Lessons in Building an Acute Dialysis Program
November 2022
Summary
Los Angeles area-based Beverly Hospital stands ready to provide in-house hemodialysis services after transitioning from its outsourced provider. The result? Consistency, control and cost savings.
Beverly Hospital is a 202-bed, nonprofit acute care facility serving the community in East Los Angeles County, and it is under pressure. Its service area population, nearly 80% Hispanic/Latino, is medically and socioeconomically underserved. Many residents have a history of diabetes, obesity and hypertension, that has led to a high rate of kidney failure and demand for dialysis, says Charlene Chu, Director of Acute Care and Dialysis at Beverly Hospital, where she manages the nursing staff and ER, ICU, hemodialysis and stroke programs.
Due to this growing need for renal replacement in the community, including cases entering the emergency room, the hospital was experiencing challenges from the outsourced acute dialysis provider that it depended on for intermittent hemodialysis (IHD) treatments. The situation became urgent during the spring 2021 COVID-19 surge. At that time, the average monthly dialysis patient census was over 200, and the outsourced provider was unable to provide stat treatment to critically ill patients. (This compares to a census exceeding 300 a month during the first COVID surge, and a current census of about 150, with most patients now requiring dialysis for chronic kidney disease [CKD]).
“We would be fighting for the outsourced provider’s time, even for routine dialysis,” says Chu, who has been with Beverly Hospital for 32 years. “Patients would often be waiting until after midnight to receive treatment. They did not deserve this kind of service. But it was totally out of my control. Adding to that, many of the outsourced nurses refused to dialyze COVID patients, they were concerned about sitting in the room for the one-on-one treatments.”
Nancy Lee, Senior Vice President of Operations and Chief Nursing Officer, with over 30 years of healthcare management experience, joined Beverly Hospital in March 2020. During the first year of the pandemic, she and her staff found themselves faced with an overwhelming pandemic-fueled demand for dialysis, compounded by limited service from their outsourced provider. By spring 2021, Lee and other hospital leadership decided that something had to change to serve the needs of their community. The team began looking into a versatile new dialysis technology, the Tablo® Hemodialysis System, that they could use to deliver patient care themselves with their own machines and staff.
She discussed the idea with nephrologist Carlos Gonzalez, MD, and Tameem Alhayya, MD, Beverly Hospital’s Chief of the Department of Medicine and Family Practice, who were supportive of the practice transition. After financial and other analyses by hospital administration, the decision was made to forego the long-time outsourced provider for a fleet of Tablo consoles. Chu also hired two experienced dialysis nurses, John Zhang, RN, and PJ Ho, RN, in April 2021. Once the government-required policies and procedures were finalized and approved, the team underwent brief training and went live with Tablo treatments on May 26, 2021.
An Assuring Level of Safety and Efficiency
Seventeen months in, with Tablo in place the team has been able to fulfill their mission of providing high-quality, safe treatment for their patients requiring dialysis. Chu is proud that her frontline team is comprised of critical thinkers who manage the patient caseload very efficiently. “Our nurses are able to dialyze patients at the bedside one-on-one, quickly moving Tablo to any department where it is needed, including ICU, telemetry and med-surg,” she says.
Seventeen months in, with Tablo in place the team has been able to fulfill their mission of providing high-quality, safe treatment for their patients requiring dialysis.
For Lee, Tablo has also contributed to the quality of care at the bedside. “It’s most impressive to me that the equipment itself is supporting our mission to provide a healing environment,” she says. “It doesn’t overwhelm the patient or their family who are there trying to support them. They can have conversations with the nurse and each other during treatment, without the machine being so intrusive. You get to see a very different exchange, in comparison to the situation with other large and daunting machines. And it allows us to pivot so much faster and orchestrate the treatment plan with the patient at such a higher level. That has been so fulfilling for our team.”
Zhang has nearly 20 years of patient care experience using a variety of dialysis machines and treatment settings, in his previous work at large dialysis organizations. He had also used Tablo at a previous hospital where he worked in Southern CA. Ho has worked in inpatient and outpatient dialysis settings for nearly 10 years but had no previous experience on Tablo. Both nurses are feeling comfortable and assured by the safety features built into Tablo, and the impact on their patients.
