited clinics for failing to adhere to minimum standards of care.

These incidents are among the most gruesome -- and most preventable -- lapses in a dialysis system that has some of the highest mortality and hospitalization rates in the industrialized world. Each year, about 1 in 5 patients die, almost twice the mortality rate of countries with the best outcomes.

No one knows for sure how often line separations or dislodgements occur during dialysis. They are relatively rare, but 5 percent of patients who responded to a 2007 safety survey by the Renal Physicians Association said they had a needle dislodge mid-treatment within the previous three months. Another review, based on incidents in a Pittsburgh hospital system, suggested that each year hundreds of patients may fall victim to more serious bleeding episodes.

The absence of more precise data points to a broader problem, patient safety advocates say. Though the government pays for most dialysis through Medicare, federal regulations do not compel clinics to report treatment-related errors, injuries or deaths, whether from bleeds or other mishaps. That's despite an overhaul of dialysis regulations in 2008, which, among other things, mandated that clinics have programs to improve patient safety.

"People don't want it out there -- it's liability, it's exposure -- but we have to have transparency to learn from one another's mistakes," said Tricia West, a nurse and former dialysis clinic owner who also served as president of the California Association for Healthcare Quality. "Things can and do happen, but it shouldn't be the same things over and over."

Officials at the Centers for Medicare and Medicaid Services said the agency's new administrator, Dr. Donald Berwick, a longtime patient-safety advocate, may bring a more aggressive approach to this issue.

"We are being challenged to do everything we can ... to address patient safety and to reduce errors in [all] settings of care," said Dr. Barry Straube, CMS' chief medical officer. "The dialysis world is an area in which we'd like to see that happen more."

Barbara Scott never really recovered. She was rushed to the hospital in shock and stayed for more than three weeks. Just 5 feet tall and always petite, she dropped below 100 pounds. Her face grew gaunt, her skin papery. When she finally went home, she was so frail she couldn't walk her dog or work in her garden.

The Dutchess Dialysis Center in Poughkeepsie, N.Y., where patient Barbara Scott received her dialysis treatments. (Dan Nguyen/ProPublica)

The Dutchess Dialysis Center in Poughkeepsie, N.Y., where patient Barbara Scott received her dialysis treatments. (Dan Nguyen/ProPublica)

"She'd sit and cry for no reason," said her daughter, Cathleen Sharkey.

Scott died soon after of heart failure. On the final day of her life, she hired an attorney to sue her clinic, Dutchess Dialysis Center, for negligence.

A spokeswoman for Fresenius Medical Care North America, which owns Dutchess Dialysis through an affiliate, said the company could not comment on the matter because of patient privacy rules. The company agreed to a $300,000 settlement in 2008, Sharkey said.

"This didn't have to happen," Sharkey said. "My mother was a woman to be reckoned with. She was dealing with dialysis the way she dealt with everything. She was organized, she kept track of her test results, she ate and drank exactly what they told her. She would still be here today."

Discovered Too Late, a Deadly Drip

Close to 400,000 Americans receive chronic dialysis, a number that has almost tripled in the last 20 years as obesity and diabetes have reached epidemic proportions. More than 90 percent of them receive what's called in-center hemodialysis, thrice-weekly treatments at outpatient facilities.

In a typical treatment, a technician attaches the patient to the machine by inserting two needles into the patient's access point. Each needle is attached to tubing. One tube carries the patient's blood into a filter called a dialyzer. Dialysate solution flows in the opposite direction, removing toxins and restoring the blood's chemical balance. The other tube returns the clean blood. Sessions average three to four hours in length.

Advances in technology have made dialysis simpler and safer, but it's hardly foolproof.

A patient in Petaluma, Calif., died soon after an incident in which a contract nurse -- given just one day of orientation -- reversed her bloodlines without using a clip to hold the tubes in place, and one became disconnected, inspection records show. At a clinic in San Diego, a staffer mistakenly connected a bloodline to a machine drain and not the needle returning blood to her body, regulators found. The patient, a 61-year-old woman, lost about a pint of blood and had to be hospitalized for a transfusion.

In their current generation, dialysis machines cycle patients' blood at a rate of 300 milliliters to 500 milliliters per minute, making dislodgements more dangerous than in earlier eras when treatments were done more slowly.

"It’s like turning up the pressure on your garden hose," said Jane Hurst, a registered nurse who consults on dialysis-related medical malpractice lawsuits for both plaintiffs and defendants. "The time it takes to lose a significant amount of blood is less" – in some cases, fewer than 10 minutes.

