Calls for government to fix gaps in kidney dialysis delivery before “the system breaks”

A new report has exposed the perilous state of haemodialysis capacity and staffing in the country’s fifteen kidney dialysis treatment units.

The report, the first undertaken surveying Aotearoa New Zealand’s kidney dialysis regions, shows some are operating beyond capacity, placing a huge burden of care on over -stretched staff in order to get by.

Kidney Health New Zealand (KHNZ) says the report’s findings paint a concerning picture of a health service struggling to cope and at breaking point, despite the best efforts of dedicated staff.

KHNZ Acting General Manager Traci Stanbury says all 15 dialysis regions admit to being affected by capacity constraints, with half struggling from chronic under-staffing, too few dialysis treatment chairs, and a lack of physical infrastructure.

“We are calling for the government ,Te Whatu Ora and Te Aka Whai Ora to urgently address shortages in haemodialysis capacity nationwide. While some investment is indeed underway, the capacity coming on-stream this year will not address current gaps, nor urgent staffing shortages. This shortfall is due to a lack of planning over many years to provide critical infrastructure across the system. Longer-term planning and strategy are required, and soon” says Stanbury.

The report, carried out between June 2022 and February 2023, shows there are 1980 patients currently receiving long-term outpatient haemodialysis at a hospital or satellite facility, (with hundreds more dialysing at home). However, with 441 outpatient spaces, and a preferred care model requiring patients to receive haemodialysis three times per week for a minimum of four hours at a time, there is current capacity for only 1764 patients weekly. What’s more, one dialysis machine space can accommodate 4 patients during daytime hours, 8 of the 15 renal units are reporting a space ratio greater than 4, with three units reporting a ratio of 6 patients per machine daily (which often means hours are reduced).

KHNZ says the capacity crisis is compounded by a 25 per cent shortfall in dialysis unit staff up and down the motu, with most regions reporting their current staffing levels can’t meet demand.

The survey suggests a staffing ratio of just over 5 patients per staff member is desirable. However, to achieve this, the country’s 15 regions would need to hire an extra 100 fulltime dialysis staff over and above the current 398 staff numbers employed to make up the shortfall. The average staff to patient ratio in all 15 units currently is 6 patients per FTE, as opposed to the recommended standard of 4 patients per FTE.

Head of Nephrology for Te Whatu Ora Southern, Professor Rob Walker, says despite the pressures, Aotearoa’s dialysis units and their staff are doing a fantastic job coping with this challenge.

“They are going “above and beyond” on a daily basis, and we salute the work they are doing to prioritise patient safety and provide the best care possible for their patients. However, we cannot keep asking the workforce to carry on this way, day after day, week in, week out. As well as being unacceptable for patients, it’s also having a significant impact on staff morale, mental health, recruitment, and retention,” says Professor Walker.

“Renal teams report struggling to either attract or keep staff, with a lack of adequate staffing causing burnout. Some have seen mass resignations and an exodus of nurses and physiologists, with one team reporting a loss of 8 dialysis nurses over one six-month period alone,” Stanbury says.

Professor Walker says many dialysis units are adopting interim measures to ensure patient safety is prioritised, balancing need with capacity in the short term.

“Some units are reducing staff-to patient ratios, asking staff to work overtime and double shifts, and stopping home dialysis training to get by. Home dialysis training requires much more hands-on involvement by staff, so a training patient-to-staff ratio should be 2 to 1. However, by stopping home dialysis training, this then adds to the congestion within the dialysis units, as well as preventing the individual from being at home with their whānau and in many cases preventing them from returning to work – all of which means a sub-optimal outcome for both our patients and community.

“Ideally, we like to plan the commencement of dialysis with an individual and their whānau in such a way that they don’t become unwell with their kidney failure yet not start too early. However, of concern, six units reported delaying the start of haemodialysis treatment for new patients because of a lack of space, with several admitting their patients remained on sub-optimal therapies due to a lack of capacity. Whilst all patients who need dialysis will get dialysis, a sub-optimal start can lead to acute hospitalisations and a “crash-start “as opposed to a planned start for their dialysis. This in turn then prolongs their recovery with further costs to the health system,” Professor Walker says.

He stresses that dialysis is a life-preserving treatment – if patients do not receive it, their health can decline rapidly within a couple of weeks.

The report makes 27 recommendations – among them; inviting the government to re-think its delivery of all kidney services in Aotearoa; and screening to detect kidney disease earlier, to slow down the progression of kidney disease.

KHNZ says 1 in 11 people in Aotearoa New Zealand have chronic kidney disease yet less than half are aware of it – and with kidney disease usually silent, early and effective intervention is cost-effective, and reducing the number of patients reaching end-stage would also reduce the escalating financial burden of haemodialysis on the health system.

It says it’s also important to stress the current inequity of access to dialysis facilities nationwide, particularly in rural areas where Māori are disproportionately represented. Its calling for more effective delivery of dialysis treatments closer to where patients live.

“Nearly half of all centres report having patients who travel over 2 hours each way to access dialysis, a round trip of over 4 hours on top of a dialysis session of 4-6 hours, three times per week, creating clear inequity of access due to rurality,” says Stanbury.

“We suggest the use of long-term capacity planning to shift hospital-based services to satellite and community-based services, such as rest homes providing hospital-level care, located closer to where many Māori and rural patients reside” says Stanbury.

KHNZ says demand for dialysis is forecast to grow by 30 per cent over the next decade, which will see costs increase by $150 million per annum in the next decade.

“The solution is to slow the growth of kidney disease and kidney failure in Aotearoa by developing a new, patient-centred approach to the early detection and management of kidney disease, as well as addressing inequities in care and the impacts on Māori and Pasifika who make up 61 per cent of all patients starting dialysis,” says Traci Stanbury.

The Australian and New Zealand Society of Nephrology (ANZSN) backs KHNZ’s call for action, calling the report’s findings “extremely concerning”.

“ANZSN strongly supports KHNZ’s call for the New Zealand Government to not only urgently address the haemodialysis capacity crisis, but also long-term planning and implementation of adequate resourcing to provide optimal kidney health for all people,” says President David Johnson.

“Unless swift corrective and preventative action is taken, there is a high risk of serious clinical incidents and loss of life, which will disproportionately affect the most vulnerable and disadvantaged sections of the community, particularly those living in rural and remote locations.”

ENDS

WHAT IS HAEMODIALYSIS?

Haemodialysis is a form of dialysis where a patient’s blood is cleansed by a dialysis machine. The patient is “hooked up” by a tube from a vein in the arm to a dialysis machine, where the blood is cleaned of wastes (which is what working kidneys do). Haemodialysis can be done – with training – at home; but is more commonly done with trained staff support in a hospital setting or in a community dialysis setting (a dedicated facility with trained staff away from a hospital).