ESRD Network 6 5 Diamond Patient Safety Program

1. ESRD Network 6 5 Diamond Patient Safety Program Decreasing Patient & Provider Conflict Polishing Up on Professionalism 2008

2. Objectives

3. What is professionalism?

4. Why care about professionalism? Network- Grievances often center around professionalism Employee- Code of Ethics; builds confidence Employer- Prevents burnout and promotes mutual respect Patient- Patient is satisfied The focus on emergency preparedness has increased significantly since 9/11/2001, and most recently, Hurricane Katrina in August 2005. What did the dialysis community learn from Hurricane Katrina? Almost all of the 2500 PD and HD patients dialyzing in 43 units in New Orleans were displaced to other U.S. cities, including Baton Rouge, Houston, and Atlanta. Some even ended up in Network 5 (about 8 patients)The focus on emergency preparedness has increased significantly since 9/11/2001, and most recently, Hurricane Katrina in August 2005. What did the dialysis community learn from Hurricane Katrina? Almost all of the 2500 PD and HD patients dialyzing in 43 units in New Orleans were displaced to other U.S. cities, including Baton Rouge, Houston, and Atlanta. Some even ended up in Network 5 (about 8 patients)

5. Case Scenario 1 Patient calls the Network and files a grievance. Among many things, he states that he refuses to have a certain technician cannulate him because the technician had been talking about the horrible divorce she was going through, and she was angry. He was afraid that she wouldn�t concentrate on his arm. Many of the patients who were displaced had been without dialysis for 1 week or longer before restarting. In all, 94 facilities closed for at least 1 week (in Louisiana, Mississippi, and Alabama). As of June 2007, 17 facilities remained closed (16 in Louisiana, 1 in Mississippi). The majority of dialysis facilities had detailed patient evacuation plans, including dietary recommendations, medication supplies, and contact numbers. Additional info: USRDS data report that Louisiana and the surrounding region have the highest incidence of CKD and ESRD in the nation. A quarter of the population had household incomes below the federal poverty level. In Louisiana, the number of patients who had ESRD and were receiving dialysis fell from 7557 patients on July 31, 2005 (before the storm), to 6213 on August 31, 2005, immediately after the storm (an 18% reduction). By December 31, 2005, the Louisiana ESRD population had grown to 6731 (89% of the pre-hurricane census). Of the 5849 Gulf Coast dialysis patients who were affected by Hurricane Katrina (including those in Louisiana, Mississippi, Alabama, and northern Florida), 148 deaths occurred in the first month after the storm (mortality rate 2.5%; CMS claims data, provided by ESRD Network 13, 2005). However, morbidity and mortality related to Hurricane Katrina are difficult to establish for two reasons. First, patients with ESRD have high rates of morbidity and mortality, particularly from cardiovascular disease, for which mortality rates are 10- to 30-fold higher for dialysis patients compared with similarly aged patients from the general US population. Under these circumstances, identifying �storm-related� deaths may be difficult. Second, many patients remain permanently displaced after the hurricane and securing information on their health remains a challenge.Many of the patients who were displaced had been without dialysis for 1 week or longer before restarting. In all, 94 facilities closed for at least 1 week (in Louisiana, Mississippi, and Alabama). As of June 2007, 17 facilities remained closed (16 in Louisiana, 1 in Mississippi). The majority of dialysis facilities had detailed patient evacuation plans, including dietary recommendations, medication supplies, and contact numbers. Additional info: USRDS data report that Louisiana and the surrounding region have the highest incidence of CKD and ESRD in the nation. A quarter of the population had household incomes below the federal poverty level. In Louisiana, the number of patients who had ESRD and were receiving dialysis fell from 7557 patients on July 31, 2005 (before the storm), to 6213 on August 31, 2005, immediately after the storm (an 18% reduction). By December 31, 2005, the Louisiana ESRD population had grown to 6731 (89% of the pre-hurricane census). Of the 5849 Gulf Coast dialysis patients who were affected by Hurricane Katrina (including those in Louisiana, Mississippi, Alabama, and northern Florida), 148 deaths occurred in the first month after the storm (mortality rate 2.5%; CMS claims data, provided by ESRD Network 13, 2005). However, morbidity and mortality related to Hurricane Katrina are difficult to establish for two reasons. First, patients with ESRD have high rates of morbidity and mortality, particularly from cardiovascular disease, for which mortality rates are 10- to 30-fold higher for dialysis patients compared with similarly aged patients from the general US population. Under these circumstances, identifying �storm-related� deaths may be difficult. Second, many patients remain permanently displaced after the hurricane and securing information on their health remains a challenge.