Seemingly routine treatments can suddenly become anything but. Larry Grammer's vital signs were stable a half-hour into his May 1, 2008, dialysis treatment at a clinic in Jacksonville, Ill. When his machine's alarm sounded 21 minutes later, however, the 68-year-old retiree was already unresponsive and gasping for air, a government complaint investigation shows.

Workers discovered that the tubing to the catheter in his chest had disconnected. "A large pool of blood" was found under his chair, the report said. Grammer was pronounced dead less than two hours after the incident began. The clinic's operator, DaVita Inc., declined to comment on the case, citing patient privacy rules. The company reached a confidential settlement with Grammer's widow.

Government regulations require clinic workers to keep patients in view continuously during treatments, and facilities can be cited for not keeping access points for bloodlines and needles visible at all times. On this, staffers can face resistance from patients themselves, who, despite the risks, often prefer to cover up for warmth or privacy.

Though dialysis machines are designed to sound an alarm or stop the flow of blood if they detect a significant drop in pressure, they can miss smaller fluctuations. Staffers, beleaguered by false alarms, sometimes change settings to be less sensitive or reset machines after an alarm without checking patients' lines.

ProPublica examined inspection records for more than 1,500 clinics in California, New York, North Carolina, Ohio, Pennsylvania and Texas from 2002 to 2009. We found at least one fatality resulting from needle dislodgements in each state during this period, plus dozens of additional cases in which patients required hospitalization, blood transfusions or other emergency interventions.

In several instances in which patients suffered fatal or near-fatal hemorrhages, inspectors concluded that clinics had too few staffers on duty to properly monitor patients. "I see it in almost every case I work on," Hurst said. She also often finds staffers have been working 12 or even 16 hours at a stretch. "That's when mishaps occur."

Employees at a Cleveland clinic in 2001 didn't notice Kathryn Stevens' line had become disconnected until she fell from her chair, unconscious from loss of blood, according to published accounts of a lawsuit filed by Stevens' survivors. Left with irreversible brain damage, Stevens lived another five months, unable to speak or eat on her own, before dying of an infection.

"She was a vegetable," said Ivory Stevens, her son. "Seeing her like that was two heartbreaks at one time. I almost wished they hadn't kept her alive." In 2002, the Stevens family obtained a $4.75 million settlement from her dialysis and nursing facilities.

Help also came too late for Shelton Crosland, whose bloodline disconnected during a September 2007 treatment at a dialysis center in Queens, N.Y.

According to an investigation conducted by state inspectors the following month, the technician tending to the 47-year-old construction site manager was also monitoring two other patients, collecting data from their dialysis machines, and ending the treatment of a third patient. A nurse was unavailable to help him because she was covering for a colleague on a break.

By the time clinic workers discovered Crosland’s line separation, the attending nurse said she did not use the center’s defribrillator to try to revive him because there was “so much blood that she was afraid for the safety of the staff,” the investigation report said. Crosland was dead on arrival at the emergency room.

Regulators cited his facility for not ensuring it had an adequate number of trained staff members on duty to provide safe care. Fresenius Medical Care, which operates Crosland's clinic, declined to comment on the case, again citing federal privacy laws. Crosland's widow has filed a lawsuit against the clinic; the case is ongoing.

Few States Require Reporting

Preventable lapses in care have received heightened attention since the Institute of Medicine's landmark 1999 report, "To Err is Human," which said as many as 98,000 patients died each year in U.S. hospitals as a result of medical errors.

More than 25 states now require certain facilities – most often, hospitals, ambulatory surgical centers and birthing centers – to report some types of adverse events. Several states use the 28 “never” events (as in, they should never happen) identified by the National Quality Forum, a nonprofit that sets standards for health care.

So far, these changes have mostly bypassed dialysis. Only a handful of states, including Colorado, Georgia, New York and Tennessee, mandate that dialysis units report incidents resulting in unexpected patient deaths or injuries.

Under Medicare regulations, clinics are obliged to record such incidents internally and to analyze them for purposes of quality improvement. Many do so, but some do not: ProPublica's six-state inspection review turned up more than 100 instances in which clinics were cited for not documenting or investigating errors and adverse events.

Nurses and other clinic staffers acknowledged that bleeding incidents sometimes aren't reported, particularly if patients do not need to be transferred to a hospital.

Natasha Smith, a technician in Colorado Springs, said her current facility records such incidents properly. That wasn't so at another center where she worked for three years. "Techs didn't want to do them. It's saying they did something wrong," she said. "There were all kinds of problems that were never reported."

