Core Curriculum for the Dialysis Technician Fourth Edition PDF

 Fourth Edition Core Curriculum for the Dialysis Technician A Comprehensive Review of Hemodialysis Core Curriculum for the Dialysis Technician Acknowledgments Having worked on all four editions of Amgen’s Core Curriculum for the Dialysis Technician since 1...

 Fourth Edition Core Curriculum for the Dialysis Technician A Comprehensive Review of Hemodialysis Core Curriculum for the Dialysis Technician Acknowledgments Having worked on all four editions of Amgen’s Core Curriculum for the Dialysis Technician since 1992, I know what a tremendous team effort goes into writing, editing, illustrating, referencing, and reviewing each module—and my gratitude toward all of the stellar individuals who contributed their time and dedication to this vital project is boundless. Our mutual goal, as always, is to help dialysis centers across the nation train patient care technicians to do the best possible job of caring for people on dialysis. This much-awaited fourth edition incorporates 2006 KDOQI™ Guidelines, USRDS figures, AAMI Standards, the national Fistula First breakthrough initiative, Life Options research, and much more. The American Nephrology Nurses Association (ANNA) and the National Association of Nephrology Technicians/Technologists (NANT) contributed their tremendous expertise and focus on professionalism, and the Core Curriculum is better for it. Both organizations have a long tradition of initiatives to improve dialysis technician training, and their efforts are very much appreciated. We were extremely fortunate to have an outstanding group of expert authors who worked together tirelessly via conference call and email to divide and conquer the material; update the module content, posttests, and illustrations; verify each other’s suggestions; and reference each key point. Our Advisory/Review Board contributed decades of clinical knowledge and practical experience, validating and expanding on the work of our authors, and adding an additional layer of verification so that the Core Curriculum will, in fact, be the resource we all intend it to be. In addition, several members of the Medical Education Institute’s team made contributions so numerous and important that I’d like to acknowledge them here: n Susan Hossli, MSN, RN, who coordinated the entire author revision and review process, wrote and edited modules, tracked down references, contributed illustration ideas, and helped us pull everything together n Eva Duran, who did layout for the entire project, proofread text, verified references, worked with the medical illustrator and graphic artist, managed the schedule, and fine-tuned each module n Kristi Klicko, who proofread text, verified references, tracked figures and permissions, managed the print production process, and updated the glossary n Paula Alt, Brian Frick, and Sharon Sahr, who provided a “fresh eye” to review each module, asked pertinent questions, and made a number of suggestions that improved the final product n Todd S. Ing, MD, and Zbylut J. Twardowski, MD, who provided careful, thoughtful nephrologist reviews of each module to ensure that the science was accurate, clear, and up-to-date II The mission of the non-profit Medical Education Institute is to help people with chronic disease learn to manage and improve their health. Thus, the Core Curriculum for the Dialysis Technician is a project that has always been close to my heart, because of its potential to help improve patients’ day-to-day lives by enhancing the preparation and professionalism of patient care staff. Technicians who treat patients with respect, courtesy, and dignity and who encourage patients’ efforts to learn and self-manage their kidney disease have the opportunity to influence countless lives for the better. Dori Schatell, MS Executive Director, Medical Education Institute, Inc. September, 2008 No part of this publication may be duplicated, reproduced, stored in a retrieval system, translated, transcribed, or transmitted in any form or by any means without the express prior written permission of Amgen Inc. ©2008 Amgen Inc. All rights reserved. Developed by the Medical Education Institute, Inc., with support from Amgen Inc. III X Core Curriculum for the Dialysis Technician Foreword Each year, the number of ESRD patients rises by 5% to 7%. And, patients are getting older and have more health problems, which complicates their care. The dialysis care team must cope with fixed payment levels, more regulations, and a nursing shortage. Yet, they have the vital job of delivering optimal care. Technicians—the largest number of caregivers in dialysis—need skill, professionalism, and knowledge to meet the ever-changing challenges of dialysis. Your role as a technician is central to the delivery of safe, high quality care. Better technology has made dialysis safer and more efficient. But, technology alone can never replace the commitment and dedication of committed patient care staff. Other members of the care team—nurses, doctors, social workers, dietitians—complete a formal course of study to learn their jobs. Their years of learning and respect for their chosen field leads to professionalism. Plus, the history of their profession garners respect from their peers and the patients they serve. However, there are very few formal dialysis technician training programs in the United States. As of this writing, most states do not require technicians to become certified. Each dialysis provider takes on the task of training technicians, and how that training is done varies from clinic to clinic. You can obtain voluntary certification and enhance your own knowledge and professionalism. I’ve been a witness to more than 30 years of challenges and changes in dialysis. I became a dialysis technician straight out of the military, and at the time, had no concept of what the job would entail. My training back then was entirely done on the job. The pace, patient load, and focus was quite different then than it is now. Typical treatment times were 5 to 6 hours. The shift turnover time wasn’t such a stress. Nursing shortages were not an issue, and staff-to-patient ratios were not yet a concern. We didn’t focus on kinetic modeling and had no concept of sodium profiling. Our goal was to have the patient feeling “well.” My educator had my undivided attention to her teaching, and she, in turn, was able to dedicate her time to me. Today, a typical treatment time is 3 hours. A Kt/V goal must be met. A 4:1 patient/staff ratio is not unusual. Training can be with a preceptor. Learning “how to do dialysis” becomes the focus, and the rationale for why things are done may become secondary. I’ve always approached dialysis as “a life sustaining treatment, a life threatening procedure.” In the fast pace of today’s dialysis clinics, the severity and incidence of errors can be exaggerated. You, as a dialysis technician, are in the forefront of ensuring each patient’s safe and efficient treatment. How well you understand the treatment and the consequences of improperly applied procedures is critical to keeping your patients safe and healthy. As technicians, we hold our patients’ lives in our hands by virtue of our skill and knowledge of dialysis. IV The Core Curriculum for the Dialysis Technician is a tool that has been widely used and accepted for educating new patient care technicians about the history, principles, theory, application, and practices of dialysis care. The Core Curriculum can improve the consistency of training content between clinics and across the nation. With the Core Curriculum in hand, you can learn to care for your patients safely and efficiently. Danilo B. Concepcion, CCHT, CHT President, National Association of Nephrology Technicians/Technologists (NANT) February, 2006 Providing quality dialysis in today’s healthcare environment presents many challenges. Skilled technicians, with the help and supervision of the nephrology nurses who work alongside them, play a critical role. As Danilo Concepcion points out, the need for comprehensive dialysis technician training is as great—or greater— than it was when the first edition of the Core Curriculum for the Dialysis Technician was published in 1992. The newly-revised 4th edition of the Core Curriculum will help to fill that need. Like previous editions, it will serve as a single, comprehensive source of information on every aspect of dialysis, including scientific principles, devices, reprocessing, water treatment, and more. Producing this edition was a collaborative effort. Many dialysis nurses and other professionals spent hours of their own time updating the contents, illustrations, and references to reflect current dialysis practices. Speaking for the ANNA members involved in the process, I can assure you that we take pride in our contributions. Our work on the Core Curriculum is a reflection of our longstanding commitment to improve the training and educational opportunities available to dialysis technicians. Nephrology nurses and skilled dialysis technicians share a common goal—providing safe, effective dialysis care that enables our patients to live long and live well. We must come to our task as well- prepared as possible, using all the resources available to enhance our skills and knowledge. The newly- revised Core Curriculum will be a welcome addition. Suzann VanBuskirk, BSN, RN, CNN President, American Nephrology Nurses’ Association (ANNA) September, 2008 V X Core Curriculum for the Dialysis Technician Reviewers Cindy Allegretti, MS, RD, LDN Danilo B. Concepcion, CCHT, CHT Director of Anemia Management Manager, Renal Technology Services Fresenius