6. Case Scenario 2 A facility calls to report a behavior problem in a patient. He refuses to allow but one technician to cannulate him. It was discovered that this technician had been telling him that she would take the best care of him and that she would ensure nothing would happen to him. DCI � Tulane reopened on November 17, 2006 in a new location.DCI � Tulane reopened on November 17, 2006 in a new location.

7. Case Scenario 3 A grievance was filed by a patient who stated she had been giving a nurse $20 per treatment to provide her with the best care possible. Subsequently, the nurse did provide great care, but became overwhelmed with the amount of work it took to keep the patient happy. Most patients were displaced to Baton Rouge� All Baton Rouge facilities had generators. Water was available thanks to Baton Rouge Water Company�s planning efforts after Hurricane Betsy in 1965. Louisiana Dept. of Public Health set up surge hospital/triage center in athletic facilities at Louisiana State University. Treatment was provided by US Public Health Services officers, medical emergency response teams from various states, and many volunteers. In the 1st week post-Katrina, 700 ESRD patients who were evacuated from the New Orleans area received dialysis. This was in addition to the 1000 patients who concurrently received their regular treatments in the Baton Rouge area. Most patients were displaced to Baton Rouge� All Baton Rouge facilities had generators. Water was available thanks to Baton Rouge Water Company�s planning efforts after Hurricane Betsy in 1965. Louisiana Dept. of Public Health set up surge hospital/triage center in athletic facilities at Louisiana State University. Treatment was provided by US Public Health Services officers, medical emergency response teams from various states, and many volunteers. In the 1st week post-Katrina, 700 ESRD patients who were evacuated from the New Orleans area received dialysis. This was in addition to the 1000 patients who concurrently received their regular treatments in the Baton Rouge area.

8. Case Scenario 4 Limited early evacuation for vulnerable individuals, including dialysis and transplant and those with limited mobility. Both landline and cell phone networks overwhelmed and functioned poorly. Some patients delivered to out of area hospitals for dialysis, overwhelming the capacity of facilities to handle all patients, not set up to take dialysis patients. Not enough medical staff. Some needed PD supplies but did not have contracts with suppliers. No designated shelter for dialysis patients, making them transient. Made tracking and transportation difficult. Dialysis staff didn�t know where patients were and couldn�t contact them. No easily accessible dialysis patient database available (no way to estimate number of patients coming). Difficulty obtaining supplies because of transportation. Limited early evacuation for vulnerable individuals, including dialysis and transplant and those with limited mobility. Both landline and cell phone networks overwhelmed and functioned poorly. Some patients delivered to out of area hospitals for dialysis, overwhelming the capacity of facilities to handle all patients, not set up to take dialysis patients. Not enough medical staff. Some needed PD supplies but did not have contracts with suppliers. No designated shelter for dialysis patients, making them transient. Made tracking and transportation difficult. Dialysis staff didn�t know where patients were and couldn�t contact them. No easily accessible dialysis patient database available (no way to estimate number of patients coming). Difficulty obtaining supplies because of transportation.