Unpublished government cause-of-death data confirms that treatment-related bleeds kill patients each year: From 2006 to 2008, facilities gave "hemorrhage from dialysis circuit" as the primary cause of death for 18 patients and as a secondary cause for six more.

For many patients, however, cause of death is uncertain. Of almost 240,000 deaths reported to Medicare during this period, almost 1 in 5 were attributed to "unknown" or "other" causes, with no further information provided. Almost 700 deaths were attributed primarily to "hemorrhages from vascular access," or, more rarely, "accidents related to treatment." In a handful of cases, facilities checked off one of these, as well as "hemorrhage from dialysis circuit," as causes for the same deaths.

Ultimately, the true toll of such incidents remains unknown.

"This is the sort of thing no one keeps statistics on. It's bothered me for years," said Dr. Stephen Sandroni, now a professor at Texas Tech University's Paul L. Foster School of Medicine in El Paso. "The government pays for dialysis, and it's very expensive. Yet the government hasn't pursued data collection in this area. If this is a preventable cause of death, why isn't someone researching it?"

Frustrated by the lack of systemwide data, Sandroni reviewed the frequency of catastrophic hemorrhages in the dialysis units he supervised when he was director of nephrology and hypertension at Allegheny General Hospital in Pittsburgh, which had about 300 patients. He found that they occurred at a rate of 1 per 126,718 treatments and that 1 in 3 was fatal.

Based on his research, Sandroni co-authored an abstract for the November 2008 Journal of the American Society of Nephrology suggesting that -- even assuming a far lower fatality rate -- needle dislodgements might be killing more than 40 patients a year and injuring more than 400. To his disappointment, the work drew little interest from regulators or other dialysis providers.

"People want the good news," he said. "These are pretty tragic deaths. Someone may have years in front of them and suddenly, boom, they're gone. If you have even a couple a year, they're preventable, and in fact, you may be having scores a year."

Preventive Steps at VA Clinics

When the Renal Physicians Association conducted its safety survey, members discussed trying to establish an independent registry where dialysis providers could report adverse events such as treatment-related hemorrhages, but they concluded it would face too many hurdles, said Dr. Alan Kliger, the group's former president.

The association launched a website, Keeping Kidney Patients Safe, that offers ideas for improving patient safety and urges doctors and providers to share best practices.

There is one segment of the health care system that has embraced reporting accidents and errors as a way to guide improvement: the U.S. Department of Veterans Affairs.

All VA facilities, including its 66 dialysis units, are required to report not only events in which patients suffer harm, but also near misses. Reports are entered into a central, searchable database and are coded according to severity.

In October 2008, the VA's National Center for Patient Safety published an advisory (PDF) based on reports of bleeding episodes during dialysis. VA units logged 40 incidents considered "serious" between March 2002 and April 2008, or about 1 for every 62,500 treatments given in this period.

The VA’s study encompassed events less grave than those considered by Sandroni. Fewer than one-third of the incidents resulted in extended hospitalizations or deaths, in part because researchers considered episodes in which patients lost as little as 100 cubic centimeters of blood, about enough to fill an espresso cup. But by looking systematically at these cases, patterns emerged. Certain types of patients were clearly at higher risk, including those receiving treatment in isolation areas and those with dementia.

Based on these findings, the VA issued two safety alerts earlier this year aimed at reducing or preventing hemorrhages during dialysis treatments. It has ordered units to buy clips (PDF) that snap onto bloodlines and prevent them from loosening.

Starting this month, VA units also will use Redsense alarms, electronic blood-loss sensors, on patients getting dialysis in areas outside of chronic dialysis units or beyond staffers' sight lines; in addition, they may use the device on patients identified as at high-risk for needle dislodgements. The VA also has augmented training for staffers, putting new emphasis on keeping access sites visible.

Dr. Jim Bagian, a former astronaut, led the VA patient safety center from its founding in 1999 until last month, when he took an executive position with the University of Michigan Hospital System. He said there were two keys to launching the reporting program: First, persuading medical staffers to share information about adverse events without fear of reprisal or legal exposure; and second, showing them that their information could make a difference.

"You have to be willing to admit you're not doing as well as you could," Bagian said. "Most people don't have the guts to say that."

Researcher Lisa Schwartz contributed to this report.

Roberta Mikles, RN Dialysis Patient Safety Advocat

Nov. 10, 2010, 12:34 p.m.

