Frontline Clinic Case Summary

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An End Stage Renal Disease (ESRD) patient in her 30’s has sickle-cell anemia. She has only dialyzed intermittently as an out-patient for a total of a month since admission almost three months ago. She has been hospitalized numerous times in that short duration. The dialysis clinic operates within a certain guideline that prompts movement from having the least recommended dialysis access to one that is considered the most effective and efficient.
The patient has a central line as an access. The clinic as it stands is not meeting the Centers for Medicare and Medicaid Services or CMS guideline (Compton, 2005) to replace her central venous catheter (CVC) or central line access within a ninety day period. If not contraindicated, a permanent access
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The Quality Indicators purpose is to make sure that patients’ quality of life improves. It is to help identify problems, analyze the root cause, and have interventions put in place. Time-bound guidelines such as the 90-day conversion from central lines to fistulas are just guidelines. They are not the law of the land. Hence, frontline clinicians should not be placed under duress just because their corporate rating is less than desired. Also, QI’s are not to label patients either as “problem” patients and make them feel isolated and alienated. Her sickle cell has to be dealt with no matter what. Her choice to not have a fistula is also her choice and her right. The other alternatives are she gets transferred out of the clinic e.g. transfer to another dialysis clinic and let them deal with her; transfer to a PD clinic when she finally has a PD cathether placed in; refer to transplantation which takes months or years, that is if she is even qualified; or hope that she has an acute hospitalization greater than 30 days then she gets discharged from the clinic and be denied readmission. The latter is so ridiculously unethical yet casual conversations as such may possibly occur in break rooms out of desperation. The possibility of transferring to another dialysis clinic is high as most patients or families of patients who are not content in their current facility are given the option to go elsewhere. Staff can never enforce compliance to the point of coercion, to the point of patient transferring elsewhere just to avoid pressure. Most often than not, clinics that are in good standing will comb through medical records to screen their admission. Some clinics that are battling between good standing versus low census will in fact take the hit on their scores and accept even the most problematic patients of all long as they have a private commercial insurance (Conte,

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