Medical Care North America & Materials Management Lexington, MA St. Joseph Hospital Renal Center Orange, CA Barbara Bednar, MHA, RN, CNN President Caroline S. Counts, MSN, RN, CNN Bednar Consulting Group, Inc. Research Coordinator, Division of Nephrology Naples, FL Medical University of South Carolina Charleston, SC Kay Bregel, RN, CNN Clinical Specialist John Dahlin, CHT, CWS-1 Medisystems Corporation Regional Technical Manager Rogers, MN Fresenius Medical Care, Southwest Business Unit Dallas, TX Deborah Brooks, RN, MSN, ANP, CNN Nurse Practitioner/Research Coordinator Hazel Dennison, MSN, RN, CNN, APNC Medical University of South Carolina Quality Improvement Administrator Charleston, SC TransAtlantic Renal Council (ESRD Network 3) Cranbury, NJ Deborah Brouwer, RN, CNN Director, Therapeutic & Clinical Programs Claudia Douglas, MA, RN, CNN, APNC Renal Solutions, Inc. Administrative Director Pittsburgh, PA Hackensack University Medical Center Hackensack, NJ Sally Burrows-Hudson, MS, RN, CNN President Susan K. Hansen, RN, CNN, CHT, MBA Nephrology Management Group, Inc. Director of Clinical Business Development Sunnyvale, CA Renal Solutions, Inc. Lake Forest, CA Loni J. Cloutier, BS, MS, CCHT, CHT Manager, Clinical Engineering/Nephrology Services Lorus A. Hawbecker, RN, CNN Spectrum Health Clinical Hemodialysis Educator Grand Rapids, MI Independent Consultant Oldsmar, FL VI Diane Hlebovy, RN, BSN, CHN, CNN Marianne Neumann, RN, CNN Director of Clinical Affairs Clinical Manager HemaMetrics, Corp. Albany Dialysis Center Elyria, OH Albany, NY Martin V. Hudson, CNBT Glenda M. Payne, RN, MS, CNN Immediate Past Chairperson, National Nephrology Nurse Consultant Certification Organization (NNCO) ESRD Clinical Lead, Regions 4 & 6 Sunnyvale, CA Centers for Medicare & Medicaid Services Dallas, TX Peggy J. Lynch, BSN, RN, CNN Medical Quality Manager Patricia Baltz Salai, MSN, RN, CNN, CRNP ESRD Network of New England, Inc. Renal Clinical Specialist Woodbridge, CT VA Pittsburgh Healthcare System Pittsburgh, PA Joe Mazzilli, MBA, CCHT Director of Operations Clare Sasak, MPA, RN, CNN M4 Consultants, Inc. New Jersey Regional Vice President New York, NY Fresenius Medical Care North America West Paterson, NJ Susan McGovern, ARNP, MS Quality Improvement Coordinator Richard Van Der Plas, CHT FMQAI: The Florida ESRD Network Regional Administrator, HIPAA Security Officer Tampa, FL NANT Southwest Regional Vice President Manager, Technical Operations Sheila McMaster, MSN, RN, CNN Innovative Dialysis Systems, Inc. Quality Improvement Coordinator Long Beach, CA Network 8, Inc. Flowood, MS Donna Merrill, RN, CCRC Nurse Coordinator, Interventional Nephrology University of Miami, Miller School of Medicine Division of Nephrology and Hypertension Miami, FL VII Core Curriculum for the Dialysis Technician About this Core Curriculum This Core Curriculum for the Dialysis Technician is offered as a general educational guide for dialysis technicians and other medical professionals. When using these materials, the reader must be aware of certain limitations. This Core Curriculum is not to be used as a substitute for professional training, or as a substitute for practice guidelines and protocols of the particular hospital or clinic providing dialysis treatment. This is important, since certain hospital or clinical protocols may differ from those discussed in this Core Curriculum. There may also be local, state, and federal regulations imposed on the technicians, hospital, or clinic which require different practices from those outlined in this guide. It is important to consult product labeling for any pharmaceutical or medical device referenced in this Core Curriculum. Educational curricula such as this one can only draw from information available as of the date of publication. Although the authors of these materials have used considerable effort to assure that the information contained herein is accurate and complete as of the date of publication, no guarantees of accuracy or completeness can be provided. The authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. Neither the Medical Education Institute, Inc., the authors, the reviewers, nor the funder are under any obligation to update information contained herein. Future medical advances; product information; or revisions to legislative, administrative, or court law may affect or change the information provided in this Core Curriculum. Technicians and other medical professionals using this Core Curriculum remain responsible for monitoring ongoing medical advances relating to dialysis. This Core Curriculum is provided with the understanding that neither it nor its authors are engaged in rendering medical or other professional advice. If medical advice or other expert assistance is required, the reader should seek the advice of a competent professional. The reader must recognize that dialysis involves certain risks, including the risk of death, which cannot be completely eliminated, even when the dialysis procedure is undertaken under expert supervision. Use of these materials indicates acknowledgment that neither the Medical Education Institute, Inc., the authors, the reviewers, nor the funder will be responsible for any loss or injury, including death, sustained in connection with, or as a result of, the use of this Core Curriculum. VIII Table of Contents Module 1 – Today’s Dialysis Environment: An Overview.......................................................... 1 Objectives.................................................................................................................. 2 Introduction.............................................................................................................. 3 Overview of Dialysis.................................................................................................. 3 History of Dialysis.................................................................................................. 4 Medicare Payment for ESRD Patients...................................................................... 6 Quality in Dialysis...................................................................................................... 7 Dialysis Quality Standards...................................................................................... 8 Guidelines for Dialysis Care.................................................................................... 9 Continuous Quality Improvement in Dialysis.......................................................... 11 Dialysis Technician Professionalism........................................................................ 13 Dialysis Technician Associations............................................................................ 14 Technician Certification........................................................................................ 14 Conclusion................................................................................................................ 16 References................................................................................................................ 17 Module 2 – The Person with Kidney Failure............................................................................ 21 Objectives................................................................................................................ 22 Introduction............................................................................................................ 23 Renal Anatomy & Physiology.................................................................................... 23 How Healthy Kidneys Work.................................................................................. 23 Types of Kidney Disease.......................................................................................... 26 Acute Kidney Failure............................................................................................ 26 Chronic Kidney Disease (CKD).............................................................................. 27 Conditions Caused by Chronic Kidney Failure........................................................ 29 Uremia................................................................................................................ 29 Anemia................................................................................................................ 30 Secondary Hyperparathyroidism.......................................................................... 31 Pruritus (Itching)................................................................................................ 31 Pericarditis.......................................................................................................... 32 Amyloidosis........................................................................................................ 32 Neuropathy (Nerve Damage)................................................................................ 32 Sleeping Problems................................................................................................ 33 IX Core Curriculum for the Dialysis Technician Bleeding Problems................................................................................................ 33 Electrolyte Imbalances.......................................................................................... 33 Common Dialysis Blood Tests................................................................................ 34 Treatment Options.................................................................................................... 34 Transplant.......................................................................................................... 