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ObjectivesAfter 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.

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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.

IntroductionAs a patient care technician, your job is to helppatients with chronic kidney disease (CKD)receive safe and effective dialysis. To do this well,it will help you to learn what dialysis is, how itwas developed, how to ensure high-quality carefor patients, and how to perform and carry outyour duties in a professional manner. We coverall of these topics in this module.

While there are many treatment goals for patientswith CKD, the main goal is to help each patientreach the highest level of wellness possible. Helpingpatients to reach this goal is one of the mostrewarding parts of caring for patients with CKD.

Dialysis is provided by a team that includestechnicians, nurses, dietitians, social workers,doctors—and, most important of all, patients.Some patients choose to take a very active role intheir care and know a lot about their treatment andhow it affects them. The team should support thisinterest and knowledge: research shows thatpatients who self-manage their care and knowmore about it stay healthier and live longer. Ittakes a team to make sure that patients’ needsfor treatment, nutrition, medications, and socialservices are met. Other specialists, such as physicaltherapists, pharmacists, exercise physiologists,and clergy, may be called on as well.

With good dialysis, many people with CKD can leadfull and active lives. For others, having a good qualityof life is harder. A person’s health depends on anumber of factors. These can include age, formeractivity level, proper treatment, other illnesses (suchas diabetes or high blood pressure), and supportfrom loved ones. With training and experience, adialysis technician can help patients feel their best,and at the same time, have a rewarding career.

Overview of DialysisWhen the kidneys fail, patients need treatment tolive. Dialysis is the main treatment for end-stagerenal disease (ESRD). It replaces three main kidneytasks: removing wastes from the blood, removingexcess fluid from the blood, and keepingelectrolytes (electrically charged particles) inbalance. There are two main types of dialysis:hemodialysis (HD), and peritoneal dialysis(PD). HD is most common (see Figure 1).

To do HD, an entry into the patient’sbloodstream is needed. This is called a vascularaccess. During a treatment, needles are placedinto the access. Blood flows out of the patient,through an artificial kidney (dialyzer) where

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FRESENIUS

Figure 1: Hemodialysis

Drawing adapted with permission from Fresenius Medical Care–North America

the blood is cleaned, and back to the patient.The dialyzer contains a semipermeablemembrane which allows some substances, suchas wastes and excess water out, but keepsothers, such as blood cells, in. Wastes and waterpass through the membrane into a fluid calleddialysate and some substances pass from thedialysate into the blood. The dialysis machine,or delivery system, controls the flow of blood to the dialyzer, includes safety alarms tomonitor the machine during a treatment, andmixes and delivers dialysate. HD is most oftendone in a center 3 times a week, for about 4hours per treatment. Some patients do HD athome, and may do short treatments 5 or 6 daysa week. Or they may do longer treatments atnight while they sleep for 3–7 nights per week.

Access for PD is through a catheter (tube)placed in the abdomen. The blood never leavesthe body; instead, the lining of the abdomen,which has many tiny blood vessels, acts as afilter in the same way as a dialyzer. In the

most common type of PD,1 patients use a cyclermachine at home at night, while they sleep, tocycle sterile dialysate in and out of the abdomen.PD can also be done by hand, usually with fourexchanges of fresh dialysate for used dialysateeach day. PD goes on 7 days per week. ManualPD can be done at home, at work, or while traveling.

HISTORY OF DIALYSISDialysis as a treatment for kidney failure was notalways the sleek, high-tech process it is today. Thefirst hemodialysis treatment in a patient, usingcellulosic membrane, was done in 1943 using arotating drum artificial kidney (see Figure 2)developed by a Dutch doctor named Willem Kolff.2

Before that time, patients with kidney failure hadno effective treatment; the disease was always fatal.

Kolff ’s rotating drum device featured a largewooden wheel dialyzer made of slats wrappedwith 30–40 meters of sausage casing (thecellophane membrane). To gain access to theblood, a fresh artery and vein had to be used for

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Figure 2: Rotating drum device

Actual size: 42” high, 54” wide, 28” deep

Wooden slats wrapped with sausage-skinsemipermeable membrane

Dialysate in vat

Drum turns to bring membranes into contact with dialysate

each treatment and tied off after. Because apatient had limited blood vessels, dialysis couldonly be used to treat patients whose kidneyswere expected to recover.