9. Case Scenario 5 A dialysis facility dietitian has been trying to explain the importance of monitoring potassium. The patient begins yelling at the dietitian that she didn�t eat much potassium, and she was sick and tired of being harassed. The patient continues to get louder and tells the dietitian, �What do you know? You are too fat yourself!� The dietitian says to the patient, �If you don�t shut up you can never come back here!�

10. The purpose of this slide, aside from humor, is to drive home the point that emergencies are local. We cannot depend on the federal or state government to take care of us in an emergency. Patients must take personal responsibility for their care through education and planning. Facility staff bear some responsibility for assisting patients in acquiring this education and planning for emergency events. The goal of this training is to get participants thinking about what they can do in the facility and their home lives and that of their patients to prepare for and respond to emergency events. The key to a successful response is proper planning and preparation ahead of time! The purpose of this slide, aside from humor, is to drive home the point that emergencies are local. We cannot depend on the federal or state government to take care of us in an emergency. Patients must take personal responsibility for their care through education and planning. Facility staff bear some responsibility for assisting patients in acquiring this education and planning for emergency events. The goal of this training is to get participants thinking about what they can do in the facility and their home lives and that of their patients to prepare for and respond to emergency events. The key to a successful response is proper planning and preparation ahead of time!

11. Case Scenario 7 Patient called the Network and stated that last Friday the head nurse took him home from dialysis because his brother was sick. When he returned on Monday his brother was still sick, but the nurse wouldn�t take him home. He was upset that the staff didn�t care.

12. Professionalism Pitfalls Over self-disclosure-discussing personal problems Super-Nurse, Super-Tech, Super Social Worker, Super Dietician Special treatment to a patient-bending the rules Patient giving staff special attention Selective communication �You and Me against the World� Name calling Threatening Discussing employer/employee issues (salary, staff errors, etc.) Most of the emergencies impacting patients and providers will be natural disasters (hurricanes, flooding) but your facility�s disaster plan should be broad enough to address most types of internal and external events Most of the emergencies impacting patients and providers will be natural disasters (hurricanes, flooding) but your facility�s disaster plan should be broad enough to address most types of internal and external events

13. More Pitfalls Moralizing Ordering Psychological diagnosing Gossip Flirtations Inappropriate dress Gifts Assist facilities in developing disaster plans. MARC has a template available to assist facilities in developing a plan webpages for emergency prep and pandemic flu facility and patient emergency preparedness guides (English and Spanish) presentations throughout Network 5 region (Back to School, American Kidney Fund, annual Council meetings) 2. Coordinate with providers, emergency workers, and other essential persons to ensure that the needs of individuals are being met and that patients have access to dialysis. The Network has participated on all KCER Coalition calls as required, and the Director of Operations remains active with the Coalition�s Patient and Provider Tracking Workgroup. In April 2006, a letter was sent to state and federal emergency management and health departments highlighting the needs of dialysis patients and requesting their inclusion (as well as that of dialysis facility workers) in the �high risk� priority group for vaccinations and/or anti-virals in the event of a pandemic flu. Have worked closely with the Hampton Roads (Virginia) Planning District Commission to educate them on the special needs of dialysis patients. 3. Assist providers and patients in determining status of dialysis facilities. MARC requires that facilities report their open/closed status to MARC ASAP, and then twice weekly post event. �OPEN� = potable water, power from any source, and sufficient staff and supplies to provide dialysis; �CLOSED� = anything else MARC will post facility status info to https://dialysisunits.com and MARC website if possible If MARC is impacted by emergency event, patients and providers can call Kidney Community Emergency Response (KCER) Coalition toll-free Hotline 866 -901-ESRD (866-901-3773) to get contact information for the designated alternate Network which can assist them 4. Provide information to family members and treating facilities on where a patient previously/currently is receiving services to assist in the location of individuals and the exchange of critical medical information. KCER Coalition has developed a Disaster Patient Activity Report (DPAR) to be used by facilities to report on the status of current and transient patients twice weekly post-event. The KCER Coalition also developed a standardized emergency dataset (which has been approved by FMC, DaVita, and NRAA) with the recommendation that providers produce paper copies of the dataset in any form from their databases at least quarterly for each patient. Patients should be instructed to carry the dataset with them in the event of evacuation. Assist facilities in developing disaster plans. MARC has a template available to assist facilities in developing a plan webpages for emergency prep and pandemic flu facility and patient emergency preparedness guides (English and Spanish) presentations throughout Network 5 region (Back to School, American Kidney Fund, annual Council meetings) 2. Coordinate with providers, emergency workers, and other essential persons to ensure that the needs of individuals are being met and that patients have access to dialysis. The Network has participated on all KCER Coalition calls as required, and the Director of Operations remains active with the Coalition�s Patient and Provider Tracking Workgroup. In April 2006, a letter was sent to state and federal emergency management and health departments highlighting the needs of dialysis patients and requesting their inclusion (as well as that of dialysis facility workers) in the �high risk� priority group for vaccinations and/or anti-virals in the event of a pandemic flu. Have worked closely with the Hampton Roads (Virginia) Planning District Commission to educate them on the special needs of dialysis patients. 3. Assist providers and patients in determining status of dialysis facilities. MARC requires that facilities report their open/closed status to MARC ASAP, and then twice weekly post event. �OPEN� = potable water, power from any source, and sufficient staff and supplies to provide dialysis; �CLOSED� = anything else MARC will post facility status info to https://dialysisunits.com and MARC website if possible If MARC is impacted by emergency event, patients and providers can call Kidney Community Emergency Response (KCER) Coalition toll-free Hotline 866 -901-ESRD (866-901-3773) to get contact information for the designated alternate Network which can assist them 4. Provide information to family members and treating facilities on where a patient previously/currently is receiving services to assist in the location of individuals and the exchange of critical medical information. KCER Coalition has developed a Disaster Patient Activity Report (DPAR) to be used by facilities to report on the status of current and transient patients twice weekly post-event. The KCER Coalition also developed a standardized emergency dataset (which has been approved by FMC, DaVita, and NRAA) with the recommendation that providers produce paper copies of the dataset in any form from their databases at least quarterly for each patient. Patients should be instructed to carry the dataset with them in the event of evacuation.