38 Dialysis................................................................................................................ 39 No Treatment...................................................................................................... 43 HD Care Team.......................................................................................................... 44 Patient................................................................................................................ 44 Nephrologist........................................................................................................ 44 Nurse.................................................................................................................. 44 Social Worker...................................................................................................... 44 Dialysis Technician.............................................................................................. 45 Renal Dietitian.................................................................................................... 45 Nutrition for People on In-center HD...................................................................... 45 Protein................................................................................................................ 46 Calories.............................................................................................................. 46 Malnutrition........................................................................................................ 47 Fluid.................................................................................................................. 48 Sodium................................................................................................................ 50 Potassium............................................................................................................ 51 Calcium and Phosphorus...................................................................................... 51 Vitamins.............................................................................................................. 52 Helping Patients Cope.............................................................................................. 52 Financial Concerns.............................................................................................. 53 Travel.................................................................................................................. 53 Body Image/Sexuality.......................................................................................... 53 Pain.................................................................................................................... 54 Life Changes........................................................................................................ 54 Communication.................................................................................................... 54 Patient Education......................................................................................................56 Readiness............................................................................................................ 57 Need.................................................................................................................... 57 Appropriate Level................................................................................................ 57 X  Reinforcement...................................................................................................... 57 Belief.................................................................................................................. 58 Rehabilitation............................................................................................................58 Improving Patient Outcomes.................................................................................. 58 Patient Self-management...................................................................................... 59 The Importance of Hope........................................................................................ 60 Patient Resources......................................................................................................63 American Association of Kidney Patients (AAKP).................................................. 63 American Diabetes Association (ADA).................................................................. 63 American Kidney Fund (AKF).............................................................................. 63 Dialysis Facility Compare (DFC)............................................................................ 63 End-Stage Renal Disease Networks........................................................................ 64 Home Dialysis CentralTM........................................................................................ 64 Kidney SchoolTM.................................................................................................... 64 Life Options Rehabilitation Program...................................................................... 64 National Kidney Foundation (NKF)...................................................................... 64 PKD Foundation.................................................................................................. 65 Renal Support Network (RSN).............................................................................. 65 Conclusion................................................................................................................65 References................................................................................................................ 66 Module 3 – Principles of Dialysis.............................................................................................. 75 Objectives................................................................................................................ 76 Introduction............................................................................................................ 77 Scientific Principles Used in Dialysis........................................................................ 77 Solutions.............................................................................................................. 77 Semipermeable Membrane.................................................................................... 77 Diffusion.............................................................................................................. 77 Osmosis.............................................................................................................. 79 Filtration and Ultrafiltration................................................................................ 80 Fluid Dynamics.................................................................................................... 80 Applying Scientific Principles to Dialysis................................................................ 81 Fluid Compartments............................................................................................ 82 Fluid Dynamics in Dialysis.................................................................................... 82 XI Core Curriculum for the Dialysis Technician Diffusion in Dialysis.............................................................................................. 83 UF in Dialysis...................................................................................................... 84 Convection in Dialysis.......................................................................................... 84 Osmosis in Dialysis.............................................................................................. 85 Conclusion................................................................................................................ 85 Learning Activities.................................................................................................. 86 References................................................................................................................ 87 Module 4 – Hemodialysis Devices............................................................................................ 89 Objectives................................................................................................................ 90 Introduction............................................................................................................ 91 Dialyzers.................................................................................................................. 91 Functions and Components.................................................................................. 91 Dialyzer Characteristics........................................................................................ 91 Dialyzer Design.................................................................................................... 94 Membranes.......................................................................................................... 95 Measuring Dialyzer Effectiveness............................................................................ 96 Determining Dialyzer Clearance............................................................................ 97 Dialysate.................................................................................................................. 97 Purpose of Dialysate............................................................................................ 