The science and technology of dialysis made greatstrides during the Korean War (1950–1953).Dialysis was used to treat soldiers with acute renalfailure, improving their chances of survival.3

Vascular AccessIn 1960, Dr. Belding Scribner and his colleaguescame up with a way to reenter and use bloodvessels multiple times for dialysis. They linkeda patient’s artery and vein using a plastic tubeoutside the skin. Called a shunt (see Figure 3),this first vascular access made it possible totreat patients with chronic kidney failure, whowould need dialysis for the rest of their lives.But shunts often became infected or clotted.4

In 1966, Dr. James Cimino and colleagues found away to connect an artery and a vein together insidethe arm. The arteriovenous (AV) fistula causedfewer infections and blood clots than the shunt.Even today, the AV fistula, or native fistula, lastslongest and is the best access for HD.4

DialyzersKiil dialyzers used in the 1960s were 70-poundflat plates (see Figure 4). Their large surfaceareas were covered by sheets of cellophane.After each treatment, the membranes werecleaned and stored in a chemical bath or theplates were taken apart and the membranesreplaced. Each corner of the dialyzer had to beuniform and “torqued down”—a lengthy taskcalled “building a dialyzer.” Treatments took upto 14 hours, 3 times a week.

The first dialyzer to be mass-produced was thecoil dialyzer—a membrane supported by amesh screen coiled around a central core. It wasprimed with a large amount of blood, set in aholding container called a canister, and bathedwith dialysate. Coil dialyzers were sterile anddisposable, which made them very costly.

With the advent of technology in the mid 1960scame a new membrane material calledcuprophane. This launched another type of

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Figure 3: Scribner shunt in the forearm position

Silastic tubing

Connection brokenhere for dialysis

Figure 4: Kiil dialyzer

Latches Inside the Kiil, two pairs of membranesheets (4 sheets) were separated by

three grooved, polypropylene boards.

dialyzer: the Gambro flat plate (see Figure 5).Considered small at the time, early flat platedialyzers were more than 30 inches long, withmany layers of membranes in pairs. Each pair ofmembranes formed an envelope. During a treatment,blood flowed between the pairs of membranes,and dialysate flowed around the outside.

In the late 1960s, researchers made a small,lightweight, hollow fiber dialyzer (see Figure 6).Blood flowed through the insides of the fibers—thousands of tiny hollow tubes the size of hairs.

Dialysate flowed around the outside of the fibers.The hollow fiber dialyzer, much improved overthe years, is the only type on the market today.

Since the 1960s, many advances have madedialysis more safe and reliable. Bettermembranes that are more compatible with thetissues of the human body (biocompatible),increase treatment comfort for patients.Machine alarms and automated functions inthe machine help protect patients from harm.

MEDICARE PAYMENT FOR ESRD PATIENTS

What if we knew how to save the lives of patientswith kidney failure, but we didn’t have enoughmachines to treat them all? Who would decide whichpatients would live and which would die? Before1973, this really happened all across the country.

Hospitals had “Life and Death” committeesmade up of lay people and clergy.5 They chosepatients for treatment based on age, maturity,education, whether they had children tosupport, could afford the care, and how muchthey might give back to society if they couldlive. For patients who were chosen, the costs oftreatment were very high. Some chose death ratherthan impose this burden on their loved ones.

To make sure that people could get treatment forkidney failure that could help them live full lives,Congress passed Public Law 92-603, the MedicareEnd-Stage Renal Disease (ESRD) Program, in 1972.This program gives Medicare to patients who areentitled to Social Security based on their workrecord (93%) of all patients. It covers both dialysisand kidney transplants. Medicare pays 80% ofallowable costs; insurance, Medicaid, state programs,or patients pay the other 20%.6 Once the law

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Figure 6: Hollow fiber dialyzer

Figure 5: Flat plate dialyzer

Blood out Blood in

Dialysate outDialysate

Support structure

Blood flows betweenpairs of semipermeablemembranes

Pair ofsemipermeablemembranes

Dialysate flows between thesupport structure and theoutsides of the membranes

Dialysate in

Dialysate out

Blood from

patient

Blood back to

the patient

Dialysate in

Fibers

passed and more machines were built, shortageswere no longer a life-or-death problem. Today,kidney failure is still the only disease with itsown Medicare program.

Government funding changed dialysis. Before1972, many patients did their treatments athome with a helper. Most centers were based inhospitals. After the Medicare ESRD Programbegan, more centers began to open. Today, most centers are free-standing—not hospital-based—and about 2/3 of them are part of alarge dialysis organization (LDO), a companythat owns many centers all over the country.Each year, there are fewer and larger LDOs, as they buy more centers.

