Every day, patients with end-stage renal disease (ESRD) require lifesaving dialysis. It removes waste from their blood, doing the work their kidneys can no longer do. In Houston, many of them come to Harris Health System, which does the work that other hospitals can’t – or won’t – do. Many of these patients are undocumented immigrants who don’t qualify for chronic dialysis care. They come to Harris Health’s emergency department (ED), where they are quickly triaged and given emergency dialysis treatment – and hope for survival.
Finding the Needles
Federal and Texas state laws prohibit outpatient dialysis for undocumented immigrants. So, these patients have to qualify for dialysis under emergent criteria, which means potassium at a near life-threatening level. “It’s very challenging,” explains Valerie Howell, RN, MSN, MBA, administrative director of nursing at Harris Health’s Ben Taub Hospital. “We have to abide by the law, but if we wait too long, something can happen to them.” It’s a tightrope, and when these patients reach the ED, timing is crucial.
“We have 140 patients who visit our ED on a regular basis, Howell says. “And we have to process them very quickly to see where they stand.” To do so, Harris Health created a special triage model. “When they check in, we check their labs immediately to see if they meet the emergent dialysis criteria,” Howell says. Those who meet the emergent threshold receive immediate treatment. Others are discharged, but are back in the ED within days.
Even though Harris Health technically provides these patients acute care, for many, this is the only dialysis treatment they can get. Recognizing this fact, Harris Health has incorporated multiple best practices into its care model. These protocols include the following:
- checking patients’ hepatitis B status
- managing anemia
- admitting patients to the hospital when the need arises
- placing a hemodialysis catheter (a tube placed under the skin for access to a patient’s blood) in patients so they don’t have to get re-catheterized each time they come in
- bilingual education, including caring for their catheter, recognizing the symptoms indicating the need for dialysis, understanding the importance of going to the hospital when symptoms arise, and following dietary restrictions
Pushing for Progress
“In the last 10 years, the number of patients in the Houston area with ESRD has increased exponentially,” Howell says. As of June 2014, Harris Health System was providing roughly 500 emergent criteria dialysis assessments per month, as many as 30+ walk-ins per day at its two acute inpatient hospitals. This growth is partially due to the fact that Houston’s undocumented immigrant population is growing and the fact that people are coming to Harris from other cities that have discontinued dialysis services. “It’s simply too expensive,” Howell notes.
In response to the growing population, Harris Health built Riverside Dialysis Center, a chronic care dialysis center for patients who reside in Harris County. The center quickly reached capacity by filling its 150 spots. When the rare opening does occur, an interdisciplinary committee reviews patients’ medical records and determines eligibility for placement in the dialysis unit.
The benefits of chronic care are clear. In addition to the improved health outcomes for patients receiving care at Riverside versus the ED, their quality of life is that much better. “Processing through the ED is an all-day ordeal,” Howell explains. “Our patients can’t maintain jobs because of this.” In fact, employment for this population drops from 90 percent to 14 percent after being diagnosed with ESRD.
Indeed, Riverside is the goal for many of these patients, but when full, it leaves many still waiting in the ED. “It gives them hope and keeps them going,” Howell says.
And in the meantime, Harris continues to search for better treatment options. “We are looking at home peritoneal dialysis programs,” Howell says. Peritoneal dialysis is the process of filtering blood through the lining of the abdominal cavity versus through a machine, as in hemodialysis. Because it can be done at home or even at work, it offers more flexibility for patients and is more cost-effective for the hospital. But, at the same time, it also requires more of the patient. “The majority of our dialysis population is undocumented, non-English-speaking individuals,” Howell notes.“Could they be good candidates for this? They would have more control over their lives. But do they have the right environment and skill set to do it?”
As Harris Health weighs these factors and explores this option, it remains the only essential hospital in Houston and the surrounding region providing hope and a home for acute-care dialysis patients.
For more information on Harris Health System’s dialysis program, please contact:
Valerie Howell, MSN, MBA, RN
Administrative Director of Nursing
Ben Taub Hospital