97 Composition of Dialysate...................................................................................... 97 Hemodialysis Delivery Systems.............................................................................. 100 Purpose............................................................................................................ 100 Dialysate Delivery System.................................................................................... 100 Extracorporeal Circuit........................................................................................ 107 Sorbent Dialysis.................................................................................................. 114 Conclusion.............................................................................................................. 115 Appendix: Formula for Dialyzer Solute Clearance.................................................. 116 References.............................................................................................................. 117 Module 5 – Vascular Access...................................................................................................... 121 Objectives.............................................................................................................. 122 Introduction.......................................................................................................... 123 Fistulae.................................................................................................................. 124 How Fistulae Are Created.................................................................................... 124 XII  Fistula Procedure................................................................................................ 126 Pros and Cons of Fistulae.................................................................................... 126 Assessing Maturity of a Fistula............................................................................ 127 Initiating Dialysis with a Fistula................................................................................ 128 Fistula Care Postdialysis...................................................................................... 135 Fistula Complications................................................................................................ 136 Dialysis-related Complications of Fistulae.................................................................. 136 Long-term Complications of Fistulae........................................................................ 139 Grafts.................................................................................................................. 143 Graft Materials.................................................................................................. 144 Graft Procedure.................................................................................................. 144 Graft Pros and Cons............................................................................................ 144 Starting Dialysis with a Graft.............................................................................. 145 Preparing to Use a Graft............................................................................................ 146 Inserting Needles................................................................................................ 146 Graft Care Postdialysis................................................................................................ 146 Graft Complications.................................................................................................. 146 Dialysis-related Complications of Grafts.................................................................... 148 Complications Related to Poor Needle Site Rotation.................................................. 148 Central Venous Catheters........................................................................................ 149 Types of Catheters and Port/Catheter Devices........................................................ 149 Catheter and Port/Catheter Device Sites................................................................ 150 Placement of Catheters and Port/Catheter Devices.................................................... 151 Pros and Cons of Catheters and Port/Catheter Devices.............................................. 153 Care of Catheters and Port/Catheter Devices.............................................................. 153 Improving Vascular Access Outcomes.................................................................... 156 Continuous Quality Improvement (CQI).............................................................. 156 Clinical Practice Guidelines.................................................................................. 157 Conclusion.............................................................................................................. 157 References.............................................................................................................. 158 Module 6 – Hemodialysis Procedures and Complications.................................................. 163 Objectives.............................................................................................................. 164 Introduction.......................................................................................................... 165 Patient and Staff Safety.......................................................................................... 165 XIII Core Curriculum for the Dialysis Technician Body Mechanics.................................................................................................. 165 Transferring Patients.......................................................................................... 166 Emergency Preparedness............................................................................................ 168 Infection Control........................................................................................................ 168 Medications and Solutions........................................................................................ 175 Documentation.......................................................................................................... 177 Predialysis Treatment Procedures.......................................................................... 179 Treatment Plan.................................................................................................. 179 Equipment Preparation...................................................................................... 179 Initiation of Dialysis.............................................................................................. 185 Removing Fluid.................................................................................................. 186 Venipuncture...................................................................................................... 186 Laboratory Tests................................................................................................ 187 Measuring Dialysis Adequacy.............................................................................. 188 Factors Affecting Dialysis Treatment.................................................................... 190 Starting the Dialysis Treatment............................................................................ 191 Monitoring During Dialysis.................................................................................... 192 Patient Monitoring............................................................................................ 192 Technical Monitoring.......................................................................................... 193 Anticoagulation.................................................................................................. 194 Hemodialysis Complications.................................................................................. 198 Clinical Complications........................................................................................ 198 Technical Complications...................................................................................... 198 Postdialysis Procedures.......................................................................................... 198 Discontinuing Dialysis........................................................................................ 198 Postdialysis Patient Evaluation............................................................................ 200 Equipment Clean-up.......................................................................................... 200 Conclusion.............................................................................................................. 201 Appendix 1: Calculating Transmembrane Pressure (TMP).................................... 202 Appendix 2: Urea Reduction Ratio (URR) and Urea Kinetic Modeling (UKM) Formulas.......................................... 203 References.............................................................................................................. 204 XIV Module 7 – Dialyzer Reprocessing.......................................................................................... 207 Objectives.............................................................................................................. 208 Introduction.......................................................................................................... 209 History of Dialyzer Reprocessing............................................................................ 