Centers today are paid a composite rate by Medicarefor each treatment. This rate is based on thepatient’s age, weight, and height, and is differentfor each patient. The amount must coveroverhead, staff wages and training, equipment,rehabilitation, and some drugs. The compositerate is not raised each year for inflation the wayhospitals and nursing home rates are. Instead,Congress must pass a law to raise the rate. In1974, the average rate per treatment was $138.In 2002 it was $130.50—which was worth only$34 in constant dollars.5 At this point, centersmay lose $5 to $10 per treatment on patientswho have Medicare only. This has forcedcenters to become ever more efficient—withoutreducing the quality of the care they provide.

There is a second source of income for centers:insurance. During the first 30 months oftreatment, if patients have an employer grouphealth plan (EGHP) through a job or a spouse’sjob, that plan is primary—it pays first.6 Onaverage, EGHPs pay $126,000 per patient, per

year, while Medicare itself pays about $63,000.7

So, centers that offer work-friendly treatmentsand/or schedules can help patients keep theirjobs and insurance—and improve their ownbottom line at the same time.

In 1978, ESRD Networks were set up to overseethe quality of dialysis care across the country.8

There are 18 ESRD Networks; most are non-profit,and all are under contract with Medicare to covera region of 1–6 states (see Figure 7). Networksare charged to promote rehabilitation, collectand report data, and do quality improvementprojects. Networks also offer a patient grievanceprocess and provide resources to staff and patients.

Quality in DialysisWhat is quality care? In 1990, the Institute ofMedicine (IOM) defined quality as: “The degreeto which health services for individuals andpopulations increase the likelihood of desiredhealth outcomes and are consistent with currentprofessional knowledge.”9 The IOM studied many

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Figure 7: ESRD Network map

Drawing adapted with permission from the Forum of ESRD Networks

aspects of the care and treatment of Medicarepatients, and found that changes were needed toimprove care.9

The IOM still assesses our healthcare system; in2001, it put out a report that found ongoingproblems. The IOM set a strategy and action planto improve care, with six Aims for Improvement.10

Providers and users of the healthcare systemmust commit to the six aims to foster innovationand improve the delivery of high quality care.The aims are to provide care that is:

1. Safe: avoid harm to patients from care thatshould help them.

2. Effective: provide care based on science toall who could benefit.

3. Patient–centered: provide care that respectsand responds to patient wishes, needs, andvalues, and ensure that patient values guideclinical decisions.

4. Timely: reduce waits and sometimes harmfuldelays for those who receive and give care.

5. Efficient: avoid waste of equipment, supplies,ideas, and energy.

6. Equitable: provide care that does not vary inquality due to gender, ethnicity, geography,education level, and income.

The quality of dialysis care has been a focussince the Medicare ESRD Program was passedin 1972. The original purpose of dialysis wasnot just to keep patients alive, but to help themstay active, work, and pay taxes. Once therewere enough machines to treat all patients, wewere able to focus on whether dialysis wasmeeting this goal. Because of the cost, Congressneeds to be assured that the Medicare ESRD

Program is worth the money. This is done, in part, by showing that centers and staff areproviding good quality care. There is pressurethroughout healthcare to look at how wellpatients are doing, so we can keep costs downwhile still having high quality.

DIALYSIS QUALITYSTANDARDS

Since the 1970s, quality in dialysis has beenchecked by comparing centers to presetstandards. This is called quality assurance.Centers that do not meet these standards risklosing their Medicare certification to provideESRD services and the payments they receivefor these services.

For example, the Centers for Medicare andMedicaid Services (CMS) is the federal bodythat oversees Medicare. CMS inspects dialysiscenters through contracts with stateDepartments of Health. State surveyors havechecklists of standards and conditions thatcenters must meet to keep their certification.Centers that do not meet these can lose theirMedicare funding. With so many centers andnursing homes to inspect, years may go bybetween surveys—but a center should always be ready for a survey and work each day as if it will be inspected.

Many other dialysis standards exist:

n ESRD Networks have Medical ReviewBoards that collect patient and center data to measure outcomes.

n The Joint Commission on the Accreditationof Healthcare Organizations (JCAHO) hasstandards for hospital-based dialysis centers.

