August 3, 2004
Ms. Laura Rhodes, Executive Director
West Virginia Board of Registered Professional Nurses
101 Dee Drive, Suite 102
Charleston, WV 25311
Dear Ms. Rhodes:
The American Nephrology Nurses’ Association (ANNA) is an organization of over 11,000 registered nurses nationwide, including nearly 100 in West Virginia, who practice in all areas of nephrology. The majority of our members practice in outpatient dialysis settings. We are writing today in response to your request for comments on the Board’s emergency rule 19CSR13, “Dialysis Technicians.” Over the years, ANNA has worked successfully with many state Boards of Nursing in clarifying the uniqueness of the dialysis clinical practice setting, and the role of unlicensed personnel in such settings.
Section 19-13-2.5 We suggest the following substitution language: “Initiation of dialysis care” includes appropriately preparing the dialysis machine and extracorporeal circuit for dialysis according to physician order; evaluating the patient pre-dialysis, including vital signs and state of the fistula or graft. Any abnormality is to be reported to the responsible registered nurse prior to proceeding with accessing the patient’s fistula or graft site to begin the procedure.
Rationale: Appropriately trained and experienced dialysis technicians can and do evaluate the patient and the vascular access independently and initiate dialysis without a nurse or physician conducting a full patient/access assessment. Nurses should be subjectively assessing all patients of technicians for whom the nurse is responsible. If it is only the nurse who can access and initiate dialysis through a catheter this does not need to be included in this rule for technicians.
Section 19-13-2.7 We suggest the following substitution language: “Preceptor” means a registered professional nurse or a dialysis technician with at least one year of experience in the dialysis process and care of patients on dialysis who has been approved to be a preceptor by the nurse responsible for nursing service at the facility.
Rationale: We disagree with the requirement that a preceptor must have two years of experience. To our knowledge, no other state requires this level of experience.
Section 19-13-2.9 How does a dialysis technician register with the Board?
Section 19-13-2.10 Since there is a psychometrically sound national certification examination that tests for initial competence, we suggest that the 12-month technician trainee temporary status period can be reduced or avoided by the use of this examination. We suggest adding NNCC to the list of approved testing organizations.
Rationale: The Nephrology Nursing Certification Commission (NNCC) is an independent, separately incorporated, professional certification organization that was originally established in 1987. The NNCC currently offers three different examinations: the Certified Nephrology Nurse (CNN), the Certified Dialysis Nurse (CDN), and the Certified Clinical Hemodialysis Technician (CCHT). All examinations are endorsed by the American Nephrology Nurses Association (ANNA) and the CCHT examination also is endorsed by the National Association of Nephrology Technicians/ Technologists (NANT). It is our understanding that NNCC has submitted information to the Board.
Background: The CCHT examination was initially envisioned when ANNA was working with the Ohio Renal Administrators as they worked with the legislature and regulatory bodies to credential unlicensed dialysis technicians in that state. The lack of a valid test for initial competence led to cumbersome statutory language and awkward and burdensome regulations. Such can now be avoided with the availability of the CCHT examination, which is administered by the NNCC.
That said, if the trainee status remains in the final rule, it should be made clear that technician trainees, once they take and pass a certified training program, may do the tasks outlined in the rule during their trainee status period. That is not made clear in the draft.
Section 19-13-3.3.b. We believe the proposed wording “immediately prior to” is too restrictive and should be deleted.
Rationale: An assessment by a registered professional nurse “prior to” delegation is sufficiently safe for the patients.
Section 19-13-3.3.e. Our review of the authorizing legislation does not indicate sufficient statutory authority for the establishment of staffing ratios and we therefore question the Board’s authority for this section and suggest deletion of this language. However, to further inform the Board’s decision-making should it be determined that the Board has the authority to set ratios in regulation, we suggest ratios that are typical throughout the country, i.e., RN:patient of 1:12, total staff:patient of 1:4. None of the surrounding states, e.g., Ohio, Kentucky, Pennsylvania, Virginia, and Maryland, has any staffing ratio requirements. The ratios as proposed are unworkable in the outpatient dialysis clinical practice setting.
Section 19-13-4.2 We suggest the following substitute language: Administration of any blood products or intravenous medications is a nursing responsibility, except as outlined in section 19-13-4.1.
Rationale: Since technicians do not have a license to practice independently, they do not have a “scope of practice,” so we strongly suggest deleting that phrase in particular. Further, this suggested language avoids any confusion about the fact that this section does authorize dialysis technicians to administer specific intravenous medications.
Section 19-13-5.2 We suggest the following replacement language: No more than sixty days after receipt of a complete application for approval, the Board shall make a determination regarding the approval status of the training program.
Rationale: One hundred sixty days is too long to wait for the approval of a training program and could cause severe staffing problems for dialysis providers.
Section 19-13-6.1.a.4 and Section 6.1.a.5 We suggest the deletion of this language.
Rationale: While a BSN is preferred, it is not always feasible and therefore this requirement may be too restrictive and unnecessary. Neither Kentucky nor Ohio has these provisions, and we aren’t aware of any state that does have such a requirement. The bachelor’s degree education requirement for the training program administrator exceeds that required by Medicare and other states for the nurse responsible for nursing services for dialysis facilities.
Section 19-13-6.1.c.and 6.1.d.3 These requirements seem unnecessary, as the programs will be periodically reviewed for compliance.
Section 19-13-6.1.f.3.G See previous comments to Section 19-13-2.7.
Sections 19-13-6.1.g.6.A, B and C This seems unnecessarily burdensome for everyone involved.
Section 19-13-11.1 As stated previously at Section 19-13-2.10, we suggest adding NNCC to the list of approved testing organizations.
Section 19-13-12.1 Dialysis is essentially a one DRG business, and nearly 40 percent of dialysis patients are dually eligible for Medicare and Medicaid. The fee structure outlined in this section is excessive and cannot be afforded by dialysis providers. In addition, they appear to yield significant funds in excess of $45,000 per year above the stated program cost.
Section 19-13-12.3 Under what a circumstance is a reinstatement fee required?
Section 19-13-12.6 Any fee for a “periodic evaluation” of the training program should be subsumed in the initial and renewal fees.
We appreciate the opportunity to comment on this proposed rule and we hope the Board will seriously consider our suggestions. We have concerns that some of these changes are necessary to avoid affecting the delivery of care in dialysis facilities throughout West Virginia. We will be happy to meet with members of the Board to answer any questions they may have about the training of dialysis technicians or the patient care delivery issues in the dialysis setting.
Please find enclosed copies of ANNA’s position statements:
1.The Role of Unlicensed Assistive Personnel in Dialysis Therapy
2. Delegation of Nursing Care Activities
3. Joint Position Statement of the American Nephrology Nurses Association (ANNA) and the National Association of Nephrology Technicians (NANT) on unlicensed personnel in dialysis.
Lesley Dinwiddie, MSN, RN, CNN, FNP
cc: Board of Directors