209 Dialyzer Reprocessing Demographics.................................................................... 210 Why Dialyzers Are Reused...................................................................................... 210 Medical Reasons for Dialyzer Reuse...................................................................... 211 Safety of Reuse.................................................................................................. 211 Non-medical Reasons for Dialyzer Reuse.............................................................. 211 Dialyzer Reprocessing Procedure.......................................................................... 211 Types of Dialyzers.............................................................................................. 212 Automated Versus Manual System........................................................................ 212 Preparing for the First Use of a Dialyzer................................................................ 212 Dialyzer Labeling.............................................................................................. 212 Total Cell Volume................................................................................................ 213 Preprocess.......................................................................................................... 214 After Dialysis.......................................................................................................... 214 Pre-cleaning...................................................................................................... 214 Performance Tests.............................................................................................. 214 Dialyzer Rejection.............................................................................................. 214 Disinfection........................................................................................................ 215 Handling Hazardous Materials............................................................................ 216 Storage of Reprocessed Dialyzers.......................................................................... 216 Preparing for Next Use............................................................................................ 216 Dialyzer Inspection............................................................................................ 216 Removal of Germicide........................................................................................ 217 Prior to Treatment.............................................................................................. 217 Potential Hazards.................................................................................................... 217 Bacteria and Endotoxin...................................................................................... 217 Chemicals.......................................................................................................... 218 Altered Dialyzer Performance.............................................................................. 218 Documentation...................................................................................................... 218 XV Core Curriculum for the Dialysis Technician Quality Assurance and Quality Control.................................................................. 219 Conclusion.............................................................................................................. 219 References.............................................................................................................. 221 Module 8 – Water Treatment.................................................................................................... 225 Objectives.............................................................................................................. 226 Introduction.......................................................................................................... 227 Water Supply.......................................................................................................... 227 Components of a Water Treatment System............................................................ 229 Feed Water Components...................................................................................... 230 Pretreatment Components.................................................................................. 230 Reverse Osmosis Process and System.................................................................... 233 Deionization...................................................................................................... 234 Ultraviolet (UV) Irradiator.................................................................................. 235 Submicron and Ultrafilters.................................................................................. 236 Distribution System................................................................................................ 236 Water Storage.................................................................................................... 236 Water Distribution Piping Systems...................................................................... 237 Disinfection of Water Treatment Systems.............................................................. 237 Monitoring a Water Treatment System.................................................................. 237 Monitoring of the System Components.................................................................. 237 Temperature Blending Valve................................................................................ 237 Backflow Prevention Device................................................................................ 239 Depth Filtration.................................................................................................. 239 Water Softeners.................................................................................................. 239 Carbon Tanks.................................................................................................... 239 RO Device (Operating Parameters)...................................................................... 240 DI Systems (Operating Parameters)...................................................................... 241 Water Quality.................................................................................................... 241 Microbiological Testing........................................................................................ 242 Chemical Monitoring.............................................................................................. 243 Chlorine and Chloramines.................................................................................. 243 Sodium and Potassium........................................................................................ 244 Calcium and Magnesium.................................................................................... 244 Fluoride............................................................................................................ 244 XVI  Nitrates.............................................................................................................. 245 Sulfates.............................................................................................................. 245 Aluminum........................................................................................................ 245 Copper and Zinc................................................................................................ 246 Arsenic, Barium, Cadmium, Chromium, Lead, Mercury, and Selenium.................... 246 Patient Monitoring.................................................................................................. 246 Conclusion.............................................................................................................. 247 Appendix: Water Quality Testing Chart.................................................................. 248 References.............................................................................................................. 249 Preceptor Module...................................................................................................................... 251 Introduction.......................................................................................................... 253 The Preceptor Method............................................................................................ 253 What Is a Preceptor?............................................................................................ 253 Why Use a Preceptor Model?................................................................................ 254 The Preceptor in a Dialysis Setting........................................................................ 255 Planning a Training Program................................................................................ 256 How to Use the Core Curriculum.......................................................................... 256 Other Training Models........................................................................................ 258 Core Curriculum Modules.................................................................................. 259 Individualizing the Curriculum............................................................................ 261 Resources.......................................................................................................... 261 Precepting the Adult Learner................................................................................ 