The bill, carried by State Sen. Ricardo Lara, institutes mandatory nurse, technician, dietitian and social worker staffing ratios in dialysis clinics and, I understand, will increase staffing costs in dialysis clinics by 35 percent on average. This large a cost increase could force cutbacks in the number of patients that can be seen by clinics, potentially endangering patients’ access to treatment.
While I am supportive of improving patient safety, I have concerns about the unintended consequences of this legislation, with demand for dialysis in California growing at about 5 percent per year.
The legislation will require facilities to hire more staff to treat the same number of patients, which can be difficult in certain regions of the state; there will be clinics that can’t afford it.
At this time, there is no clinical evidence that staffing ratios lead to better care. In fact, evidence from the federal Centers for Medicare & Medicaid Services (CMS) proves that California on average outperforms the rest of the nation in both quality of patient care and in patient satisfaction, including when compared to the handful of states that have mandatory ratios. The same CMS data shows that California’s standardized infection rate is lower than that of all states with staffing mandates, except for Oregon’s with which it is tied.
As the National Kidney Foundation points out, the alternative to hiring staff required by SB 349 is to meet the ratios with existing staff, but treat fewer patients. This means many patients may have to change their treatment schedule, which is a significant burden for patients, many of whom have other responsibilities during their day including jobs. The bill could also lead to fewer patients being served by their current clinic, forcing them to inconveniently seek treatment elsewhere.
The requirement in SB 349 to maintain the ratios “at all times” in the day could also lead to challenges if someone on staff is unable to show up for work or has an emergency and needs to leave early. This could cause clinics to not be able to serve some patients and patients to miss dialysis treatments, which can increase hospitalizations and mortality.
In addition, some clinics operate nocturnal dialysis where treatment is provided at a slower pace overnight. This option gives patients the ability to sleep during dialysis and have their days free to work or tend to other daily responsibilities. Thus, I find that nocturnal dialysis is an excellent treatment modality. Less staffing is needed for nocturnal dialysis, as patients are receiving a longer, slower dialysis and are usually sleeping during the treatment. I am concerned that facilities may choose not to offer nocturnal programs because the staffing requirements and costs to serve a small number of patients would be too high.
That’s why, as a nephrologist who has practiced in Bakersfield for over 30 years and who has cared for hundreds of kidney patients during that time, I am opposed to Senate Bill 349 (Lara). If I knew that staffing ratios would lead to better care, I’d be in favor of this bill.
The bill will be heard in the Assembly Appropriations committee this month. I urge our local Assemblyman, Rudy Salas, and other assembly representatives to reject this bill in its current form.
Harold J. Baer, MD, FACP, FACN, is assistant clinical professor of medicine and past medical director of the Bakersfield Dialysis Center.