November 27, 2006
Ray Sherer, Director
Division of Provider Services
State of Alabama Department of Public Health
The RSA Tower
201 Monroe Street
Montgomery, AL 36104
Re: Amendments to Rule Number 420-5-5-.03 Patient Care, of the End Stage Renal Disease and Treatment Center rules.
Dear Mr. Sherer:
The American Nephrology Nurses Association (ANNA) is the professional nursing organization representing over 12,000 registered nurses (RNs) nationwide, and nearly 200 in Alabama, who care for patients with chronic kidney disease and kidney failure. The majority of our members practice in a variety of roles in outpatient hemodialysis settings. As such, they are heavily invested in the rules that directly affect their patients, their practice setting, or - as is the case with the proposed rule referenced above - their own practice.
The proposed amendments to Rule Number 420-5-5-.03 Patient Care, of the End Stage Renal Disease and Treatment Center rules, would require that an ESRD facility have Advanced Cardiac Life Support (ACLS) available immediately for emergencies, including supplies and certified staff.
We appreciate the concerns that led to this rule, but, while well founded, they were not well informed. That is the value of the public comment process and we hope through this letter to demonstrate that the proposed amendment is not necessary, could be harmful to patients and nurses, and would not result in better patient outcomes. We suggest an alternative amendment that we believe would be more likely to support a positive outcome for dialysis patients who experience a cardiac arrest at a dialysis facility.
A description of the outpatient hemodialysis clinical practice setting is appropriate. Most dialysis units operate with very few registered nurses. These nurses have tremendous responsibility for the safe delivery of hemodialysis care, patient education about their disease and about their medication and dialysis regimens, administration of intravenous medications throughout the treatment, and supervision of unlicensed assistive personnel.
The conduct of ACLS requires a foundational knowledge base coupled with a set of skills that can only be developed and maintained by continuous exposure to their application. Fortunately, this is just not the case in dialysis units, a finding which has been well documented in the medical literature. Delivery of chronic hemodialysis is not of the same acute patient care intensity as that found in a hospital Intensive Care Unit or Emergency/Trauma Department. Training and certification is simply not sufficient to render a nurse a safe practitioner of ACLS some time later.
As an example, if a nephrology nurse achieved ACLS certification, s/he would need to be reviewing cardiac rhythm strips frequently to remain proficient in their interpretation. Electrocardiogram monitoring is not a routine component of care delivery during a hemodialysis treatment. Since dialysis patients are not ordinarily attached to a cardiac monitor, if a patient had a sudden problem, the nurse would not have the opportunity to identify the cardiac dysrhythmia to begin initiation of the appropriate cardiac support medications. Without a good monitor, it can be extremely difficult to accurately assess the patients condition, and administering the wrong drug or the wrong dose for the situation would likely result in a poor patient outcome.
The nephrology nurse would also be responsible for proper intubation of the patient to establish or maintain the airway. Again, this is a difficult skill to master, and one that requires a great deal of experience. The patient would be better served by initiation of CPR with chest compressions, respirations, and the application of oxygen, which is available in the facilities.
Most often there are no physicians in a dialysis unit and the licensed and unlicensed staff that are present are needed to care for the patients on dialysis. If the nurse were responsible for running a full cardiac resuscitation, s/he would have little or no support in this delivery of care, whereas in acute care settings the ACLS team typically includes 6 individuals: the team leader (typically a physician); someone who manages the airway, intubation and oxygen administration; a third to monitor heart rhythm and defibrillate; a fourth to apply chest compressions; a fifth to gain IV access and push medications through that line; and a sixth to document everything. Such resources do not exist and are not necessary in a chronic outpatient hemodialysis unit.
The 2005 Nephrology Nursing Standards of Practice and Guidelines for Care do not require nephrology nurses working in dialysis to be ACLS certified. Many nurses would not want to expose themselves to such liability which might further discourage registered nurses from seeking employment in dialysis units. This would lead to a drastic decrease in the quality of care for dialysis patients in Alabama and could negatively affect access to this lifesaving therapy if facilities could not be appropriately staffed.
The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative, Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients, Guideline 8, reads: All dialysis units should have on-site capability for external cardiac defibrillation. Automatic external defibrillators are the simplest, most cost-effective means to achieving this guideline, as they do not require advanced life support training by staff for operation, require minimal maintenance, and are designed for use by non-medical personnel
The guideline goes on to state: Basic life support (CPR) training for dialysis unit staff is recommended as an enhancement to the effectiveness of AEDs, as it includes instruction in use of AEDs, airway and circulatory support during cardio respiratory arrest, and management of noncardiac emergencies (such as choking).
Many, if not most, dialysis facilities in Alabama already have AEDs. Therefore, ANNA believes it would be in the best interest of the dialysis patients in Alabama who experience a cardiac event if the nurse performed Basic Cardiac Life Support, or CPR, maintaining a pulse and respirations, and used the AED as indicated until EMS assistance arrived on the scene.
We further suggest that the proposed amendment be deleted and that the Alabama Department of Public Health amend the rule to require dialysis facilities to have AEDs and staff trained to use them.
Thank you for consideration of these comments. If you have any questions, please contact me at 888-600-2662.
JoAnne Gilmore, BSN, RN, CNN
cc: Board of Directors
Kathleen Smith, State Health Policy Consultant