Dialysis Center Shapes Up

After a surprise investigation last November, state regulators reported hazards at UC Irvine’s dialysis center, which serves about 124 patients. UCI has since reported that all issues have been addressed and fixed.

While they did not have to close at any time, a 70-page report from inspectors of the California Department of Public Health (CDPH) revealed that standards surrounding infection control, the physical environment and the responsibilities of the medical director and governance were not properly met.

“Looking at the big picture and all the measurements possible, including the opportunities we provide patients to get on a transplant list, we could conclude that we were doing a good job,” said John Murray, a spokesman for the UCI Medical Center.

“But we were aware of issues, particularly that we needed better management of the center.”

Among the infractions were blood-spotted dialysis chairs and walls, as well as water damage, dusty wheelchairs and rusty supply carts.

Unsanitary conditions were observed as patient equipment, like electronic thermometers and syringe stoppers, were not disinfected. There was also a build up of “dust and white deposits” on the backs of machines.

Equipment was also found taped together and in poor condition. According to the report, the nurse manager told inspectors that the “‘grey tape’ was used to hold together a piping system to ‘prevent disintegration.’”

Nurses failed to change gloves and wash their hands after direct contact with patients. Behind treatment chairs and dialysis machines, clean supply cabinets were accessed with contaminated gloves and hands.

Furthermore, biohazard waste containers, which contained bloody tubing, dressings and used dialyzers were left in the middle of the hallway.

Acid concentrate was not contained in secure storage containers, nor were water treatment systems, making it difficult to prevent public tampering.

Dr. Alpesh Armin, chair of the UCI Medical School’s department of medicine, wrote a letter to state regulators on Feb. 23, saying, “We appreciate the seriousness of the issues raised … By surveying our dialysis unit and giving us guidance about what should and must be improved, you have helped us become better.”

UCI Chief Executive Terry Belmont and Dean of the School of Medicine, Ralph Clayman, addressed medical faculty and staff on Feb. 28. In it, they wrote that they have “instituted a top-down review and made all changes CDPH requested along with others designed to improve the center’s operation.”

They also noted how the dialysis center has the lowest patient infection rates and annual observed mortality rate in Orange County and is “better than state and the national averages – 11 percent at UC Irvine compared to 18 percent in California and 20 percent nationally.”

One of the major steps they have taken was hiring a new medical director and nurse manager to oversee the facility, a process that was completed last month.

In addition, proper data has been recorded and staff has been retrained to understand current policies and practices. Nursing administration is helping by checking that nurses are properly exercising the requirements, which will continue even after CDPH’s next survey.

In the past three months, the building has been updated and equipment is in much better condition.

UCI has also responded by considering long-term improvements. While the initiatives still have yet to be officially confirmed, they look to remodel the center to address various ways that will make the center run more efficiently.

“Federal rules don’t require us to maintain a certain level of staffing, but at UCI, we have more nurses and make sure a doctor is always present and a physician is on call,” Murray said. “We hope this will let us administer the best care possible.”

The last time UCI’s dialysis center was reviewed was on Jan. 4, 2003. However, every facility that treats end stage renal disease is required to be recertified once every three years.

Ralph Montano, spokesman for the CDPH, explained that, given the budget and the list of priorities set by the federal government, it has been difficult to keep up.

The way the priority system is categorized is similar to a three “layer cake.”

Hospitals and nursing homes comprise Tier I. These are deemed top priority and must be surveyed by the CDPH every year.

In addition, the state of California considers complaints at any health care facility to have a top tier priority.

“There have been no complaints regarding UCI’s dialysis center since it was recertified in 2003, which is why it never moved up in priority status,” Montano said.

The Center for Medicare and Medicaid Services (CMS), which is part of the federal government, plays a part in determining Tier II.

According to Thomas Hamilton, director of the CMS Survey and Certification Group, the CMS contracts the University of Michigan to process data from dialysis center facilities and create targeted Dialysis Facility Reports. The data is integrated in a database to analyze the outcomes and measures of every facility in the entire country.

“We have very good information about these outcomes,” Hamilton said. “What this allows us to do is rank the facilities in order, based on quality measures.”

Tier III has a lower priority, but the CMS still calls for a survey of each dialysis center every three years.

“Due to limited resources and competing priorities, CDPH’s Licensing and Certification (L&C) program is not able to conduct these surveys,” Montano said.

Since 2009 however, CDPH has been instituting changes to better serve the dialysis population. The recent survey done at UCI was actually a result of these programmatic changes.

“We have decentralized this survey workload and, by June 2011, all of our district office staff will have trained surveyors to conduct these surveys,” Montano said. “We hope to conduct more surveys in the future.”

As for UCI, they have already filed a plan of correction, awaiting the CDPH’s next survey. In order to get recertified and prevent any termination action from being pursued, CDPH will have to verify that that compliance has indeed been satisfied.

“We have met all the issues CDPH raised and exceeded them. All of them were assessed within a day of the survey and completed in early January,” Murray said. “Now we are waiting for CDPH to verify our plan of correction and make the appropriate recommendation to CMS.”