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n The Association for the Advancement ofMedical Instrumentation (AAMI) hasstandards for dialysis water treatment,dialysis solution preparation, and dialyzerreprocessing.

The Food and Drug Administration (FDA)oversees the safety and effectiveness of all medicaldevices. In 1991, the FDA put out QualityAssurance Guidelines for Hemodialysis Devices.11

These guidelines, still in effect, cover dialyzersand blood tubing, monitoring devices andalarms, dialysis machines, dialyzer reprocessingequipment, water treatment, and all otherdialysis devices. The FDA requires healthcareproviders to fill out special reports to tellmanufacturers and the FDA about problems withdevices and equipment, as well as adverse events.11

National dialysis data can serve as standards.The United States Renal Data System (USRDS)puts out a report each year that compares datafrom all the dialysis centers in the United States.Data in the USRDS include annual mortality(death) rate, number of patients, cost oftreatment, and much more. The results may beused to find out if outcomes for all patients aregetting better or worse. Centers can use the datato compare their outcomes with national averages.

Another source of national data is the ESRDClinical Performance Measures (CPMs) project.This is a team effort of CMS, the ESRDNetworks, and dialysis centers. The CPMscompare the quality of Medicare dialysis. Dataare gathered each year from a random sample ofpatients from each center.12 The CPMs are basedon the National Kidney Foundation (NKF)Kidney Disease Outcomes Quality Initiative

(KDOQI™) Clinical Practice Guidelines. Thehemodialysis CPMs are adequacy of dialysis,vascular access, anemia, and albumin. A reportis put out each year.12 Dialysis centers cancompare the CPM results with their ownoutcomes.

GUIDELINES FORDIALYSIS CARE

To measure the quality of care in a center,outcomes (results of care) must be used. Theseoutcomes must be agreed upon by providersand patients and based on the most currentknowledge. They are then measured for eachpatient, for groups of patients, or for centers, and are tracked over time.

Today, patients whose kidneys fail can livelonger than ever before. Some patients live fordecades. But, too many patients still die early or suffer ill effects from kidney disease. Evenwith standards, patient outcomes like morbidity(sickness) and mortality (death) vary fromcenter to center. This may be due, in part, todifferences in care at centers or in approach to care and treatment among nephrologists(doctors who specialize in kidney disease).

How can we improve outcomes for all patients?By finding the best way to provide dialysis careand sharing these ideas with all centers. Clinicalpractice guidelines are efforts to do just that.

Renal PhysiciansAssociationThe first clinical practice guideline for kidneyfailure was written in 1993 by Renal PhysiciansAssociation (RPA) nephrologists.

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The guideline, Adequacy of Hemodialysis,covered the dose of treatment a patient shouldreceive.13 Healthy kidneys work 24 hours a day, 7 days a week. Dialysis done three times a weekprovides only about 15% of the function ofhealthy kidneys. Patients who do not getenough treatment feel ill and are at risk of dyingsooner. So, the RPA guideline suggested aminimum dose of hemodialysis for all patients.

The RPA has written other guidelines, whichinclude: Appropriate Patient Preparation (careof patients with advanced CKD who are not on dialysis); ESRD Workgroup (care of ESRDpatients); and Shared Decision Making(starting and ending dialysis).13

National KidneyFoundation-KDOQIIn 1995, the NKF’s Dialysis Outcomes QualityInitiative (NKF-DOQI) was formed, supported bya grant from Amgen. Teams wrote guidelines infour key areas: anemia, hemodialysis adequacy,peritoneal dialysis adequacy, and vascularaccess.14 The hemodialysis adequacy guidelinesbuilt on the 1993 RPA guideline.

Since 1999, the NKF has increased the scope ofDOQI to include all phases of kidney disease,and updated the first set of guidelines. Now it is called the Kidney Disease Outcomes QualityInitiative (KDOQI). Its goal is to improve thecare and outcomes of all people with CKD.14

In 2003, a new NKF program called KidneyDisease: Improving Global Outcomes (KDIGO)was launched. Its mission is to improve the care and outcomes of kidney patients aroundthe world. KDIGO is an effort to write andimplement global clinical practice guidelines.14

To work, the KDOQI guidelines must be put intodaily practice. The guidelines change the waysome centers provide care. As a technician, youwill be a key member of a healthcare team thatuses these guidelines and helps patientsunderstand their purpose.

