An analysis of the increased demands placed on dialysis health care team members by functionally dependent hemodialysis patients

A team of health care providers is integral to the care of chronic hemodial ysis patients and includes nephrologists, social workers, dietitians, and n urses. Increasingly, the chronic hemodialysis population is composed of old er patients with multiple comorbid conditions and reduced functional indepe ndence. The demands placed on social workers, nurses, and dietitians caring for the increasingly fragile chronic hemodialysis population have not been examined. We compared the interventions required by social workers, dietit ians, and nurses caring for two demographically matched chronic hemodialysi s patient groups undergoing dialysis in two outpatient units over a 6-month period to examine the demands imposed by these functionally dependent pati ents. Patients underwent dialysis in either a step-down unit or an ambulato ry unit. Patients undergoing dialysis in the step-down unit had more corona ry artery disease (6 of 12 patients [50%] versus 1 of 12 patients; P < 0.02 5) and peripheral vascular disease (6 of 12 versus 0 patients; P < 0.004), Mean urea reduction ratio, hematocrit, and serum albumin values, as well as number of hospitalizations and mean days hospitalized for the 6-month stud y period, were not different between the groups. Patients undergoing dialys is in the step-down unit were more likely to have lower scores on activitie s of daily living (11 +/- 5 versus 15 +/- 3; P < 0.02), live in a nursing h ome (58% versus 8%; P < 0.01), be nonambulatory (66% versus 0%; P < 0.01), and have a catheter as permanent dialysis access (66% versus 9%; P < 0.004) , Significantly more social worker and dietitian time in hours per week wer e provided to the patients in the step-down unit (social workers, 259 versu s 201 h/wk; P < 0.001; dietitians, 115 versus 96 h/wk; P < 0.001), Similarl y, dialysis treatments requiring nursing interventions (treatments with hyp otension, 36% versus 13%; obtaining blood cultures, 7% versus 2%; administe ring intravenous medications, 9% versus 2%; communicating with other health care providers, 3% versus 0.1%; and non-dialysis-related interventions, 5% versus 0.5%; all P < 0.005) were more common in the patients in the step-d own unit. We conclude that increased dialysis provider care is required by patients who are functionally dependent and have increased comorbid conditi ons. The increased demands this fragile patient population places on dialys is providers must be recognized, examined more closely, and reimbursed appr opriately. (C) 2000 by the National Kidney Foundation, Inc.