How to Address Workforce Shortages in Dialysis Centers

Dialysis centers are facing shortages of the nurses that run the facilities and the technicians who operate the dialysis machines.

Using a calculated risk score to monitor hemodialysis vascular access stenosis can help ease workforce shortages at dialysis centers, a Detroit-based nephrologist says.

About 37 million Americans have kidney disease, according to the American Kidney Fund. About 800,000 Americans are living with kidney failure, and nearly 570,000 of those people are on dialysis, the American Kidney Fund says.

Dialysis centers nationwide are facing workforce shortages among the nurses who run the centers and the technicians who operate the dialysis machines, says Robert Provenzano, MD, a nephrologist at Ascension St. John Hospital in Detroit and a co-author of a recent journal article on using a calculated risk score to monitor blockages in vascular access for dialysis known as hemodialysis vascular access stenosis.

"The workforce in dialysis centers has always been challenging. … During COVID, the dialysis nurses faced a major challenge, not only from all the masking and personal protective equipment, but also from a very high acuity rate. In other words, their patients were very sick, and they started dying in very large numbers. As a matter of fact, for the first time in 30 years, the number of people on dialysis dropped. That's how significant the mortality was. So, the nurses who were both emotionally and physically overwhelmed just went elsewhere. They went to hospitals, which also had shortages. The hospitals can afford to pay more," he says.

Hemodialysis vascular access stenosis is a primary complication of dialysis, and it requires labor intensive efforts to monitor the condition, Provenzano says.

"The protection of vascular access is so important that the Centers for Medicare and Medicaid Services, which is the primary funder of dialysis services, has mandated that all patients receive surveillance. Surveillance is a very broad term, and they leave it up to the providers of dialysis care to determine what surveillance is. For the most part, dialysis centers do a physical examination on the access. A physical exam on the access is where you examine it, you touch it, you palpate it, and you listen with your stethoscope and try to make a determination whether there's a blockage," he says.

Physical examinations are a burden for the nursing staff at dialysis centers, Provenzano says. "Often, the caregivers doing the physical exam are the nurses who are understaffed, very busy, and they don't have the time to do it. So, it often isn't done. As a result, providers have adopted other methods of doing surveillance. One is an ultrasound that is usually conducted by a technician. They can see if there's a blockage. The problem with that technique is it's very expensive and it also slows down operations in the dialysis unit."

Using a calculated risk score, which estimates the probability of a vascular access blockage on a scale of 1 to 10, with higher scores indicating higher risk, helps dialysis center nurses to focus on fewer patients, he says.

"There are typically about 100 patients in each dialysis unit. If a nurse is running around trying to figure out which one of those 100 patients needs attention for their access, it's more efficient for the nurse to know which of those 100 actually has a problem. What this technology does is it shows the seven people who are going to have an event. So, the nurse can focus on seven instead of the other 93, and just make a simple referral to the vascular surgeon or the interventional radiologist to prevent the blockage. So, it takes just a few minutes instead of hours and hours."

Combining the calculated risk score with a physical examination is an effective way to conduct vascular access surveillance, Provenzano says. "When you have the people who are identified by the algorithm as a high risk for blockage, then those few people have a physical exam to verify whether there's evidence that a blockage exists. So, they build on each other to improve the positive predictive aspect of the process."