Chapter 1 The hemodialysis team

Dialysis, the process of cleansing the blood of accumulated waste products, is a complex treatment requiring a team of highly trained individuals with a variety of skills. For this chronic treatment to be successful, the interdisciplinary team must work with the patient and family, supporting them in the areas of clinical need, psychosocial needs, and religious beliefs. Team members will include, but not be limited to, the physician, nurse, technician, dietitian, social worker, and administrator. Other team members might include a biomedical technician, psychologist, dentist, child development specialist, pharmacist, physician’s assistant, vocational rehabilitation counselor, member of the clergy, nurse practitioner, and clinical nurse specialist, or others who have special skills needed to help the patient reach maximum potential. The patient and family members are integral components of the dialysis team; without them, all efforts of the other team members would be fruitless.

Structure of the dialysis facility

Every dialysis facility has a medical director who is ultimately responsible for medical care in the facility. He must have completed a board-approved training program in nephrology and have at least 12 months of experience in nephrology. The medical director also must be certified in internal medicine or pediatrics. The medical director is required to be knowledgeable of and responsible for the integrity of the water treatment system in the facility. He must ensure that the system will produce water that meets the standards of the Association for the Advancement of Medical Instrumentation (AAMI). The medical director is also responsible for the Quality Assessment and Performance Improvement (QAPI) program. Each dialysis facility has written policies and procedures that guide staff members in the clinical practice and patient care and that monitor established standards of care, quality assurance, equipment and maintenance standards, reuse, and any pertinent medication or treatment protocols. These policies are written by the team and approved by the facility and nursing administrator, as required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for a special care unit. Freestanding facilities do not fall under the aegis of JCAHO. However, their policies and procedures must be approved by the facility’s governing body, which includes the medical director, director of nursing, and administrator, and be in accordance with the laws of that state and the rules of the Centers for Medicare & Medicaid Services (CMS). Whenever a patient in acute renal failure or a severely uremic patient is dialyzed in the hospital setting, a physician should be readily available to handle crises or complications of the treatment.

Role of the physician

The nephrologist assesses the patient and determines when chronic kidney disease (CKD) has advanced and requires the initiation of dialysis treatment. A nephrologist is an internist with further specialty training of two to three years in the field of nephrology. Evidence points increasingly to the importance of having patients seen and followed by a nephrologist early in the course of CKD, and long before progression to the time when maintenance dialysis is required. With early nephrological intervention, appropriate medical therapy can be instituted, perhaps improving or at least maintaining renal function and slowing the need for dialysis.

When the need for dialysis is determined, the nephrologist is responsible for writing the orders for the dialysis prescription—those components of the procedure that make it therapeutic. These include the specific dialyzer, blood and dialysate flow rates, the anticoagulation requirements, the duration or length of time of dialysis, the frequency, and whatever unique instructions may be required for the specific vascular access.

Role of the nurse

What are the functions of the dialysis nurse?

Although nurses are responsible for the direct care of patients undergoing dialysis, technical staff performs much of this care under the nurse’s supervision. The CMS requires that a registered nurse who is responsible for nursing care must always be present in the unit when in-center dialysis patients are being treated. The registered nurse must meet all practice requirements in the state in which she is employed to be able to provide care in the dialysis facility. Patient and family education and ongoing reinforcement and support for self-care are more critical services provided by the nurse. In addition, the nurse is responsible for ongoing assessment of the patient and is generally the one who initiates multidisciplinary care conferences when the patient’s physical, emotional, or social condition indicates the need.

Nursing administration or nursing service organizations may differ among dialysis units. In those facilities using a primary nursing model, each patient has a specifically designated primary nurse who is responsible for overall patient care. However, case management is also appropriate for the care of dialysis patients. This model expands the nursing care and responsibility beyond the dialysis unit to the hospital, ambulatory care or outpatient facilities, and home. Case management ensures continuity of care from both a quality of care and an economic perspective. Whichever model is used, the goal of nursing is to serve as an advocate for those patients who require assistance and to empower them to become their own advocates.

With increasing emphasis being placed on continuous quality improvement (CQI) as one means to ensure delivery of quality care to patients, nurses are taking the lead in this activity. Nurses are also seen in the roles of business manager, research coordinator, fiscal administrator, and chief technician in some settings.

What experience and background are essential for a nurse to be successful in dialysis?