14. Proper Professional Behavior

15. Why is professionalism hard in the dialysis unit? Staff have baggage Difficulties at home Challenging situations at work Time constraints Not enough staff Multiple losses Patients have baggage Decreased ability to function independently Multiple losses Difficulties at home Minimum requirements for dialysis facilities, More commonly know as �v-tags�, can be cited by State Survey Agency for non-compliance There is an established written plan for dealing with fire and other emergencies Should be developed in cooperation with fire and other expert personnel Should have 4 components � prevention (when possible), preparation, response, and recovery Should address emergency equipment, transportation, staffing, communications, evacuation, health records, and continuity of patient care 2. All personnel are trained as part of their orientation. The written emergency preparedness plan provides for orientation, regular training, and periodic drills in all procedures; each person is able to promptly and correctly carry out his or her role in an emergency 3. There is fully equipped emergency tray available at all times. To include emergency drugs, medical supplies, equipment Staff should be trained on use 4. Staff are familiar with the use of all dialysis equipment and procedures to handle medical emergencies 5. Patients are trained to handle medical and non-medical emergencies (how to get off dialysis machine if they need to evacuate, etc.) Should assist patients in developing individual emergency plans and review the plan regularly Patients should know what to do, where to go, and whom to contact if an emergency occurs Minimum requirements for dialysis facilities, More commonly know as �v-tags�, can be cited by State Survey Agency for non-compliance There is an established written plan for dealing with fire and other emergencies Should be developed in cooperation with fire and other expert personnel Should have 4 components � prevention (when possible), preparation, response, and recovery Should address emergency equipment, transportation, staffing, communications, evacuation, health records, and continuity of patient care 2. All personnel are trained as part of their orientation. The written emergency preparedness plan provides for orientation, regular training, and periodic drills in all procedures; each person is able to promptly and correctly carry out his or her role in an emergency 3. There is fully equipped emergency tray available at all times. To include emergency drugs, medical supplies, equipment Staff should be trained on use 4. Staff are familiar with the use of all dialysis equipment and procedures to handle medical emergencies 5. Patients are trained to handle medical and non-medical emergencies (how to get off dialysis machine if they need to evacuate, etc.) Should assist patients in developing individual emergency plans and review the plan regularly Patients should know what to do, where to go, and whom to contact if an emergency occurs