For example, anemia is a shortage of oxygen-carrying red blood cells. It causes fatigue, heartdisease, and many other problems. The KDOQIanemia guidelines help centers identify andtreat anemia so patients stay healthier. You maybe able to help reduce anemia by making surepatients get more of their blood back after atreatment, keeping dialyzers from clotting, andstopping excess blood loss when you put in ortake out the needles.

Patients sometimes get less than the minimumdose of dialysis. The KDOQI adequacyguidelines suggest that the doctor prescribe ahigher dose, so patients will at least reach theminimum amount of treatment—or more. Youcan help ensure that patients get adequatedialysis. You can correctly draw blood fortesting, and check that the entire prescription isgiven. For example, you could make sure thecorrect blood flow rate is used, and explain whypatients should stay on for the prescribed time.

The vascular access guidelines give ways to checkand preserve a patient’s access. You can help protectpatients’ accesses when you use good technique toput in needles, help patients put the right pressureon needle sites after a treatment, and report problemswith the access to a nurse or doctor right away.

KDOQI guidelines have also been written for heart disease, CKD, nutrition, high bloodpressure, bone disease, and lipid disorders.

Updates and new guidelines are in process. Youneed to be aware of these changes and how theymay affect your practices and those of your center.

DOPPSThe Dialysis Outcomes and Practice Patterns Study(DOPPS) is a long-term study of patients in 12countries (Australia, Belgium, Canada, France,Germany, Japan, Italy, New Zealand, Spain, Sweden,the United Kingdom, and the United States).The goal of DOPPS is to help patients live longerby looking at practice patterns in centers.14 Thedata are used to help find treatment factors thatcan be changed to improve patient outcomes.14

CONTINUOUS QUALITYIMPROVEMENT IN DIALYSISImproving patient outcomes by giving high-quality, efficient care has become a goal of thedialysis industry. There are efforts by CMS and insurance companies to control costs andimprove quality. One way to meet these goals isthe use of continuous quality improvement (CQI).

Like quality assurance, CQI is a way to improvecare. The focus of quality assurance is on auditsand reviews to look for problems. The focus of CQI is to see how things are working, takesteps to make them better, and prevent futureproblems.15

CQI can be both “top-down” and “bottom-up.” Top-down means management commits to a CQIculture and uses resources to help CQI projectssucceed. Bottom-up means workers find bestpractices and barriers to better care, and makechanges to improve care.16 CQI projects can be:

n Clinical (e.g., anemia, adequacy, accessproblems)

n Technical (e.g., water treatment, dialyzer reuse)

n Organizational (e.g., staff schedules, patient safety)

CQI ProcessDifferent CQI models exist, but their goals arethe same. All dialysis centers should use amodel of CQI. The large dialysis organizationshave developed CQI programs that are used inall of their centers.

Below is an example of a four-step CQIprocess.15 Steps one through three are where the CQI models may differ.

I. Identify Improvement Needs

The goal of this step is to find an area that needs to be improved. There are four substepsto finding improvement needs:

1. Collect data.

2. Analyze the data.

3. Identify the problem/need forimprovement.

4. Prioritize activities.

II. Analyze the Process

This step has four substeps:

1. Choose a team– CQI teams should includedifferent members of the care team based onthe problem: doctors, nurses, dietitians,technicians, social workers, and patients.

2. Review the data – The CQI team shouldreview the data collected in the first step.

3. Study the process/problem – Review theliterature on the problem to see if there arestandards or guidelines for it. Find reasonswhy the problem may have occurred.

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4. Identify patterns/trends – Review all of the possible reasons for the problem,using the data.

III. Identify Root Causes

From research, discussion, and data, decide theexact causes of the problem.

IV. Implement the “Plan, Do, Check, Act” Cycle

The last step is to use the plan, do, check, act(PDCA) cycle (see Figure 8). The four steps tothe PDCA cycle are:

1. Plan – Make a plan to address theproblem. Include outcomes, solutions tothe problem, a task list for each teammember, and a time frame.

2. Do – Implement the action plan.

3. Check – Monitor the results of the plan, assess results after the plan is done,and assess the plan for any neededchanges.

4. Act – Adopt the plan in the center on aformal basis and continue to monitorprogress.

The PDCA cycle is an ongoing process. Once a solution to the problem is started in the center, you can’t assume that the problem issolved. The new process needs to be checked to ensure that it is being used in day-to-daypractice.

