Dialysis technicians can help increase use of home hemodialysis
The use of technicians to assist in delivering dialysis to the end-stage kidney disease population has been a recognized role since the early 1970s. Today, that role should be extended to expanding home dialysis.
The early function of the dialysis technician was to work alongside and under the supervision of a registered nurse. The standard training was provided on the job by the dialysis facility.
Since 2010, when CMS required all technicians who perform and participate in the dialysis treatment to be certified, the role, function, scope of practice and regulatory requirement for dialysis technicians has evolved tremendously. Dialysis technicians now participate and perform roles in water treatment, quality assurance, supply purchasing/inventory/ordering, mentoring, preceptorship, teaching, vascular access surveillance, pediatric dialysis, acute dialysis, emergency preparedness, infection control and home dialysis.
The first patient started treatment for chronic kidney failure by repeated hemodialysis on March 9, 1960, at the University of Washington Hospital in Seattle. In 1964, the University of Washington team developed a home hemodialysis program. HHD was effective and provided patient independence, greater opportunity for rehabilitation and better survival.
In 1973, when the Medicare End-Stage Renal Disease program began, some 40% of U.S. patients using dialysis were on HHD, but since then, both the percentage and the number of patients on this treatment has steadily decreased, and such patients currently comprise approximately 1.3% of the U.S. dialysis population.
Initial decline in HHD
The drop in HHD was caused, at least in part, by the following:
New interest in HHD
There is now renewed interest in HHD sparked by the development of equipment specifically designed for this use, the opportunity for adequate dialysis while increasing quality of life and an interest in the use of daily (or nightly) hemodialysis. Consequently, more than 30 years later, it appears that HHD may again become the preferred treatment for many more patients.
HHD is growing more popular among patients and physicians. Physicians now recognize that home hemodialysis can treat more patients more cost-effectively, reach more patients from rural regions, add a valuable new service to an existing in-center program and bring many of patients improved quality of life.
Patients understand that HHD might help them feel better, maintain their lifestyle and help them have control of their disease. Patients using HHD can keep working and be more active, and have freedom and flexibility to travel with their therapy with newer, portable machines.
Use of technicians in dialysis
The original home dialysis model was dependent on a care partner, typically a family member who had relatively little or no medical training, but who was trained by the facility to perform effective and safe dialysis in the home. This model was embraced by the dialysis community as a means of filling the growing need for in-center dialysis staffing.
The 2010 CMS requirement for mandatory certification improved on the in-center training concept by requiring that dialysis clinical technician training include subjects such as principles of dialysis; care of patients with kidney failure, including personal skills; dialysis procedures and documentation, including initiation, proper cannulation techniques, monitoring and termination of dialysis; infection control and safety.
More than 557,000 U.S. residents are on dialysis. According to the most recent United States Renal Data System data, there were 44,797 full-time and 5,396 part-time dialysis technicians in 2022 providing most of the front-line care. The millions of successful treatments performed each year is evidence that technicians possess the skill, knowledge and competency to perform safe and effective dialysis.
HHD and PD training and support have been exclusively relegated to nephrology nurses. With challenges in staffing and growing interest in home dialysis, expanding the role of the technician as a participant in the care and teaching of HHD and PD is a job function emerging in the dialysis community. With some variations in the equipment and logistics, the skills and knowledge required to perform dialysis at home are no different from the skills and knowledge required for in-center treatments.
Data to support the extent of technicians involved in HHD are limited. A recent national job analysis survey was conducted in 2023 by the Nephrology Nursing Certification Commission, one of the testing organizations for dialysis technician certification, whose certifications number more than 50,000 nurses and technicians. The survey goal was to determine the different job functions currently performed by technicians. Of the tasks listed were practices such as PD effluent sampling, setting up the cycler, performing exchanges, assisting with exchanges, setting up HHD machines, reinforcing training and performing environmental assessment. Of the 2,443 respondents, 10% indicated that these activities were part of their job functions.
The CMS end-stage renal disease surveyor trainer interpretive guidance states, “While the qualified home training RN(s) is expected to be the primary staff member providing training and support whether training occurs in the dialysis facility or in the patient’s home, other members of the clinical dialysis staff may assist in providing the home training, within the scope of practice and expertise/competencies of those staff members.”
Since the early 1970s, dialysis technicians have demonstrated the confidence, trust, reliance, skill, knowledge and patient-centered dedication in the various job functions in the outpatient setting. It is, therefore, conceivable that expanding the technician’s role in assisting with care and training for home dialysis would result in similar success experienced in the in-center outpatient setting.
References:
Blagg CR. Adv Ren Replace Ther. 1996;doi:10.1016/s1073-4449(96)80048-3.
Blagg CR. Am J Kidney Dis. 2007;doi:10.1053/j.ajkd.2007.01.017.
Blagg CR. Home Hemodial Int. 1997;doi:10.1111/hdi.1997.1.1.1.
CMS. ESRD surveyor trainer interpretive guidance. Published Oct. 3, 2008. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/esrdpgmguidance.pdf. Accessed March 4, 2025.
NIDDK USRDS. 2024 Annual Data Report. https://usrds-adr.niddk.nih.gov/2024. Accessed March 4, 2025.
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Danilo B. Concepcion, CBNT, CCHT-A, FNKF, is a Healio | Nephrology News & Issues Editorial Board Member. He is operations manager for renal services at Providence St. Joseph Hospital in Orange, California. He can be reached at danilo.concepcion@stjoe.org.
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