I just wanted to see what you all considered an acceptable level of care during HD treatments. My clinic has about 25 patients per shift, divided between 3 bays. Each bay usually has between 6 and 10 patients. There are usually two techs assigned to each bay and anywhere from 2 to 3 RNs on each shift. There is supposed to be an RN on the floor at all times. This is not always the case. Many times, I will see no techs or RNs in the bay that I am in for nearly an hour. Many times, my machine will be alarming while a tech is chatting with a patient (flirtint) totally oblivious to anything else that is going on. I will have to yell to get the attention of the tech. The techs receive minimal training. Many of them are either just out of high school or will be soon. They are there not because they want to work in the medical profession but because it is a job. Most of them do not care about the patients or have any understanding of what the patients are going through. They have no medical training other than how to stick a needle in a ptient and how to take them off of the machine. They don't need to know how to take blood pressure since the machine does it. Many times when a patient has a complaint, they are told to stop whining. Many times I have been told I am a whimp because I demand lidocaine before I am stuck. The level of professionalism is higher at the local video store than it is at the clinic I go to. Is this standard? What is the level of care that is expected or acceptable? I think that anyone working in a dialysis center should have some medical training, not just one days worth of training in the center on how to set up the machines and put patients on and take them off. I think they should have some background training in renal failure and treatment as well as some training from the social worker on how to deal with patients.

You are not imagining a single thing. Have the same conditions at our unit. This is the level of care at very many units nationwide. Thats why the Senate Hearings on dialysis were held in June of 2000. I'd suggest you get a copy of the transcripts. Very confirming of what you are saying and the adverse conditions were completely verified by the GAO and OIG. New federal guidelines including standards of care (400 p.) are comng out any day now. Patient advocates in different states are working for certification of dialysis techs. Advocacy groups are working for more crucial changes to be legislated.

In Canada in a clinic setting we have 3 patient to one nurse theyre is no patient care tech just a technologist that know machines water treatment and does it all except stick needle. We do have aides that help patient in and out of the clinic clean patient chair, machine and prime machines and help nurse with preparation tasks (opening concentrate, getting bundle ready helping RN with steril tray set up) But they again do no BP or sticking. That is a RN job.

I have a two word solution to your problem. Home Dialysis.

Write your congressman or woman in support of HR1759. See news items on Renalweb home page.

I have been working in dialysis for 8 months now. I am a 18 year old high school graduate. I know that many people probably think that someone of my age should not be doing dialysis, but I happen to think that I am very good at it. At my unit, it is nothing like that. I recieved an extensive amount of training. At my unit, every one pulls their own weight. I apoligize that your unit is run badly, but let's not be discriminatory to all patient care techs. The ones that I work with are very good, we are a hard working crew. We do our best and always answer machine alarms.

How long was your training?

Elizabeth,

Please do not take offense to my response here. I am not questioning your ability to put patients on, take patients off and answer alarms. My concern is that many techs do not have any medical training and do not have a thorough understanding of renal disease and the dialysis process. Many techs are simply trained in how to get the needles into the patient, set up the machines, take the patients off, fill out paperwork and tear down the machine setups. There is no medical training for many techs. This may not be the case in your center but unfortunately, it is in many. I believe that each center has the responsibility to thoroughly train all of their employees that come in contact with the paients, in the basics of renal disease and the dialysis process so they can provide the best possible treatment for the patients.

Hi everyone,

I felt complelled to respond to this issue. I have been working with patients with kidney disease for 20 years. I have worked in several outpatient units, hospital in-patient and acute unit and conducted reserch. At every outpatient unit I've worked in the staff, new staff underwent an extensive training which included all well rounded knowledge about kidney disease and its related illnesses and complications. They underwent classwork from 3 to 8 weeks and were taught hands on care for at least 3 months. I have found many techs every knowledgeable about each patient under their care. They can tell you how a patient will tolerate fluid removal, etc.

If you are finding that the staff is not knowledgeable or feel that the care is inadequate, speak up. In this day of competition, somebody will listen. The more patients complaining all the better. Then, of course, you can complain to the state department of health or the ESRD Network. Believe me, when administrators get these letters, they pay attention.

A good dialyis unit involves well trained staff, committed administration and physicians. This happens because people pays attention and because patients demand it.

The problem is that because there is no required standard training course it is left up to each individual unit! In the state I live in (NJ) there is required training, and a certification test required of nurses aides, and they don't stick needles in people, or trouble shoot problems during a dialysis treatment, and they aren't allowed to gives meds either!

Wow! I realize that this is a late response, but I am shocked at the lack of professionalism. I understand that there is a major problem in finding, training, and retaining dialysis care workers. However, their is a minumum level of acceptable care that is not being provided, as is your right as a patient (any patient). I am a hemodialysis technician in Vermont, who is also one of the primary trainers (for HDT). We go through a vigorous and in depth 8 wk. training period. Everything from manual BPs, basic understanding of ESRD, dialysis principles, transplantation, water treatment and reprocessing, to patient interaction is covered. Whereas needle cannulation is an important part of the training (in my unit many of the techs. are as proficient if not more so than the nurses in this), it is only one competency that is reviewed. It sounds like you need to discuss your treatment with the head of the unit, if not the manager at the hospital. If you dialyze in a for-profit center, I would suggest writing a letter to the state health officials or other supervising organizations such as JACHO.

Nathan,
Thanks for acknowledging that there is a problem. Can you say what company you work for? Do you feel its the management of the particular unit you are working for that has high standards or the company? Because I have heard that usually dialysis companies have good units and bad units. What do you thnk makes the difference?