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Identify Improvement Needs • Collect data • Analyze data • Identify problem statement • Prioritize activities

1 Analyze the Process • Select a team • Review the data • Study the process/problem • Identify partners/trends

2

• Identify probable root causes • Define/refine the problem

Identify Root Causes

3

4

Implement the solution, change or modify facility-wide tests, revise standards and specifications, incorporate revisions into day-to-day practices.

Obtain judgments of improvement achieved (performance, process measurements, outcomes); determine if solution, change, or medication has been successful

Deliver care, perform policy or procedure in limited trial run.

Design or redesign policies, procedures, services, or products.

Specify objectives or degree of improvement desired.

Figure 8: CQI process

DIALYSIS TECHNICIANPROFESSIONALISM

When you became a hemodialysis patient caretechnician, you became a member of the healthcareteam that cares for patients at your center. As atechnician, you will have more direct patient contactthan any other staff member. So, you need tounderstand what it means to perform and behavein a professional manner, and build that intoyour daily practice.

One of the key skills to learn is how to behave in aprofessional way. The Merriam-Webster dictionarydefines professionalism as a way of “exhibiting a courteous, conscientious, and generallybusinesslike manner in the workplace.”17

What are some ways you can be courteous to yourpatients while being both caring and professional?18

n Address patients by their titles (i.e., Mrs. Smith).Don’t use a first name without permission.

n Don’t use nicknames—especially ones that could make a patient feel dependent(i.e., baby or sweetie).

n Use “please” and “thank you” when talking topatients, families, and other staff members.

n Treat everyone with respect and pride. Maintainthe patient’s dignity. Always introduce yourselfand other members of the team to new patients,so they feel more comfortable with the center.

What are some ways you can show you areconscientious?18

n Get to work on time.

n Be ready to work when you arrive.

n Don’t talk about your personal life topatients or other staff members when in thepatient care area.

n Never discuss or burden patients with yourpersonal problems.

n Don’t talk around or over patients, as thoughthey weren’t there.

n Never talk about one patient in front ofanother patient.

n Protect everyone’s privacy and confidentialinformation.

What are some ways you can show a business-like manner?18

n Wear appropriate clothes that are clean andwell kept.

n Groom yourself well:

• Trim your fingernails and keep them free of inappropriate decorations.

• Keep makeup tasteful and minimal.

• Brush or comb your hair neatly.

• Don’t wear too much perfume, cologne, or aftershave.

n Keep things peaceful and the level of noise to a minimum:

• Don’t shout across the treatment area.

• Don’t rush or run around the treatment area.

• Don’t always appear to be too busy orindifferent—patients may feel unsafe.

• Take the appropriate amount of time withevery patient.

n Make certain all equipment is ready andworking when the patient arrives.

n Keep the patient care area clean, swept, and free of blood.

Knowing how to maintain boundaries is a key part ofprofessionalism. Boundaries keep the relationship

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between you and your patients appropriate and safe.They also protect everyone from misunderstandings.What are some examples of boundaries?18

n Never date patients.

n Never ask for or borrow money from patients.

n Never invite patients to your home or toactivities that are not related to the center.

n Never discuss your personal problems withpatients.

n Never accept tips, money, or gifts from patients.

n Never touch patients in an inappropriate manner.

n Never invade a patient’s personal space—itcan make the patient afraid and bedangerous for the staff.

Another key issue is confidentiality—maintainingpatient privacy. Your center will give yourequired training on privacy and the HealthInsurance Portability and Accountability Act(HIPAA) privacy rule.

DIALYSIS TECHNICIANASSOCIATIONS

Remember that knowledge is power, and poweris confidence. It takes time and discipline tolearn all you will need to know, but you will reapthe rewards in many ways. Knowledge can be seenin the positive outcomes of patients, and felt asthe result of your discipline and commitment.The dialysis technician organizations below can help you learn more about dialysis.

National Association ofNephrology Technicians/ Technologists (NANT)The National Association of Nephrology Technicians/Technologists (NANT) is a national, non-profit,

professional organization. NANT was foundedin 1983 to improve dialysis care; promoteeducation, certification, and licensing; aid jobsecurity; and help technicians find jobs. NANTis the only group in the country just for dialysistechnicians; it has an elected Board of Directorsand 1,300 active members.19

For more information on NANT, write to: P.O. Box2307, Dayton, OH, 45401, call (877) 607-6268, or visit their website at www.dialysistech.org.