262 Adult Learning Principles.................................................................................... 263 Learning Contracts............................................................................................ 264 Strategies for Effective Preceptorship.................................................................... 264 The Teaching Process.......................................................................................... 264 Communicating Skillfully.................................................................................... 265 One-on-one: the Preceptor/Trainee Relationship.................................................... 266 Evaluating Your Training Program...................................................................... 268 Sample Learning Contract...................................................................................... 269 Sample Student Evaluation.................................................................................... 270 Module 1 Posttest.................................................................................................... 273 Module 2 test.......................................................................................................... 274 Module 3 Posttest.................................................................................................... 276 XVII Core Curriculum for the Dialysis Technician Module 4 Posttest.................................................................................................... 277 Module 5 Posttest.................................................................................................... 279 Module 6 Posttest.................................................................................................... 281 Module 7 Posttest.................................................................................................... 283 Module 8 Posttest.................................................................................................... 285 Posttest Answer Key................................................................................................ 287 References.............................................................................................................. 288 Preceptorship Resources........................................................................................ 288 Reference Module...................................................................................................................... 291 Glossary.................................................................................................................. 293 Abbreviations........................................................................................................ 354 Organizations........................................................................................................ 355 Weights and Measures............................................................................................ 356 Index...................................................................................................................... 358 XVIII Today’s Dialysis Environment: An Overview Objectives After completing this module, the learner will be able to: 1. Discuss how dialysis therapy is reimbursed in the United States. 2. List two quality standards for dialysis treatment. 3. List the steps of the continuous quality improvement (CQI) process. 4. Describe ways that dialysis technicians can demonstrate professional behavior when working with patients. 5. Explain the certification process for dialysis technicians. Module 1 cover photo credit: Photo of Dr. Willem Kolff, in Cody TG: Innovating for Health: the Story of Baxter International; 1993. Reprinted with permission from Baxter Healthcare Corporation, 2005. 2 Introduction Overview As a patient care technician, your job is to help patients with chronic kidney disease (CKD) of Dialysis receive safe and effective dialysis. To do this well, When the kidneys fail, patients need treatment to it will help you to learn what dialysis is, how it live. Dialysis is the main treatment for end-stage was developed, how to ensure high-quality care renal disease (ESRD). It replaces three main kidney for patients, and how to perform and carry out tasks: removing wastes from the blood, removing your duties in a professional manner. We cover excess fluid from the blood, and keeping all of these topics in this module. electrolytes (electrically charged particles) in balance. There are two main types of dialysis: While there are many treatment goals for patients hemodialysis (HD), and peritoneal dialysis with CKD, the main goal is to help each patient (PD). HD is most common (see Figure 1). reach the highest level of wellness possible. Helping patients to reach this goal is one of the most To do HD, an entry into the patient’s rewarding parts of caring for patients with CKD. bloodstream is needed. This is called a vascular access. During a treatment, needles are placed Dialysis is provided by a team that includes into the access. Blood flows out of the patient, technicians, nurses, dietitians, social workers, through an artificial kidney (dialyzer) where Figure 1: doctors—and, most important of all, patients. Hemodialysis Some patients choose to take a very active role in Drawing adapted with permission from their care and know a lot about their treatment and Fresenius Medical Care–North America how it affects them. The team should support this interest and knowledge: research shows that patients who self-manage their care and know more about it stay healthier and live longer. It takes a team to make sure that patients’ needs FRESENIUS for treatment, nutrition, medications, and social services are met. Other specialists, such as physical therapists, pharmacists, exercise physiologists, and clergy, may be called on as well. With good dialysis, many people with CKD can lead full and active lives. For others, having a good quality of life is harder. A person’s health depends on a number of factors. These can include age, former activity level, proper treatment, other illnesses (such as diabetes or high blood pressure), and support from loved ones. With training and experience, a dialysis technician can help patients feel their best, and at the same time, have a rewarding career. 3 3 Today’s Dialysis Environment: An Overview the blood is cleaned, and back to the patient. most common type of PD,1 patients use a cycler The dialyzer contains a semipermeable machine at home at night, while they sleep, to membrane which allows some substances, such cycle sterile dialysate in and out of the abdomen. as wastes and excess water out, but keeps PD can also be done by hand, usually with four others, such as blood cells, in. Wastes and water exchanges of fresh dialysate for used dialysate pass through the membrane into a fluid called each day. PD goes on 7 days per week. Manual dialysate and some substances pass from the PD can be done at home, at work, or while traveling. dialysate into the blood. The dialysis machine, or delivery system, controls the flow of blood HISTORY OF DIALYSIS to the dialyzer, includes safety alarms to Dialysis as a treatment for kidney failure was not monitor the machine during a treatment, and always the sleek, high-tech process it is today. The mixes and delivers dialysate. HD is most often first hemodialysis treatment in a patient, using done in a center 3 times a week, for about 4 cellulosic membrane, was done in 1943 using a hours per treatment. Some patients do HD at rotating drum artificial kidney (see Figure 2) home, and may do short treatments 5 or 6 days developed by a Dutch doctor named Willem Kolff.2 a week. Or they may do longer treatments at Before that time, patients with kidney failure had night while they sleep for 3–7 nights per week. no effective treatment; the disease was always fatal. Access for PD is through a catheter (tube) Kolff’s rotating drum device featured a large placed in the abdomen. The blood never leaves wooden wheel dialyzer made of slats wrapped the body; instead, the lining of the abdomen, with 30–40 meters of sausage casing (the which has many tiny blood vessels, acts as a cellophane membrane). To gain access to the filter in the same way as a dialyzer. In the blood, a fresh artery and vein had to be used for Figure 2: Drum turns to bring membranes Wooden slats wrapped with sausage-skin into contact with dialysate semipermeable membrane Rotating drum device Dialysate in vat Actual size: 42” high, 54” wide, 28” deep 4 each treatment and tied off after. Because a Figure 3: patient had limited blood vessels, dialysis could Scribner shunt in the forearm position only be used to treat patients whose kidneys Silastic tubing were expected to recover. The science and technology of dialysis made great strides during the Korean War (1950–1953). Dialysis was used to treat soldiers with acute renal failure, improving their chances of survival.3 Connection broken here for dialysis Vascular Access In 1960, Dr. Belding Scribner and his colleagues The first dialyzer to be mass-produced was the came up with a way to reenter and use blood coil dialyzer—a membrane supported by a vessels multiple times for dialysis. They linked mesh screen coiled around a central core. It was a patient’s artery and vein using a plastic tube primed with a large amount of blood, set in a outside the skin. Called a shunt (see Figure 3), holding container called a canister, and bathed this first vascular access made it possible to with dialysate. Coil dialyzers were sterile and treat patients with chronic kidney failure, who