workingmomRN

Our FA told our staff this week that CMS is going to cut Medicare reimbursements by 2% for sure and is considering a nearly 10% cut that will result in a lot of smaller dialysis clinics closing causing pts to have to travel farther to get their treatments. CMS is also wanting the dialysis companies to begin providing diuretics & BP meds to their patients, as we are already providing phosphorus binders & EMLA cream or spray. This cut in Medicare will not only affect dialysis, but also hospital services, dr offices, outpatient clinics, etc. I really worry about the direction that our healthcare is going. Obama preached about making healthcare more affordable & more accessible to everyone, but this looks like it will be more costly & out of reach for the people who need it the most.

I have been hearing alot of changes coming in the future for dialysis, none sound very good. What have you all heard & how do you think it will affect our careers as dialysis professionals in the future?

I have been in dialysis since 2000, started with Fresenius then went to Davita. I have worked in some great clinics & 1 particular clinic that was an absolute hellhole. It is hard work, but I like the relationships that we develop with our patients. I do remember that the first year I wanted to quit every day, but I was not determined to let it get the best of me. And I have been here ever since. Just hang in there, it really does get better!

When I started in dialysis, I trained with a PCT to learn about the machines, cannulation, how to troubleshoot the machine when alarms go off. I learned alot from the PCT's I worked with then, and still go to the experienced PCT's if I need to. They are working with patient accesses & machines every day & can show you pretty much anything you need to know. The worst thing you can do is to feel like you should not be learning from a PCT because they are not nurses. When your PCT's figure out that this is how you feel, they will be less willing to help you when you have a problem. Unfortunately, speed is a factor in dialysis & it is related to productivity which management pushes ALOT. It is all about keeping labor hours & costs down. The more patient treatments that are done each day with the least amount of labor hours is even more of a factor now because Medicare has tightened reimbursements alot.

I agree with your post, but your insights about patients come from years of experience. Our OP may be a young nurse starting out & has not gained these insights yet. Kind words of instruction go a long way rather than being harsh & judgmental.

The nurse/patient ratios vary from state to state. In NC, there is no set limit for tech/patient ratio, but the general norm is 4 pts to each tech & 25 patients for 1 nurse. Now, with the new Medicare bundling, etc. we have been told that at the end of the day when the patients are coming off tx, we should send techs home & keep a 5 pt/1 tech ratio. However, it is the nurse's decision whether to keep techs there longer to maintain safety & stability of the floor.

I agree with Acute Dialysis RN. You should go ahead & apply for the job. Clinics would like to get nurses with dialysis experience & certification, but there are not alot of them out there. I think that a nurse has to already have some nephrology or dialysis experience before they can become certified. I'll have to check on that.

These patients with severe hypertension need to control their fluid gains, avoid high sodium foods, & take their bp meds as directed. If they are doing all these things & their bp continues to be high, then the MD needs to adjust their medication regimen. Normally, dialysis pts cannot take their bp meds prior to coming for treatment, but sometimes if their bp does not come down during tx, they may need to take their bp meds before dialysis. The MD would have to make that call, though.

The clinics that I have worked in used to have ACLS meds at one time & there was discussion a few years ago about requiring nurses to have ACLS certification. But that fell away because there has to be a MD in the building before the meds can be administered & most of the time there is no MD there, so certification would really be a waste of time & money. They also have quit keeping the meds in stock as well.

Watch the experienced techs & nurses who are good "stickers". They will give you alot of helpful tips to make it easier for you. Sticking accesses is different, but remember that the grafts are made to accommodate larger needles so they can obtain better blood flow rates during their treatment. Don't let it scare you too much! You will do fine!

In my state there are no dialysis training programs. I got a job at a dialysis clinic & got all on the job training. The clinics will train you in everything you need to know, they have classes that cover all of the aspects of the job. Then they have training beyond the basics of dialysis for the nurses that go beyond just the basics of the dialysis tech duties.

Davita is not too bad to work for. At my clinic, there are only 2 RN's so we each work 3 days a week. I'm not sure how they schedule at larger clinics, probably 4 10-hour days. Davita likes for employees to get involved in different projects like vascular access or infection control, etc. They do not match on the 401k funds, but have bonuses instead. The bonuses are based on patient outcomes, productivity, meeting goals for your clinic. Pay raises are usually based on performance & length of employment. The decline in the economy has resulted in a decrease in amount of pay raises. Davita is as good as any other company to work for, but since you are already experienced in dialysis, I'm sure you have already seen the differences in clinics within the same company.