This is why there needs to be EFFECTIVE unit-level supervision and that ALL staff are thoroughly trained and educated in correct practices. ALL facilities should be MANDATED to report these and other errors that result in injury or death. And, one has to wonder just how many other times these (or other) incidents have occurred. Perhaps the providers with all their powerful influence have stopped any movements in the direction of error reporting.

I am reminded of several units that I have been in and observed access sites covered. In fact, in the unit my father went to the problem was that if no staff were in the immediate area, e.g. when they were congregated, sitting around the nursing desk, they could not visibly see the access sites of probably about 4 or 5 (or more at times, esp if they were sitting, versus standing at the desk) out of 15 patients. There was a sign in the lobby informing patients that access sites had to be visible, etc., however, with all the signs it was overwhelming and for the most part, I wonder how many patients even read them. Also, staff can not assume that if a sign is posted that a patient has read such. Also, there are many patients who come in via stretcher, wheelchair, etc and might not read signs.

I have also observed staff, in several units, who, when alarms sound, walk to the patient, turn the alarm off and walk away without checking the patient. Often asking the patient in such a low tone if they are ok,  that the patient either does not hear or does not understand due to language barriers, often.

Again, the foundation is to ensure EFFECTIVE unit-level supervision to ensure safe practices are implemented. I have observed staff when they are short staffed, as well as when they are over staffed and there was very little difference, except when there was more staff often there was more congregating and conversing. However, I do fully support adequate nurse-technician ratios to patients and, even more, acuity staffing.

I have further observed staff walk by a patient who is holding his/her site post dialysis, when there is bleeding and just say ‘hold tighter’ versus helping the patient, esp an elderly patient.

At one point in our unit, I wrote a letter to upper management stating it was ‘unsafe’ due to low staffing. I did this as many staff came to me requesting such.

Roberta Mikles RN
Dialysis Patient Safety Advocate
http://www.qualitysafepatientcare.com

Thank you, Robin Fields and ProPublica.  Many patients feel powerless when they are dependent on the healthcare system.  My young son may need dialysis at some point due to a congential birth defect.  Because of your article, I will know to ask the dialysis nurse “why is the site covered?” and I will make a big commotion if an alarm goes off.  In other words, I know better how to protect my child.  It’s strange, though, that companies making millions of dollars seem so unconcerned about the welfare of their patients.

Jeff Strailey

Nov. 10, 2010, 1:48 p.m.

In-center dialysis is fraught with myriad safety, staff,  medical, and quality of life issues for patients.

I’m happy to have survived it and moved on to transplant but had my share of incidents including dialyzer failures that resulted in blood loss more than once.

I’ve witnessed patients “code” or die during treatment and seen very elderly patients, often unaware of their surroundings suffer through hours of hemodialysis.

In-center dialysis not only has a high mortality rate but it can be a little chamber of horrors to those who must endure it.

Mortality rates in other countries are far lower than they are in the U.S.  This can be attributed to better medical supervision, better trained and educated staff, and a higher level of government oversight than we see in the United States.

Better choices here are home hemodialysis executed and supervised by the patient and peritoneal dialysis, both treatment forms which do not require in-center treatment.

Not surprised it is the VA leading the way in reporting accidents.  I’ve been going there and have been impressed by the way they operate.  My daughter is also interning there for pharmacy and has also been impressed - so much for the dangers of government-run, government-paid-for health care.

Even BusinessWeek called it “The Best Medical Care in the U.S.”: http://dialysisethics2.org/forum/index.php?topic=495.0

Lou Lamoureux

Nov. 10, 2010, 2:41 p.m.

The floors in a McDonalds are cleaner than the floors at any of the dialsyis centers I’ve been in.  I usually had the late shift and by the evening, the floors are covered in tape, gauze, and wrappers for alcohol swabs.  There’s always some sort of white substance around the machines (I’m guessing a salt left behind when the machines leak).
My first home clinic was wicked cold, you definitely needed a blanket all the time. My last one was warm and I never had to use a blanket. 
I’ve passed out during treatment but luckily I’ve never had a needle pull out accidentally. Roberta Mikles is correct that nurses and techs often just come over and turn off the alarm without investigating. 
I’m glad it kept me alive long enough to get a transplant. 
Sincerely,
Lou

Having worked in a university hospital dialysis center in the early ‘80s, I saw the creeping commercialization of dialysis treatment where the procedure went from being a carefully controlled and monitored procedure performed by registered nurses under close physician oversight, to a barber shop style operation run by poorly trained and paid technicians. This all developed under the heavy hand of mandated reimbursement reductions by the federal government.  The deaths from blood loss are the tip of the iceberg if you add in infections, disinfectant poisonings and other incidents.  It is a complex and dangerous procedure and it offers many ways to kill or maim a dialysis patient.