disposable, which made them very costly. would need dialysis for the rest of their lives. With the advent of technology in the mid 1960s But shunts often became infected or clotted.4 came a new membrane material called In 1966, Dr. James Cimino and colleagues found a cuprophane. This launched another type of way to connect an artery and a vein together inside Figure 4: the arm. The arteriovenous (AV) fistula caused Kiil dialyzer fewer infections and blood clots than the shunt. Even today, the AV fistula, or native fistula, lasts longest and is the best access for HD.4 Dialyzers Kiil dialyzers used in the 1960s were 70-pound flat plates (see Figure 4). Their large surface Latches Inside the Kiil, two pairs of membrane sheets (4 sheets) were separated by areas were covered by sheets of cellophane. three grooved, polypropylene boards. After each treatment, the membranes were cleaned and stored in a chemical bath or the plates were taken apart and the membranes replaced. Each corner of the dialyzer had to be uniform and “torqued down”—a lengthy task called “building a dialyzer.” Treatments took up to 14 hours, 3 times a week. 5 5  Today’s Dialysis Environment: An Overview dialyzer: the Gambro flat plate (see Figure 5). Dialysate flowed around the outside of the fibers. Considered small at the time, early flat plate The hollow fiber dialyzer, much improved over dialyzers were more than 30 inches long, with the years, is the only type on the market today. many layers of membranes in pairs. Each pair of Since the 1960s, many advances have made membranes formed an envelope. During a treatment, dialysis more safe and reliable. Better blood flowed between the pairs of membranes, membranes that are more compatible with the and dialysate flowed around the outside. tissues of the human body (biocompatible), In the late 1960s, researchers made a small, increase treatment comfort for patients. lightweight, hollow fiber dialyzer (see Figure 6). Machine alarms and automated functions in Blood flowed through the insides of the fibers— the machine help protect patients from harm. thousands of tiny hollow tubes the size of hairs. Figure 5: MEDICARE PAYMENT Flat plate dialyzer FOR ESRD PATIENTS Blood out Blood in What if we knew how to save the lives of patients with kidney failure, but we didn’t have enough machines to treat them all? Who would decide which patients would live and which would die? Before 1973, this really happened all across the country. Hospitals had “Life and Death” committees made up of lay people and clergy.5 They chose Dialysate in Dialysate out Dialysate patients for treatment based on age, maturity, Pair of Blood flows between education, whether they had children to semipermeable pairs of semipermeable membranes membranes support, could afford the care, and how much Dialysate flows between the they might give back to society if they could Support structure support structure and the outsides of the membranes live. For patients who were chosen, the costs of treatment were very high. Some chose death rather than impose this burden on their loved ones. Figure 6: Hollow fiber dialyzer To make sure that people could get treatment for kidney failure that could help them live full lives, Dialysate in Dialysate out Congress passed Public Law 92-603, the Medicare End-Stage Renal Disease (ESRD) Program, in 1972. Fibers This program gives Medicare to patients who are Blood Blood back to from entitled to Social Security based on their work the patient patient record (93%) of all patients. It covers both dialysis and kidney transplants. Medicare pays 80% of allowable costs; insurance, Medicaid, state programs, or patients pay the other 20%.6 Once the law 6 passed and more machines were built, shortages year, while Medicare itself pays about $63,000.7 were no longer a life-or-death problem. Today, So, centers that offer work-friendly treatments kidney failure is still the only disease with its and/or schedules can help patients keep their own Medicare program. jobs and insurance—and improve their own bottom line at the same time. Government funding changed dialysis. Before 1972, many patients did their treatments at In 1978, ESRD Networks were set up to oversee home with a helper. Most centers were based in the quality of dialysis care across the country.8 hospitals. After the Medicare ESRD Program There are 18 ESRD Networks; most are non-profit, began, more centers began to open. Today, and all are under contract with Medicare to cover most centers are free-standing—not hospital- a region of 1–6 states (see Figure 7). Networks based—and about 2/3 of them are part of a are charged to promote rehabilitation, collect large dialysis organization (LDO), a company and report data, and do quality improvement that owns many centers all over the country. projects. Networks also offer a patient grievance Each year, there are fewer and larger LDOs, process and provide resources to staff and patients. as they buy more centers. Quality in Dialysis Centers today are paid a composite rate by Medicare for each treatment. This rate is based on the patient’s age, weight, and height, and is different What is quality care? In 1990, the Institute of for each patient. The amount must cover Medicine (IOM) defined quality as: “The degree overhead, staff wages and training, equipment, to which health services for individuals and rehabilitation, and some drugs. The composite populations increase the likelihood of desired rate is not raised each year for inflation the way health outcomes and are consistent with current hospitals and nursing home rates are. Instead, professional knowledge.” 9 The IOM studied many Congress must pass a law to raise the rate. In 1974, the average rate per treatment was $138. Figure 7: In 2002 it was $130.50—which was worth only ESRD Network map Drawing adapted with permission from the $34 in constant dollars.5 At this point, centers Forum of ESRD Networks may lose $5 to $10 per treatment on patients who have Medicare only. This has forced centers to become ever more efficient—without reducing the quality of the care they provide. There is a second source of income for centers: insurance. During the first 30 months of treatment, if patients have an employer group health plan (EGHP) through a job or a spouse’s job, that plan is primary—it pays first.6 On average, EGHPs pay $126,000 per patient, per 7 7 Today’s Dialysis Environment: An Overview aspects of the care and treatment of Medicare Program is worth the money. This is done, patients, and found that changes were needed to in part, by showing that centers and staff are improve care.9 providing good quality care. There is pressure throughout healthcare to look at how well The IOM still assesses our healthcare system; in patients are doing, so we can keep costs down 2001, it put out a report that found ongoing while still having high quality. problems. The IOM set a strategy and action plan to improve care, with six Aims for Improvement.10 Providers and users of the healthcare system DIALYSIS QUALITY must commit to the six aims to foster innovation STANDARDS and improve the delivery of high quality care. Since the 1970s, quality in dialysis has been The aims are to provide care that is: checked by comparing centers to preset standards. This is called quality assurance. 1. Safe: avoid harm to patients from care that Centers that do not meet these standards risk should help them. losing their Medicare certification to provide 2. Effective: provide care based on science to ESRD services and the payments they receive all who could benefit. for these services. 3. Patient–centered: provide care that respects For example, the Centers for Medicare and and responds to patient wishes, needs, and Medicaid Services (CMS) is the federal body values, and ensure that patient values guide that oversees Medicare. CMS inspects dialysis clinical decisions. centers through contracts with state 4. Timely: reduce waits and sometimes harmful Departments of Health. State surveyors have delays for those who receive and give care. checklists of standards and conditions that 5. Efficient: avoid waste of equipment, supplies, centers must meet to keep their certification. ideas, and energy. Centers that do not meet these can lose their Medicare funding. With so many centers and 6. Equitable: provide care that does not vary in nursing homes to inspect, years may go by quality due to gender, ethnicity, geography, between surveys—but a center should always education level, and income. be ready for a survey and work each day as if The quality of dialysis care has been a focus it will be inspected. since the Medicare ESRD Program was passed Many other dialysis standards exist: in 1972. The original purpose of dialysis was not just to keep patients alive, but to help them n ESRD Networks have Medical Review stay active, work, and pay taxes. Once there Boards that collect patient and center data to measure outcomes. were enough machines to treat all patients, we were able to focus on whether dialysis was n The Joint Commission on the Accreditation meeting this goal. Because of the cost, Congress of Healthcare Organizations (JCAHO) has needs to be assured that the Medicare ESRD standards for hospital-based dialysis centers. 