Whereas some facilities may have different requirements for the nurses filling various positions within a dialysis facility, there are minimal qualifications required by all facilities. A dialysis nurse should be a professional nurse with a nursing license in the state of employment, and certification within a specialty, such as nephrology, critical care, and so on, is preferred. A background in critical care nursing or emergency department nursing is particularly useful and, for the nurse who functions in a managerial role, experience with personnel development, leadership roles, and other supervisory positions can be helpful in ensuring success in the position in a dialysis unit. Most facilities have a formal training program for newly hired registered nurses. Less experienced nurses who assume a role as a beginning practitioner need an environment that offers extensive orientation, education, close supervision, and support. The CMS Conditions for Coverage (CfCs) for End-Stage Renal Disease (ESRD) Facilities released April 15, 2008, now require at least 12 months of nursing experience, including 3 months of dialysis experience, as minimum qualifications to act as a facility charge nurse.

What other qualities should the dialysis nurse possess?

Other important qualifications include the ability to interact effectively with patients and personnel as well as a demonstrated interest and skill in both patient teaching and problem solving. Self-confidence and patience also are important in a dialysis nurse. Caring for dialysis patients and their families can be highly stressful because of the intensity of care required, the nature of CKD, and the patients’ struggles with independence versus dependence. Dialysis nurses should be exemplars of the blend of the art and science of nursing. A significant scientific knowledge base and technical skill must be complemented by a caring, compassionate sensitivity; personal resiliency; and an ability to cope with stress. All are useful characteristics in a dialysis nurse.

Furthermore, some interest in teaching and an ability to teach are essential attributes. The dialysis nurse is frequently called upon to provide learning experiences for patients, family members, other dialysis personnel, diverse healthcare professionals, and the public. The dialysis nurse must have supervisory skills to make appropriate assignments to technicians and other personnel and to evaluate accurately the care provided by them.

What is the role of the advanced practice nurse in dialysis?

The use of advanced practice nurses (APNs) in the acute and chronic dialysis settings has become more common as the patient population continues to increase. Nurse practitioners and clinical nurse specialists specializing in renal care now work in a diversity of healthcare settings covering all nephrology specialties. APNs can manage the care of CKD patients at all stages. Some APNs function in the role of clinician, educator, consultant, administrator, or researcher. Current trends suggest an increase in the number of kidney disease patients and a decrease in the number of nephrologists available to provide their care. APNs can work collaboratively with the healthcare team to ensure that all kidney disease patients receieve quality care.

Are there established standards of practice for dialysis nurses?

Regulations governing the administration of the ESRD program under CMS describe a number of standards and criteria related to qualifications of professional staff, acceptable patient care policies and procedures, and unit administration. However, CMS does not issue standards of practice for dialysis nurses.

Professional nursing organizations promote high standards of nephrology nursing practice. In 1987 the Nephrology Nursing Certification Commission (NNCC) was established to develop, implement, and coordinate all aspects of certification for nephrology nurses in the United States; in 1988 the American Nephrology Nurses Association (ANNA) published its first Standards of Care. A nephrology nurse who meets the qualifications and passes the NNCC’s written examination is entitled to use the initials CNN (certified nephrology nurse) as a professional credential. Other certification options include the certified hemodialysis nurse (CHN) or certified peritoneal dialysis nurse (CPDN), available to both registered nurses and licensed practical nurses from the Board of Nephrology Examiners Nursing and Technology (BONENT). The certified dialysis nurse (CDN) is a credential available to registered nurses without a baccalaureate degree from the NNCC. The NNCC also offers the CNN-NP (Certified Nephrology Nurse – Nurse Practitioner) exam to those who are nationally certified as a nurse practitioner and possess a minimum of a master’s degree in nursing.

ANNA published the Scope and Standards of Advanced Practice in Nephrology Nursing. These standards describe competent APN care in nephrology and present competent behaviors of the role.

Since 1977, the Kidney Disease Outcomes Quality Initiative (KDOQI), put forth by the National Kidney Foundation (NKF), has offered clinical practice guidelines for all stages of CKD in the areas of anemia management, hemodialysis adequacy, peritoneal dialysis adequacy, and vascular access for dialysis care. It also offers an additional eight guidelines for CKD in the areas of diabetes, anemia, bone metabolism and nutrition in adults and children, hypertension, dyslipidemia, and classification of CKD. The intended goal of these outcomes is to improve the quality of care and outcomes for all persons with kidney disease and to help reduce the risk of developing kidney disease. These are practice guidelines only and are not intended to be requirements or to be specific to nursing practice; rather, they are guidelines for the general care of the CKD patient in any stage of the disease process (see p. 365 for additional information on NKF KDOQI).

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