Why do the dialysis units have to be so cold??? besides that My Husband and Mother were both on dialysis and the unit they went to was great, the nurses would take time with them and check on them. Most times I would be with them, but if I had to leave I knew they would be taken care of. I just want to say thank you to all the great staff they took care of them the five to six years there came there. And they know who they were, in kalamazoo

There is no reason why a needle should dislodge other than carelessness. If you tape correctly, this should not happen.
This is just one example of why the centers should be pushing more home dialysis where you are in charge of your treatments. It has been proven that home dialysis is less costly than in center and the patients are in much better health with less complications with many being able to return to work.
Its a shame that many in-center employees including doctors do not even know that hemo dialysis can be done at home. They are not being educated. When you tell them you are doing home hemo.
We need more advocacy. Learn more about home hemo dialysis at:
http://www.homedialysis.org
http://www.nxstageusers.com and http://www.nocturnaldialysis.org

Why is there not more patient education by physicians about home dialysis options?  There is an option called peritoneal dialysis which most patients are eligible for, which requires no needles and no blood.  It is inexpensive, effective and safe.
I hope that health care reforms include incentives for more nephrologists to advocate for their patients by encouraging home dialysis for their patients needing dialysis.

Nicholas Hoenich

Nov. 11, 2010, 5:40 a.m.

Errors in the clinical environment are unfortunate, however when systems fail, and an incident or accident occurs the traditional blame [and punishment] approach should be replaced with critical evaluation that will prompt process redesign, anticipate human fallibility, and provide warning of errors. This can be best achieved by a combination of mandatory and voluntary reporting. The first should be implemented in the event of a fatality, whilst the second used in the anonymous reporting of near misses .  Such an approach has been used in air traffic control both in the United States and elsewhere for a number of years and there is no reason why it can not be implemented in the healthcare environment. By doing so, it would demonstrate the commitment of providers as well as regulatory authorities in actively seeking information about potential weaknesses and implementing ways to redress these vulnerabilities.

I am a veteran dialysis nurse. I am concerned rabout the current methods used in securing needles and bloodlines; needles are often secured to the patient’s chair or dialysis machine and not to the patient.  Too often bloodlines are looped through a clamp attached to a sheet. Needle dislogdement can be prevented by securing the needles to the patient, both under and over the needle at the insertion site and with the needle cannula and bloodline create a “figure 8”, securing the bloodlines at the “figure 8” onto the patient’s arm and again at the wrist.. Patients should be in view at all times, with their access sites visable at all times while under the constant observation of dialysis clinical staff. Needle dislodgement can occur despite our best efforts but the incidence of this occurring can be greatly reduced by this technique! It is up to all of us to anticipate potential patient safety concerns and be proactive in our practice.

Patient Education

Nov. 11, 2010, 4:04 p.m.

In my opinion, we do not need a study to confirm what is already known to be an issue. In many cases, needle dislodgement should not occur with proper training and taping technique. There are measures to prevent this.
Instread, spend the money on educating the staff and adding more staff so the patient-dialyzor ratio is not so out of control. How can so little staff take care and look after so many patients in-center. It is simply impossible. Also, hire staff that cares what they are doing instead of hiring someone for a summer job and paycheck. This happens all too often.
We dont need studies, we need more patient involvement for those who can instead of the docs/staff frowning upon asking questions and being involved with their care.
Not only staff needs to be educated, but so do the patients. It should be mandatory that those who are able to be involved with their treatment instead of sitting down in a chair and leaving everything up to a stranger for the next 4 hours.

Johnny Springfield

Nov. 12, 2010, 12:02 a.m.

