Be ready for surveyor focus on dialysis

 Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance. Which means you should, too. Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD). A single procedure takes about several hours, during which a patient’s blood is filtered and cleaned inside their body (peritoneal dialysis) or outside of it (hemodialysis). There are many possible points of failure in a dialysis treatment, and infections are a major risk. That’s why surveyors are being extra stringent about compliance, say Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, an associate of the company. Both are Joint Commission alumni. 

The Joint Commission isn’t delicate when telling people what surveyors are looking for, nor when citing them. Three focus areas have come up repeatedly at Joint Commission presentations: sterile compounding, pain standards, and dialysis. And there’s been a corresponding uptick in scoring for all of these areas in 2018.

 “When The Joint Commission indicated that dialysis is going to be a focus area, the field should be prepared for more detailed surveys than we have seen in the past,” Cowel says. “Take this as a heads-up notice. We have seen an uptick in dialysis scoring; in fact, we have seen scoring in dialysis in more than half of the survey reports we have seen in recent months.”

There are plenty of examples that hospitals can focus on, Good notes.

“Note that hospitals that are providing inpatient hemodialysis or contracting for the service need to pay attention to the room where dialysis is being provided, particularly if [it’s] not in the patient’s room,” Good says. “I have seen rusty air conditioning units, soil around the unit, blood spots on the floor, tiles missing behind the dialysis machine, wet towels on the floor, [and] sinks designated solely for hand hygiene being used for emptying bottles of concentrate that were used for patient dialysis.” 

Cowel and Good have seen numerous findings in dialysis in recent months, including the calibration of the pH/conductivity meter not being tested per the manufacturer instructions for use (IFU). Other common findings they’ve seen include:

• Not having an eyewash station when bleaching of a portable dialysis machine is done in a patient room.
• Not conducting a special check of a patient’s catheter that was locked with high-concentration anticoagulant, in clear violation of the hospital’s policy on high-risk medications.
• Improper management of medicines administered during or before dialysis treatment. For example, a dialysis nurse transporting multidose vials of heparin, despite the fact they should be considered single-dose vials. 
• Not documenting vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, per hospital policy. 
• Not recording that consent was received from a new dialysis patient or that a conversation about risks and benefits occurred. 
• Not verifying that the amount of fluids or medications administered to a patient match the medical order. For example, if a nurse administers 100cc normal saline (NS) instead of 200cc NS per the protocol order set for hypotension during dialysis. 

More on dialysis compliance will be in the upcoming edition of Briefings on Accreditation and Quality.