Council of NephrologyNurses and Technicians(CNNT)The Council of Nephrology Nurses and Technicians(CNNT) is a professional membership council ofthe NKF. Its focus is on making health policiesthat aid professional practices and patient care.CNNT advocates for, and contributes to, theprofessional development of its members througheducation, networking, and the sharing ofinformation. The CNNT supports the mission ofthe NKF to bring help and hope to those who sufferfrom kidney disease through research, patientservices, a national organ donor program,professional education, and public education.20

For more information on CNNT, write to: NKF,30 E. 33rd Street, New York, NY, 10016, call (800)622-9010, or visit their website at www.kidney.org.

TECHNICIANCERTIFICATION

You may want to take an exam to becomecertified. Three exams are offered, one is forentry-level technicians with about 6 monthsexperience, and the other two require one ormore years of experience.

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Certified ClinicalHemodialysis Technician(CCHT) ExamThe Nephrology Nursing CertificationCommission (NNCC) offers the CertifiedClinical Hemodialysis Technician (CCHT)exam—a competency level exam. Thecertification is good for 2 years. A joint taskforce of NANT and the American NephrologyNurses’ Association (ANNA) wrote this exam.21

To take the CCHT exam, you will need:21

n At least a high school diploma or a GeneralEducation Development (GED).

n Successful completion of a training programfor hemodialysis patient care technicianswith both classroom instruction andsupervised clinical work.

n The signature of a preceptor/supervisor to prove training and clinical experience.

n Suggested (not required) 6 months full-timeor equivalent (1,000 hours) experience,including training.

n Compliance with state regulations forhemodialysis patient care technicians, ifthey apply. Applicants must meet theexperience requirement (for certification) of the state in which they practice.

The CCHT content comes from fourhemodialysis practice areas: clinical (50%),technical (23%), environmental (15%), and role (12%). NANT recognizes the CCHT examas a valid measure of basic competency forhemodialysis patient care technicians.21

NNCC was founded in 1987 to promote thehighest standards of nephrology nursing

practice through the development,implementation, and evaluation of all aspects of certification and recertification.

To learn more about the exam, check at yourdialysis center or see the exam website atwww.nncc-exam.org.

Certified HemodialysisTechnician (CHT) ExamThe Board of Nephrology Examiners—Nursingand Technology (BONENT) offers an exam tobecome a Certified Hemodialysis Technician (CHT).BONENT is an international organization thathas been providing certification of dialysisnurses and technicians for more than 30 years.

You can take the CHT exam if you have workedfor at least 12 months in a dialysis center or havecompleted an accredited dialysis course. You mustalso have a high school diploma or a GED.21

The BONENT CHT exam measures technicalproficiency in five major areas of practice andtasks: patient care (65%), machine technology(10%), water treatment (5%), dialyzer reprocessing(5%), and education/personal development(15%). NANT recognizes the CHT exam as avalid measure of technical proficiency for allhemodialysis technicians.21 The CHT exam has150 multiple-choice questions, and a 3-hour timelimit. An on-line practice exam is also available.BONENT certification is designed to:

1. Provide and measure a standard ofknowledge for nephrology practitioners

2. Encourage professional growth andindividual study

3. Formally recognize individuals who meet the requirement for certification22

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To learn more about the exam, ask at yourdialysis center or check the BONENT website at www.goamp.com/bonent/.

Certified in ClinicalNephrology Technology(CCNT) and Certified inBiomedical NephrologyTechnology (CBNT) ExamsThe National Nephrology CertificationOrganization, Inc. (NNCO) offers two exams.One is in Clinical Nephrology Technology, for aCertified in Clinical Nephrology Technology(CCNT) designation. The second is inBiomedical Nephrology Technology, leading to the Certified in Biomedical NephrologyTechnology (CBNT) designation. You must have at least 12 months of work experience to take the CCNT and CBNT exams.23

The CCNT exam measures knowledge in fourmajor areas: principles of dialysis (25%),machine preparation and operation (20%),patient assessment (20%), and treatment(35%).23 NANT recognizes the CCNT exam as a valid measure of current competence forpatient care hemodialysis technicians.

The CBNT exam measures knowledge in six majorareas: principles of dialysis (25%), scientificconcepts (15%), electronic applications (10%),water treatment (20%), equipment functions(20%), and environmental/regulatory issues(10%).23 NANT recognizes the CBNT exam as ameasure of current competence for biomedicalhemodialysis technicians.

The mission of the NNCO is promotion of safeand effective care in nephrology technology bycredentialing qualified clinical and biomedicaltechnicians.23 Both the CCNT and CBNT examsare given by the Professional Testing Corporation.