I read the article with no intention to comment on it, but I’d like to make a comment and ask a question. For background, I became caregiver to my older brother for five months before pancreatic cancer finally lead to his death. Before he was diagnosed with pancreatic cancer, his kidneys were removed during an operation and he started on the treadmill of dialysis treatment. Taking him to and fro his thrice-weekly visits, I had time to watch him during his treatment, and observe the goings-on in the dialysis facility. Fortunately for him, nothing awful happened. Other than on occasion a technician not being able to hook him up through his fistula because his blood pressure was too low - he was prescribed medicine to take before his visits to boost it up - his 4-hours plodding along uneventfully. After reading the story, and the “leaked” PR document” in response to it, I recalled some information we came across when, for a time, we were planning a trip to Europe, that necessarily involved making arrangements for dialysis while there, in Paris and in London. What caught my attention about dialysis done over there - and there is an international network that helps travelers who need dialysis find treatment facilities in other countries - seem stark when contrasted and compared with our American for-profit health insurance system, that as we know, emphasizes speed and turn over; the corporate goal being to make a dollar for headquarters. The section of the article that described how higher pressures from more powerful machines can dislodge needles, I thought, spoke to why dialysis in America seems to be done so quickly while in Europe, or Paris in our case, it is done much slower because going slower is better for the patient in several respects, not the least of which is that it allows a patient to not have to come back as often as is done here. France, as I recall, has a government-run health care system that is ranked number one in the world. It’s curious to me that there, where profit isn’t the goal of the care, a dialysis treatment takes much longer to perform because it’s in the best interest of the patient to do it that way. Here, like a restaurant that wants to turn tables as often as possible to get more paying customers in, for-profit dialysis centers want to their machines to service as many patients as possible. More powerful machines do reduce your session length, but they also maximize the company’s top revenue line. Hoping to minimize errors - from lack of training or rushing in the moment or from fatigue after too many hours on the job - can be pro-actively addressed, as some here have commented on. Once again, though, this story convinces me that, as the only advanced, industrialized country that delivers health care through a crazy quilt of profit-oriented companies that focus on speed and quantity of care - done because it’s in the best interest of the company - rather than quality of care in a time frame that is best for the patient, we are going in the wrong direction with little hope this car can be turned around. But America being America, our ego prevents us from even investigating what best practices are in other nations, let alone adopting what they do right to what we do wrong here. If anyone can corroborate or dispel what I believe to be how dialysis treatment in France is delivered, I’d like to know if I’m right or wrong in my statement on that issue.

Johnny, I don’t have much concerning France.  But I recall a short abstract about dialysis in Japan by a couple of distinguished doctors.  It dispels many of the myths created by those who would blame everything but short treatments and overworked staff:

“The cumulative survival of Japanese hemodialysis patients is more than 2.5 times better than that of dialysis patients in the United States (U.S.). The difference is particularly pronounced in older patients, being 4 times better in patients over the age of 50 years. The mortality in U.S. patients has increased from 10 to 25% over the last three decades, but has remained stable at around 10% in Japan. There is no obvious difference in patient selection. The Japanese accept almost as high a proportion of diabetic patients as does the United States, and the mean age of incident patients is higher in Japan. Renal transplantation, virtually absent in Japan, should increase mortality in U.S. dialysis patients by removing patients with the highest probability of survival, but even if one adds surviving transplant patients and studies prevalent populations, the survival rate is much better in Japan. Genetic factors are unlikely to explain differences in mortality, as older Americans live much longer than older Japanese. We speculate that the difference lies in the practice of dialysis. Patients in the United States are generally treated by much faster and shorter dialysis than in Japan. This puts a severe burden on the cardiovascular system of older patients, leading to the poorer survival rate. Japanese physicians also appear to be better trained in dialysis and to spend more time with their patients. The nursing shortage in the United States may also contribute to the increased mortality. Whatever the explanations, the U.S. dialysis community must work to equal and, hopefully, surpass the now superior survival of Japanese dialysis patients.”

I would put up a link, but the moderators seem to get a bit jumpy when I put up a link.

Um…before blaming staff….was the access visible? Did the patient repeatedly refuse to keep access visible?
I work in dialysis and we are constantly fighting with patients about this. We visualized covered accesses with each check but keep it covered can lead to the having the needle wings caught on clothing or covers contributing to dislodgement.
Another 1 sided and very biased report by Robin and Propublic….really!

As an EMT I have seen first hand how under qualified dialysis tech are. They required a trainin g that takes less than a month. After their deficient training they are allow to treat patients. Usually there is only one nurse per every 20 patients and 1 tech for every 5 or 6 patients. This dialysis centers are all about the money very fee actually cate to ensure patient con fort and safety.  Dialysis center should be held accountable to higher much higher standars. Yhet risk people’s luffas every day.

“1 in 5 patients die” I certainly hope that was a typo!

Gary Peterson

Nov. 14, 2010, 5:56 a.m.

That was no typo.

The mortality rate for dialysis patients in the U.S. remains over 20% and has been for decades. Yet, so much better care is possible and is being done in other countries.

It is becoming more common now at U.S. professional nephrology/dialysis meetings for at least one speaker to ask for a show of hands as to who would accept standard, in-center hemodialysis treatments for themselves. The typical response is some laughing and for NO ONE to raise their hand. Yet this is the therapy that over 90% of their patients receive.