I agree with the previous posts 100%. Dialysis is not the place for a new grad. You need good assessment skills & the ability to supervise the techs. They can make or break your day, & depending on the size of the clinic, you may be the only RN in the building. Scary sometimes even for us who have been doing this for a long time.

Rock nurse has described the charge nurse's duties very well. It is a lot of headaches because you are responsible not only for your own patients but for supervising the rest of the team as well. It is hard work, but some nurses are handle it very well & some do not. It just depends on what your strengths & weaknesses are.

Try to go with Davita first before FMC. I believe Davita is more patient-oriented than FMC, but it depends on the staff at the individual clinics as to how good or bad it is to work for them. If you can't find a position with either one of them, try hospital nursing. The experience there will help you get a good nursing foundation while you are looking for something else. The nursing home would be my absolute last resort.

585.6 is the code for ESRD stage V, you can use it as well for scheduling procedures such as fistulograms, thrombectomies, that are specific for dialysis pts. Blood cultures can also be 136.9 for unspecified infection The ICD-9 codes listed by dialec are the ones I use as well

I wouldn't want to go back to management again, it was for me a horrible experience. It requires alot from you, and you don't really have any time when you are not on call for your clinic. There is a lot of turnover in management with FMC, much more than Davita. I plan to stick with my regular ol' floor nurse position. When it's time to clock out, you get to go home & not have to take the job home with you.

As a medical facility, the dialysis clinic is responsible to provide O2 if the patients need it. Our clinic recently ordered 2 additional oxygen concentrators because we are getting more patients who are dependent on O2. We had one little man who had to have 6L/min so we had to use 2 concentrators for him each treatment. The NH was kind enough to send us a T-type tubing that could be connected to both concentrators & then to the nasal cannula. Eventually, he has gotten down to 3L now, and has a little portable tank with him when he comes, but it wouldn't last anytime at all. I would really be afraid of the liability of not providing O2 for patients.

I got a letter from FMC last week about unions. Is there a union trying to get into FMC?

Some of the patients will have c/o CP,SOB, not feeling right, anxiety, etc prior to arresting. Some will not have any symptoms at all. You have to be diligent when they go to sleep because they may not have any obvious symptoms. I always look for the chest rise & fall to make sure they are breathing. Another thing that some pct's & nurses both fall into is not actually looking at the patient when doing the vital checks, just the machine. The bp should be taken at the time of the vital check, not 10 or 15 minutes prior.

I've worked in HD for 10 years & have seen a few codes. It seems like it is always the one you least expect. When you have a relationship with the patient, it is certainly an emotional experience. You also don't really have time to grieve when they don't make it because you still have a other patients that need you as well.

You are exactly right about dialysis. It is a growing population of patients because people are living longer with chronic conditions than ever before. All your previous experience will be alot of help because almost all of the patients have other medical, financial, and family/home issues to deal with as well as the dialysis. It's not a bad field to work in, but it has it's share of headaches like anything else. Medicare has made alot of changes and is more outcome-driven now, so there is more pressure on the dialysis companies to be able to show that they are providing quality care. The problem is that alot of the patients were already non-compliant before they started dialysis, and are not going to change readily. The outcomes are dependent on the patients coming for every treatment and taking meds as directed. You have to do alot of teaching & motivation, but in the end it is all on the patient to comply. Some of our pts who actually are compliant have had changes in their health plans & their meds that they need are no longer being covered. I'm not sure how all this healthcare reform is going to be, but I am afraid it is not all going to be good.

I have been a nurse for 10 years, but just recently started working in hospice. My PCC recommended the articles that are posted on the hospice nursing forum in this website.

The previous posts are exactly right about having some previous experience before going into dialysis. I have been in dialysis for 10 years, and I still get uneasy about being the only nurse in the unit. People do code on the machine, have strokes & seizures, or become unresponsive if their bp drops too low. Since you will be the nurse, the staff will be looking to you for direction about what to do. It's scary! When I graduated nursing school, I absolutely hated hospital work, but I knew that I needed to learn more things before going into a specialty. I worked in a hospital for a little over a year. I'm glad I did, too. Also, if you start out in dialysis, you won't have any skills other than dialysis, which will make it really hard to get into another area of nursing. Davita benefits are pretty comparable to other companies, but they do not match any funds on the 401k. They tell you that the bonuses are more than you would get from matching 401k, but if your clinic does not meet their goals, you will not get any bonus.

You did get a lucky break! Since you will be the only one in class, you will probably be able to cover the material quicker & maybe get out of class earlier. Alot of it is stuff you have heard before, like the water system & water checks, etc. There is also a written competency exam you have to take, but you will go over it with your inservice instructor. Keep us posted on how it goes!