16. How do we stop �baggage� from affecting us? MAINTAIN BOUNDARIES!!! What is your purpose here? Why are you here? What is the goal? Whose needs are supposed to be met? HELPING RELATIONSHIPS ARE NOT RECIPRICAL!! PROFESSIONALS GET PAID! Requires a written agreement or arrangement between facility and center (hospital) for provision of services. Can also be between dialysis facilities Preferably between facilities not located in the same geographic reason where both would not be simultaneously impacted by same event b. Agreement provides that patients will be accepted and treated by the hospital/alternate facility in emergencies Both facilities/facility and hospital should have documentation on file to the effect that patients will be accepted and treated in emergencies *Agreement may also include a provision for sharing staff (e.g., in pandemic flu or post-disaster, could have staff shortages) Requires a written agreement or arrangement between facility and center (hospital) for provision of services. Can also be between dialysis facilities Preferably between facilities not located in the same geographic reason where both would not be simultaneously impacted by same event b. Agreement provides that patients will be accepted and treated by the hospital/alternate facility in emergencies Both facilities/facility and hospital should have documentation on file to the effect that patients will be accepted and treated in emergencies *Agreement may also include a provision for sharing staff (e.g., in pandemic flu or post-disaster, could have staff shortages)

17. Rational Detachment �.. Rational detachment is the ability to stay in control of one�s own behavior and not take acting-out behavior personally. Even in an emergency situation, facilities are responsible for the safeguarding of medical record information! Medical records are secured onsite with policies regarding storage, access, and retention Where are records stored? How will you protect records from water damage? Fire? Who is responsible for ensuring that records are not destroyed in emergency? Designate more than 1 person Theft can constitute an emergency: Who has access to records? What security measures are in place to protect confidential information? Even in an emergency situation, facilities are responsible for the safeguarding of medical record information! Medical records are secured onsite with policies regarding storage, access, and retention Where are records stored? How will you protect records from water damage? Fire? Who is responsible for ensuring that records are not destroyed in emergency? Designate more than 1 person Theft can constitute an emergency: Who has access to records? What security measures are in place to protect confidential information?

18. Rational Detachment Staff not able to control baggage, but can control how they react DO NOT internalize feelings DO NOT overreact This is OUR responsibility, not the clients�

19. How do we rationally detach? Know yourself What pushes your buttons? Don�t let someone find out for you. Recognize your limits What is your tolerance level? Anticipate and have a plan Positive outlets and coping skills Our response can either escalate or de-escalate the situation. Preparedness is more than knowing whether you are located in a hurricane zone Preparedness is more than knowing whether you are located in a hurricane zone

20. What if I am not sure whether I am being professional? Ask yourself these questions: Would this be allowed in another medical setting? How does this activity assist the patient in care of his or her ESRD? Can this be documented in the medical record? Are you willing to do this for all patients? 2. How ready is your facility? To minimize damage: a. Secure facility to prevent injuries during disaster: Ceiling TVs secured Machines and chair wheels locked Oxygen tanks secured Water treatment components secured Storeroom shelves secure, heavy items are on bottom shelves Emergency exits well marked and pathways clear Label utility shutoff valves Keep trees trimmed and away from power lines b. Keep patient and business records secure Keep data backed up with copies in a secure location Make paper copies of your patients� orders and medication lists on a periodic basis (at least quarterly or if changed) Distribute copies to your patients All facilities should maintain off-site copies of -comprehensive list of all pts -2728 forms -dialysis prescription -care plan for each pt -DNR or Advance Directives Should also keep copies onsite in secure water and/or fire proof box; keep in secure location and where it is easily accessible in event of evacuation; update regularly Facility medical and financial records should be backed up regularly and stored in secure off-site location c. Have a back up utility plan Power: If you do not have an onsite generator you should have a written contract with someone who will agree to provide one if needed. Have a known supply of fuel Water: Make a back up plan. You may need to have an adapter made. Phone: Telephone networks are generally designed to provide 15% capacity, assuming that most subscribers will not be using their phones at the same time. In emergency, phone lines likely to be overwhelmed Consider redundant methods of communication: satellite phone, landline, Blackberry, even amateur radio 2. How ready is your facility? To minimize damage: a. Secure facility to prevent injuries during disaster: Ceiling TVs secured Machines and chair wheels locked Oxygen tanks secured Water treatment components secured Storeroom shelves secure, heavy items are on bottom shelves Emergency exits well marked and pathways clear Label utility shutoff valves Keep trees trimmed and away from power lines b. Keep patient and business records secure Keep data backed up with copies in a secure location Make paper copies of your patients� orders and medication lists on a periodic basis (at least quarterly or if changed) Distribute copies to your patients All facilities should maintain off-site copies of -comprehensive list of all pts -2728 forms -dialysis prescription -care plan for each pt -DNR or Advance Directives Should also keep copies onsite in secure water and/or fire proof box; keep in secure location and where it is easily accessible in event of evacuation; update regularly Facility medical and financial records should be backed up regularly and stored in secure off-site location c. Have a back up utility plan Power: If you do not have an onsite generator you should have a written contract with someone who will agree to provide one if needed. Have a known supply of fuel Water: Make a back up plan. You may need to have an adapter made. Phone: Telephone networks are generally designed to provide 15% capacity, assuming that most subscribers will not be using their phones at the same time. In emergency, phone lines likely to be overwhelmed Consider redundant methods of communication: satellite phone, landline, Blackberry, even amateur radio