Far too many nephrology/dialysis professionals receive financial compensation based on corporate outcomes rather than patient outcomes.

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 14, 2010, 3:38 p.m.

Lisa, when you state the patient refused to keep access site visible, am curious if staff asked the patient ‘why?” Often asking the patient and delving deeper into reasons patients do such, often results in resolving situations that are related to patient safety. Just as staff have reasons for not implementing correct practices, etc., patients have reasons for that which they do. I would ask the patient, again, ‘why?” Is the patient Cold? Is the patient covering the access site because his arm is cold? Just ask. I believe this is a component of problems in the unit. Patients must be asked questions and focus should be on ensuring the patient understands why staff are implementing certain practices. If staff get upset with patients for covering their access sites, how do you think patients feels when the see staff not implementing correct infection control practices, etc.

Roberta Mikles
http://www.qualitysafepatientcare.com

Needle dislodgements and blood tubing disconnections, as well as other staff related accidents, are increasing, simply due to the fact that staff are being overwhelmed with too high of a patient to staff ratio.  You can’t monitor patient’s properly, or carry out safe care, when you are a dialysis technician taking care of five or six patients at a time.  This problem is compounded when the corporate time-study program is mandating a 15 mintue turn around time between dialysis patients.  Some patients are being booted out the door too quickly, causing them to experience either bleeding from their dialysis access on the way home, or passing out on the way home.  For patients who drive themselves, bleeding and particularly passing out, not only puts them at risk, but also the general public.  Rarely are these events properly documented when they occur.  Most of the time, the dialysis facility is off the hook for any injury or deaths caused by these two problems, after they leave the facility.
One other issue that is never reported is episodes of hypovolemic induced hypotension, that results in cardiac arrest during hemodialysis.  There are dialysis units out there that have EMS coming to their facilities, at least once a week, if not more often.  The implication being that patients are not being watched as closely as they should be.  For some staff, putting patients on dialysis is a “set it and forget it” scenario, where the patient is put on the dialysis machine and never looked at, again, until it’s time to take them off.  Again, much of this mentality stems from the high patient to staff ratios.  The goal of corporate dialysis chains is to maximize profit and increase the value of their stock.  The sad fact is that they could maintain excellent profit and keep the value of their stock up, and still provide the best care possible.  Common sense should lead any competent business person to realize that you can’t dialyze the dead.  As well, negative press and law suits stemming from “poor care” is not good for business.  How do I know these problems exist?  Well, besides hundreds of antedotal incidents that have been passed onto me by patients and their families, I’ve actually assisted in law suits for wrongful death on behalf of the families of patients.  When you read the medical records and take the time to clarify what happened to cause the incident, it’s disturbing to know that the great majority of the incidents could have been prevented with just a little extra care, good training and concern.  The grand majority of incidents are caused by poor leadership of management and poor to non-existant training of staff.  When a patient comes in for hemodialysis, it should be a routine, comforable treatment and a non-event.  They should be able to walk in, get their treatment without incident, and go home, again, without incident.  I realize that, no matter how careful we are, things will happen.  However, we should be able to minimize Murphy’s Law by good training of staff and giving staff numbers of patients that they can realistically and safely care for.

One-sided article

Nov. 16, 2010, 10:39 a.m.

Before you compare hemodialysis in the U.S. versus in Europe, you have to compare the patient demographics. Most European countries have an age limit. No, 95 year old grandma with dementia will NOT get dialysis. Here, if the nephrologists turn someone away who is 95 years old and frail, the families get mad. So we take the patients. That will make mortality outcomes MUCH worse. And treatment time? Patients treat staff members with hostility if their time is increased. As a dialysis dietitian, I have to go over monthly bloodwork with patients. I had a woman—argue—with me about her treatment time. She wanted a 15 minute time decrease, and started pouting (a woman in her 70s, no less,) pouting when she didn’t get her way. Yeah, dialysis is gentler when done slowly, for longer, like they do in Europe, but just try to do it with this demographic. From what I’ve seen in 5 years of dialysis work, most dialysis patients are there because they chose not to take care of their hypertension or diabetes (i.e., NOT our fault), and generally seem to be a group that feels their entitled to everyone doing everything for them. Take some responsibility for yourselves! No one wants to stay on the machine longer, and no one wants to take their meds. This is NOT OUR FAULT!

Johnny Springfield

Nov. 16, 2010, 12:22 p.m.

“No, 95 year old grandma with dementia will NOT get dialysis. Here, if the nephrologists turn someone away who is 95 years old and frail, the families get mad.”