Ho notes that she didn’t expect Tablo training to be so quick and easy, based on her prior experience with other equipment. “We appreciate that Tablo was designed to be easier for us,” she says. “And from a patient’s point of view, Tablo is so much smaller than the old machines, and that seems to lower their stress while they are on dialysis.”
“It’s most impressive to me that the equipment itself is supporting our mission to provide a healing environment.” – Nancy Lee, Senior VP of Operations and CNO
Prior to joining Beverly Hospital and using Tablo, Ho says she was used to having to troubleshoot reverse osmosis (RO) water systems, in addition to troubleshooting the machines. “We would have to stop everything and have a tech come and work on the RO, or bring another unit out of storage. That would delay treatments. With Tablo, I don’t need to worry about the separate water system anymore, which I really like. I don’t want to ever go back to using the old machines,” she says.
“I like Tablo better, it provides a higher level of safety for our patients,” adds Zhang. “That is my main concern. It is also very easy to work with, to prime and set up.”
When he first started using Tablo at his previous hospital, Zhang says that he was excited but also nervous, because it was so different. “After a few treatments, I felt really comfortable and confident. The machine is so smart and safe, it doesn’t let you skip any steps,” he says. “I don’t want to use the other machines anymore, and I used to think that they were the best thing in the world.”
“The expertise of our nursing staff has really helped us to be successful with our dialysis program, and our workflow is extremely improved. I don’t have to worry anymore about how long a patient has to wait to get their treatment,” says Chu.
Her team also had some unexpected results. “When we first started with Tablo, we kept some contracted outsourced staff on call just in case we needed additional help with treatments. This is because we were so used to having constant problems. But we canceled that contract soon after launch, as our staff took over the program and has been so efficient and successful.”
Owning their Program’s Success
The Beverly Hospital dialysis team has performed nearly 3,000 Tablo treatments since launching their in-house program last May, with a high treatment success rate over that time—including a 99.8% success rate reported in the most recent quarter.
The hospital has also achieved significant operational savings in comparison to their results under the outsourced provider. “We already have witnessed a change in our ability to be better financial stewards, and we know it will only strengthen from here,” says Lee.
Chu stresses that having a dedicated in-house team and support from Outset has been hugely beneficial to patient care. “John and PJ’s leadership and support has been so important for our success. I also have to thank the Outset team for their continuous support, anytime we need them,” she says.
“Now we own our program, and have staff that are able to provide treatment to our patients in a timely manner,” says Dr. Alhayya. “We have consistency and stability in our dialysis program. Tablo has positively impacted patient care, patient satisfaction and also our metrics such as length of stay and other factors that we are monitoring.” Dr. Alhayya, Lee, Chu and the nursing staff all look forward to moving their dialysis program to the next level in the near future, by adding a sustained low efficiency dialysis (SLED) program with Tablo to their ICU.
“Overall it’s been a positive experience for our patients, nursing staff and physicians, and I would advise any acute care facility to evaluate Tablo and see if it fits their needs,” adds Dr. Alhayya.
“Our partnership with Outset allows us to commit to being able to care for our community,” says Lee. “Timely, efficient and high-quality therapy, that’s what we wanted and we’ve been successful at it.”
ABOUT BEVERLY HOSPITAL
Located in Montebello, CA, Beverly Hospital is an award-winning, nationally recognized nonprofit hospital serving East LA and the surrounding communities. The hospital has 202 licensed beds and provides the full range of inpatient and outpatient care. Our mission is to be a leading, independent non-profit community hospital, improving the quality of life of its constituents through health education, disease prevention, and state-of-the-art illness and injury treatment. Our vision is to commit to providing quality health care through a cost-effective organization that educates and motivates all members of our health care team to become personally involved and individually responsible for the continuous improvement of our services.
Notes and disclaimer: Tablo is a next-generation, self-contained, enterprise solution hemodialysis system capable of delivering adaptive kidney replacement therapy, a term used to describe the Tablo system’s unique ability to span a wide spectrum of treatment modalities from intermittent to prolonged dialysis (2-24 hours daily), with or without ultrafiltration. Review recent data on our Clinical Evidence page.
For safety and effectiveness information, indications for use, risks, cautions and warnings, please refer to the product labeling for the Tablo Hemodialysis System.