8 n The Association for the Advancement of (KDOQI™) Clinical Practice Guidelines. The Medical Instrumentation (AAMI) has hemodialysis CPMs are adequacy of dialysis, standards for dialysis water treatment, vascular access, anemia, and albumin. A report dialysis solution preparation, and dialyzer is put out each year.12 Dialysis centers can reprocessing. compare the CPM results with their own outcomes. The Food and Drug Administration (FDA) oversees the safety and effectiveness of all medical devices. In 1991, the FDA put out Quality GUIDELINES FOR Assurance Guidelines for Hemodialysis Devices.11 DIALYSIS CARE These guidelines, still in effect, cover dialyzers To measure the quality of care in a center, and blood tubing, monitoring devices and outcomes (results of care) must be used. These alarms, dialysis machines, dialyzer reprocessing outcomes must be agreed upon by providers equipment, water treatment, and all other and patients and based on the most current dialysis devices. The FDA requires healthcare knowledge. They are then measured for each providers to fill out special reports to tell patient, for groups of patients, or for centers, manufacturers and the FDA about problems with and are tracked over time. devices and equipment, as well as adverse events.11 Today, patients whose kidneys fail can live National dialysis data can serve as standards. longer than ever before. Some patients live for The United States Renal Data System (USRDS) decades. But, too many patients still die early puts out a report each year that compares data or suffer ill effects from kidney disease. Even from all the dialysis centers in the United States. with standards, patient outcomes like morbidity Data in the USRDS include annual mortality (sickness) and mortality (death) vary from (death) rate, number of patients, cost of center to center. This may be due, in part, to treatment, and much more. The results may be differences in care at centers or in approach used to find out if outcomes for all patients are to care and treatment among nephrologists getting better or worse. Centers can use the data (doctors who specialize in kidney disease). to compare their outcomes with national averages. How can we improve outcomes for all patients? Another source of national data is the ESRD By finding the best way to provide dialysis care Clinical Performance Measures (CPMs) project. and sharing these ideas with all centers. Clinical This is a team effort of CMS, the ESRD practice guidelines are efforts to do just that. Networks, and dialysis centers. The CPMs compare the quality of Medicare dialysis. Data Renal Physicians are gathered each year from a random sample of Association patients from each center.12 The CPMs are based The first clinical practice guideline for kidney on the National Kidney Foundation (NKF) failure was written in 1993 by Renal Physicians Kidney Disease Outcomes Quality Initiative Association (RPA) nephrologists. 9 9 Today’s Dialysis Environment: An Overview The guideline, Adequacy of Hemodialysis, To work, the KDOQI guidelines must be put into covered the dose of treatment a patient should daily practice. The guidelines change the way receive.13 Healthy kidneys work 24 hours a day, some centers provide care. As a technician, you 7 days a week. Dialysis done three times a week will be a key member of a healthcare team that provides only about 15% of the function of uses these guidelines and helps patients healthy kidneys. Patients who do not get understand their purpose. enough treatment feel ill and are at risk of dying sooner. So, the RPA guideline suggested a For example, anemia is a shortage of oxygen- minimum dose of hemodialysis for all patients. carrying red blood cells. It causes fatigue, heart disease, and many other problems. The KDOQI The RPA has written other guidelines, which anemia guidelines help centers identify and include: Appropriate Patient Preparation (care treat anemia so patients stay healthier. You may of patients with advanced CKD who are not be able to help reduce anemia by making sure on dialysis); ESRD Workgroup (care of ESRD patients get more of their blood back after a patients); and Shared Decision Making treatment, keeping dialyzers from clotting, and (starting and ending dialysis).13 stopping excess blood loss when you put in or take out the needles. National Kidney Foundation-KDOQI Patients sometimes get less than the minimum In 1995, the NKF’s Dialysis Outcomes Quality dose of dialysis. The KDOQI adequacy Initiative (NKF-DOQI) was formed, supported by guidelines suggest that the doctor prescribe a a grant from Amgen. Teams wrote guidelines in higher dose, so patients will at least reach the four key areas: anemia, hemodialysis adequacy, minimum amount of treatment—or more. You peritoneal dialysis adequacy, and vascular can help ensure that patients get adequate access.14 The hemodialysis adequacy guidelines dialysis. You can correctly draw blood for built on the 1993 RPA guideline. testing, and check that the entire prescription is given. For example, you could make sure the Since 1999, the NKF has increased the scope of correct blood flow rate is used, and explain why DOQI to include all phases of kidney disease, patients should stay on for the prescribed time. and updated the first set of guidelines. Now it is called the Kidney Disease Outcomes Quality The vascular access guidelines give ways to check Initiative (KDOQI). Its goal is to improve the and preserve a patient’s access. You can help protect care and outcomes of all people with CKD.14 patients’ accesses when you use good technique to put in needles, help patients put the right pressure In 2003, a new NKF program called Kidney on needle sites after a treatment, and report problems Disease: Improving Global Outcomes (KDIGO) with the access to a nurse or doctor right away. was launched. Its mission is to improve the care and outcomes of kidney patients around KDOQI guidelines have also been written the world. KDIGO is an effort to write and for heart disease, CKD, nutrition, high blood implement global clinical practice guidelines.14 pressure, bone disease, and lipid disorders. 10 Updates and new guidelines are in process. You n Technical (e.g., water treatment, dialyzer reuse) need to be aware of these changes and how they n Organizational (e.g., staff schedules, may affect your practices and those of your center. patient safety) DOPPS CQI Process The Dialysis Outcomes and Practice Patterns Study Different CQI models exist, but their goals are (DOPPS) is a long-term study of patients in 12 the same. All dialysis centers should use a countries (Australia, Belgium, Canada, France, model of CQI. The large dialysis organizations Germany, Japan, Italy, New Zealand, Spain, Sweden, have developed CQI programs that are used in the United Kingdom, and the United States). all of their centers. The goal of DOPPS is to help patients live longer by looking at practice patterns in centers.14 The Below is an example of a four-step CQI data are used to help find treatment factors that process.15 Steps one through three are where can be changed to improve patient outcomes.14 the CQI models may differ. I. Identify Improvement Needs CONTINUOUS QUALITY The goal of this step is to find an area that IMPROVEMENT IN DIALYSIS needs to be improved. There are four substeps Improving patient outcomes by giving high- to finding improvement needs: quality, efficient care has become a goal of the 1. Collect data. dialysis industry. There are efforts by CMS and insurance companies to control costs and 2. Analyze the data. improve quality. One way to meet these goals is 3. Identify the problem/need for the use of continuous quality improvement (CQI). improvement. Like quality assurance, CQI is a way to improve 4. Prioritize activities. care. The focus of quality assurance is on audits II. Analyze the Process and reviews to look for problems. The focus of CQI is to see how things are working, take This step has four substeps: steps to make them better, and prevent future 1. Choose a team – CQI teams should include problems.15 different members of the care team based on CQI can be both “top-down” and “bottom-up.” Top- the problem: doctors, nurses, dietitians, down means management commits to a CQI technicians, social workers, and patients. culture and uses resources to help CQI projects 2. Review the data – The CQI team should succeed. Bottom-up means workers find best review the data collected in the first step. practices and barriers to better care, and make 3. Study the process/problem – Review the changes to improve care.16 CQI projects can be: literature on the problem to see if there are n Clinical (e.g., anemia, adequacy, access standards or guidelines for it. Find reasons problems) why the problem may have occurred. 11 11 Today’s Dialysis Environment: An Overview 4. Identify patterns/trends – Review all 2. Do – Implement the action plan. of the possible reasons for the problem, 3. Check – Monitor the results of the using the data. plan, assess results after the plan is done, III. Identify Root Causes and assess the plan for any needed From research, discussion, and data, decide the changes. exact causes of the problem. 4. Act – Adopt the plan in the center on a IV. Implement the “Plan, Do, Check, Act” Cycle formal basis and continue to monitor progress. The last step is to use the plan, do, check, act (PDCA) cycle (see Figure 8). The four steps to The PDCA cycle is an ongoing process. Once the PDCA cycle are: a solution to the problem is started in the 1. Plan – Make a plan to address the center, you can’t assume that the problem is problem. Include outcomes, solutions to solved. The new process needs to be checked the problem, a task list for each team to ensure that it is being used in day-to-day member, and a time frame. practice. Figure 8: CQI process 1 2 3 Identify Improvement Analyze the Process Identify Root Causes Needs Select a team Identify probable root Collect data Review the data causes Analyze data Study the process/problem Define/refine the pr