Point well taken. American families will indeed “get mad,” and American for-profit companies, who would dialyze a dead dog if that was legal, won’t get paid. Again, in my mind, this goes to the fundamental decision on whether delivery of health care here is designed for the benefit of the patient or the company.

As a proud and unapologetic non-believer (secularist, atheist, Bright, you choose the term) each of us will die one day or another. So for me and my brother, who I took care of during his remaining months and who was of the same mind as me when it comes to the reality of mortality, because our modern medical technology gives us the means to keep someone in the condition you described above alive, doesn’t mean that’s what we should do. Europeans, I gather from your comment, have collectively made that decision. Whereas in America, the land of instant everything, regardless of whether that is good or bad, keeping someone alive who ought to be allowed to die in dignity, letting nature take its course, is both unthinkable and costly for us all, because it absorbs dollars that could and should be used to address illnesses that can can and ought to be treated in younger people whose lives lie mostly in front of them rather than behind them.

Reading your frustration from haggling with an old woman who pouted because she couldn’t reduce the time of her dialysis session only shows me the great divide that exists from growing up here compared to elsewhere - maybe Europe, where my parents were born - where living has a different, slower pace, where time is thought of and used differently than here, where something as simple as cooking a meal at home with the family after having gone to the market that day to buy fresh goods is the norm, whereas it’s no longer than way in go-go America, where eating on the run, working multiple jobs and juggling a variety of other social commitments is now essential to a lifestyle that is promoted all around us. Different strokes for different folks, I guess. For better or worse, in sickness and in health, until death we do part, we are wed to the American for-profit medical health delivery system. And as the forces mounting in Washington are showing us, reforming the system to make it more patient oriented rather than corporate oriented is a bridge too far. I have no reason to want to live to 95, and have decided that I’m really not interested in delaying the inevitable when the day comes that I’m no longer myself anymore. My death will become an inconvenience to some and a money-making opportunity to others. I’ve already made the decision to be my own Death Panel, because I don’t trust others to make the right decision for me at the right time.

Roberta Mikles RN Dialysis Patient Safety Advocate

Nov. 18, 2010, 10:20 a.m.

One-Sided Article,—when you tell patients to take responsiblity for themselves, I would like to add that patients, and their loved ones, have expectations that staff will implement correct practices (that which the article focuses on). So, I ask, “Is it alright for patients to say to staff.. ‘take responsibility and accountability for your actions?” Also, I would like to ask, “Did you explore further why this patient, you mention, was exhibiting the behavior she was?” It is really important that all who work in dialysis have a true understanding, in my opinion, that it is difficult for a patient, often, to sit for hours, etc, often not feeling well during treatment, etc… Perhaps delving deeper might resolve some problems e.g. if the patient needs more dialysis, maybe her increased understanding of ‘why’ would help the situation. Those on dialysis have more to deal with in life, than those of us who are not on dialysis.

I would also like to comment that there are many patients who did, in fact, take care of themselves and still ended up on needing life-sustaining dialysis treatments. Interesting, but there are patients who require dialysis due to preventable errors, also, just as an added note.
Roberta Mikles
http://www.qualitysafepatientcare.com

Roberta Mikles, RN Dialysis Patient Safety Advocat

Nov. 24, 2010, 2:55 p.m.

Perhaps we NEED to have mandatory reporting of preventable errors that result in harm and death? Perhaps, Medicare and insurance companies should NOT reimburse facilities when these aforementioned occur.
Roberta Mikles RN
http://www.qualitysafepatientcare.com

Rebecca Freeman, Attorney

Dec. 3, 2010, 1:33 p.m.

As a specialist in medical malpractice cases, I am often appalled at the poor care many patients get.  I truly believe most nurses and techs try to provide good care but many of the dialysis clinics are owned and operated by big corporations that place profits over people.  I currently represent the family of a woman who bled to death as a result of faulty dialysis practices.  It would not have happened if the staff had been following standard practices but the staff was overworked and under trained- a deadly combination.

This article is part of an ongoing investigation:
Dialysis

Dialysis: High Costs and Hidden Perils of a Treatment Guaranteed to All

Nearly 40 years after Congress created a unique entitlement for patients with kidney failure, U.S. death rates and per-patient costs are among the world's highest while the biggest for-profit providers flourish.

The Story So Far

Dialysis holds a special place in U.S. medicine. In the 1960’s, it was the nation’s signature example of rationing, an expensive miracle therapy available only to a lucky few. A decade later, when Congress created a special entitlement to pay for it, dialysis became the country’s most ambitious experiment in universal care.

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