To learn more about the exams and schedulesfor the exams, see the NNCO website atwww.ptcny.com/clients/NNCO.

ConclusionThe history of dialysis and the current system of care are the context for your job as a patientcare technician. Efforts to improve quality and professionalism are the processes that willhelp you and your team provide the best care to patients.

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References1. U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease

in the United States. (Table D.1). Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2005). Available at: www.usrds.org/adr.htm.Accessed March 2006.

2. Corea AL: The history of nephrology nursing, in Parker J (ed): Contemporary NephrologyNursing. Pitman, NJ, American Nephrology Nurses’ Association, 1998, p 28.

3. Fresenius Medical Care: History of hemodialysis. Available at: www.fmc-ag.com/internet/fmc/fmcag/agintpub.nsf/Content/History+of+Dialysis. Accessed July 1, 2005.

4. Blagg CR: Vascular access. Dial Transplant 25(10): 674-677, 1996.

5. Lockridge RS: The direction of end-stage renal disease reimbursement in the United States.Semin Dial 17(2):125-130, 2004.

6. Life Options Rehabilitation Program: Employment: A Kidney Patient’s Guide to Working andPaying for Treatment. Madison, WI, Medical Education Institute, Inc., 2003, pp 19, 20, 33.

7. U.S. Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. (Costs of CKD and ESRD). Bethesda, MD, National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases (2005). Available at:www.usrds.org/adr.htm. Accessed March 2006.

8. Wish JB: The Forum of ESRD Networks: past, present and future. Nephrol News Issues13(10):61-64, 1999.

9. Lohr KN: Medicare: A Strategy for Quality Assurance (Volume 1). Washington, DC, NationalAcademy Press, 1990, pp 1-4.

10. Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century(Brief Report). Washington, DC, National Academy Press, 2001, p 3.

11. Vlchek DL, Burrows-Hudson S, Pressly NA: Quality Assurance Guidelines for HemodialysisDevices. HHS Publication FDA 91-4161. Washington, DC, Health and Human Services, 1991,pp 1-3 and 13-4–13-6.

12. Centers for Medicare and Medicaid Services: Clinical Performance Measures (CPMs) Project.Available at: http://new.cms.hhs.gov/CPMProject/. Accessed July 1, 2005.

13. Renal Physicians Association: Clinical Practice Guidelines. Available at: www.renalmd.org.Accessed July 1, 2005.

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14. Port FK, Eknoyan G: The Dialysis Outcomes and Practice Patterns Study (DOPPS) and theKidney Disease Outcomes Quality Initiative (K/DOQI): A cooperative initiative to improveoutcomes for hemodialysis patients worldwide. Am J Kidney Dis 44(5 Suppl 2):S1-S6, 2004.

15. Wick G: Continuous quality improvement: a problem-solving approach (Part 1). NephrolNurs Today 3(1):1-8, 1993.

16. Wish JB: Quality improvement, in Nissenson AR, Fine RN (eds): Dialysis Therapy (3rd ed).Philadelphia, PA, Hanley & Belfus, Inc., 2002, pp 127-30.

17. Merriam-Webster: Online dictionary. Available at: www.merriam-webster.com. Accessed July 1, 2005.

18. Mid-Atlantic Renal Coalition: Professionalism in dialysis care, in: Dialysis Care:Communication for Quality. Available at: www.esrdnet5.org/inservice.asp. Accessed July 1,2005.

19. National Association of Nephrology Technicians/Technologists: Who we are. Available at:www.dialysistech.org/whoweare/whoarewe.htm. Accessed July 1, 2005.

20. National Kidney Foundation: Council of Nephrology Nurses and Technicians mission andgoals. Available at: www.kidney.org/professionals/CNNT/mission.cfm. Accessed July 1, 2005.

21. Nephrology Nursing Certification Commission: Certified clinical hemodialysis techniciancertification. Available at: www.nncc-exam.org. Accessed July 1, 2005.

22. Board of Nephrology Examiners—Nursing and Technology: Certified hemodialysistechnician. Available at: www.bonent.org/exam_policies/candidate_handbook.html.Accessed July 1, 2005.

23. National Nephrology Certification Organization: Certification examinations in clinicalnephrology technology and biomedical nephrology technology: handbook for candidates.Available at: www.ptcny.com/clients/NNCO. Accessed July 1, 2005.