21. How to Promote Professionalism in the Dialysis Unit Be aware- if you deny power you are at risk for misusing it Be observant In-service over and over again 3. Prepare staff a. Identify the disaster organizational structure you will use in the event of a disaster. Who is the person in charge? Who will account for all patients and staff? Who will contact your patients? Who will grab the emergency evacuation box? Who will call the utilities? b. Develop a communications plan: How will you keep in contact with each other, patients and local disaster response teams? Give patients a number to contact you with (designate at least 2 �disaster contacts� and the Network requires 2 disaster contacts with a work phone number and 2 alternate means of communication) Run PSAs on tv, radio; update website if possible Have an �out of area� contact number (facility you have agreement with?) c. Educate key personnel in their roles during a disaster. Hold periodic disaster drills (at least quarterly) Include your patients in the drills Evaluate and modify your plans based on how the drill goes 3. Prepare staff a. Identify the disaster organizational structure you will use in the event of a disaster. Who is the person in charge? Who will account for all patients and staff? Who will contact your patients? Who will grab the emergency evacuation box? Who will call the utilities? b. Develop a communications plan: How will you keep in contact with each other, patients and local disaster response teams? Give patients a number to contact you with (designate at least 2 �disaster contacts� and the Network requires 2 disaster contacts with a work phone number and 2 alternate means of communication) Run PSAs on tv, radio; update website if possible Have an �out of area� contact number (facility you have agreement with?) c. Educate key personnel in their roles during a disaster. Hold periodic disaster drills (at least quarterly) Include your patients in the drills Evaluate and modify your plans based on how the drill goes

22. Where to go for help �Drawing the Lines of Professional Boundaries� NKF The Ethics of Relationships Mary Rau-Foster �Professional Boundaries: A nurse�s guide� d. Have a back up facility agreement with a facility that can take your patients Nearby facility because this simplifies transportation issues, but if event is regional should have back-up in a noncontiguous geographical area as it is less likely to be affected. e. Know in advance whom to contact for assistance and information Your ESRD Network (Required to report open/closed status to Network "Open" facilities are defined as facilities that have potable water, electricity from any source, and supplies and staff sufficient to provide dialysis, and that are performing dialysis. Anything less than this is considered "closed."Required to submit DPAR 5 days post event and then semiweekly until return to normal operations) City, County and State Emergency Response Teams American Red Cross Chapter Security Company d. Have a back up facility agreement with a facility that can take your patients Nearby facility because this simplifies transportation issues, but if event is regional should have back-up in a noncontiguous geographical area as it is less likely to be affected. e. Know in advance whom to contact for assistance and information Your ESRD Network (Required to report open/closed status to Network "Open" facilities are defined as facilities that have potable water, electricity from any source, and supplies and staff sufficient to provide dialysis, and that are performing dialysis. Anything less than this is considered "closed."Required to submit DPAR 5 days post event and then semiweekly until return to normal operations) City, County and State Emergency Response Teams American Red Cross Chapter Security Company