I work for a hospital outpatient facility. I feel that the hospital has good management. However, I feel that it is our unit coordinator who deserves the most credit, as she is tireless in her efforts to maintain the best quality. I feel lucky in that I work with others who feel that minimal care is not acceptable, and that optimal care (however impossible that goal may be) is our primary objective. I feel that it is the reponsibility of EVERYONE who works at any unit to ensure that proper patient care is recieved. In answer to your question Rob, I think that management must set the standards, but it is everyone who works that makes the difference...Must make the difference.

Something that everyone needs to keep in mind is that the current state of dialysis care is a victim of the reimbursement environment we are required to work within.

The vast majority of the reimbursement for dialysis treatments comes from Medicare, so it is unfair to compare dialysis in the US to dialysis in Canada or Europe. The federal government keeps shrinking and shrinking the composite rate for dialysis treatments, but do you think the cost of medical supplies, or medications, or wages are going down?? Of course, they are not. Lets be honest... EVERYTHING costs money. And that includes training for new dialysis personnel and staffing a facility.

Another problem is that state nurse boards are restricting the duties that can be performed by a technician. I am not saying that a technician should be able to do everything. For 7 1/2 years I worked as a dialysis technician, and was allowed to initiate treatments with catheters, do dressing changes, draw up lidocaine and heparin for my patients, and write progress notes. Now, due to changing state regs, and corporate fear of liability, technicians are no longer allowed to perform these duties. Most dialysis training programs spread over a 6-8 week period and often include a large amount of dialysis theory. Yet, the technicians start performing dialysis and are not allowed to utilize that knowledge. Is it any wonder that the caliber of technician has diminished as a result?

I think it IS fair to compare dialysis in the US to dialysis in Canada and elsewhere. You have explained why the caliber of care has diminished but that does not make it right. If the level of care dialysis patients are getting is not what it should be, due to whatever reason, something needs to be done to fix it. If it is a case of lobbying the government to increase funding, so be it. We should not accept sub-standard care for any patient with any medical condition for any reason.

I also work in an understaffed chronic care clinic. I posted a complaint on the legal site, as a way to obtain advise on how to change this situation. This was my problem:
I was in charge of a bay with 7 patients for the afternoon shift. The tech who I was working with had hit her head on a piece of equipment and was sent at 12:30 to an outside emergency facility where she received several stitches to the cut on her forehead, while I went to lunch. The clinic charge nurse (who had her own bay) monitored my bay while I was gone. When I returned at 1:15pm, she instructed me that I would receive help when she returned from lunch.
The problem is, she did not return from lunch until 2:45pm;(she started her lunch break late because of understaffing). 5 of my 8 patients were scheduled to come off the machines between 2:00 to 3:00, (1 of which had a perm cath). This delay, and the lack of a replacement tech, could have led to a dangerous situation.
The charge nurse has been telling our administrator that we are insufficiently staffed if unexpected incidents were to occur (such as cramping, symptomatic hypotensive incidents, chest pains, or bleeding from pulled sticks).
The first two patients off had to wait up to 15 minutes after their sticks stopped bleeding before I could get around to taping up their sites. A 3rd patient came off an hour early because she was not feeling well. This was very unlike her, and I had to spend time assessing for cardiac symptoms (which she did not have) or a recurrent GI bleed (which was also negative) while stabilizing her blood pressure. A 4th patient, who also needed an attentive assessment, had to wait 30 minutes before she could have her needles pulled and held from her thigh graft (her neurological condition is so bad that she is unable to hold her own sticks at this time). A 5th patient had to be taken off at her scheduled time (without delay)because of cramping and a dropping blood pressure. By this time, it was 3pm and the 6th patient was scheduled to come off... and she is not the patient type.
All this happened between 2pm and 3pm. Team work (helping each other) is very good at our clinic, and on this day I received the assistance of 2 techs (at individual times) to take my 30-minute blood pressures for me while I was caring for those that needed more attention. I paged my charge nurse twice; the first time she let me know that she would be out as soon as she was free from lunch, while the second time she was tied up in her own bay (when she came back from lunch) and could not join me. My bay was not the only one with difficulties that day, but such difficulties are more pronounced when staffing is short.
I finally got the assistance of the inventory tech. While she began her career as a PCT, she was promoted to take on the responsibility of clinic inventory and the collection of blood for lab results. However, she is often taken away from these responsibilities while she is pulled to the floor to work. Because more and more she is being used as the "extra" in staffing, we are seeing more delays in needed supplies or preparation of labs. In other words, she cannot do the inventory and be "extra" without having a lot of unaccounted overtime. Extensive overtime would put her at a great inconvenience since she is the single mother of three children.
I later approached our administrator, who essentially said that it was not her fault that I got into a bind, since I did not call her. I was told that it was the responsibility of the charge nurse to provide the appropriate staffing.
I also approached the charge nurse, who said it was not her fault, since there was no staff available; that she was trying to let the inventory coordinater (the "extra" tech) do her job so that we could have supplies later that week; that she had been trying to tell the administrator of these staffing problems, but is told that "the numbers indicate staffing is adequate" and to make do with what we have.
All I know is that I feel squeezed in the middle. There is not even enough nurses for a nurse to call in sick (to care for her children, of course... Heaven forbid that nurses ever call in sick for themselves!).
I have been working in this clinic for a number of years, but am frustrated with the compromises of care that I have seen. While we all pitch in to help each other, there are numerous times when others cannot help because they have similar crises occurring. We still struggle to provide quality care, which generally is provided for, but at a cost. The cost being that most of us are exhausted at the end of a day from the stress and the fast pace required to provide quality. My question is: how can I avoid being caught in the middle again? Will hemodialysis ever return to the tolerable stress level that I remember?