Dialysis Technicians and Home Dialysis Aides; Care of ESRD Patients

Subject:

Requested By: Rodney C. Hobbs, Chief Administrative Services Division of Health Services

Question: May a dialysis technician or a home dialysis aide initiate dialysis utilizing established access routes, determine clotting times, adjust heparin dosage according to written standing orders and administer heparin and other dialysis related medications when performed under the orders or directions of a physician?

Conclusion: A dialysis technician or home dialysis aide may perform such task when performed under the orders or directions of a physician.

During the last ten years there has been a notable expansion of dialysis facilities and services in the United States for the treatment and care of patients with end-stage renal disease. This growth has produced a concomitant multiplication of nephrology-based personnel, especially nurses and technicians. Estimates of nurses and technicians currently providing dialysis services range from five to ten thousand.

Patients requiring dialysis receive treatment either at a dialysis center or at home. The patient, who receives treatment at home, is trained in the technique of dialysis. Another person, usually a family member, is also trained and assists in the dialysis. Although home dialysis is more economical and effective than in-center dialysis, more patients are treated in the centers than at home. Several agencies and institutions wish to promote home dialysis by utilizing paid aides. The question presented, therefore, is whether the activities of the dialysis technicians in the center and the home dialysis aide in the home of the patient are in conformity with North Carolina law, particularly the Nurse Practice Act (G.S. 90-158 et seq.).

The Nurse Practice Act provides for the licensing of registered nurses and licensed practical nurses. G.S. 90-158(3) defines the terms "Nursing", "Nursing by Registered Nurse", and "Nursing by Licensed Practical Nurse". The unlicensed practice of nursing is prohibited by G.S. 90-167. the second paragraph of that section provides:

"Nothing in this article shall be construed in any way to prohibit or limit the performance by any person of such duties as specified mechanical acts in the physical care of a patient when such care and activities do not require the knowledge and skill required of a registered nurse or licensed practical nurse, or when such care and activities are performed under orders or directions of a licensed physician, licensed dentist or registered nurse."

The dialysis technician or home dialysis aide is a person who performs artificial kidney treatments on and for patients. This treatment includes the connection of the dialysis machine to the patient and the administration of medications and solutions necessary for treatment. A comparison of the foregoing with the definition of "Nursing" (. . . the ministering to, the assisting of, and the sustained, vigilant, and continuous care of those acutely or chronically ill . . .) clearly indicates that the activities of the technician and aide falls within the definition of nursing and licensure under the Act is required unless the second paragraph of G.S. 90-167 is applicable.

In an opinion dated March 10, 1975, to Mr. Wade Avant, Chief, Licensure and Certification Section, Division of Facility Service (44 N.C.A.G. 253), this Office construed the same statute and concluded that a person, not licensed as a registered nurse or a licensed practical nurse, may take a pill from a bottle, with the patient’s name and the prescribed dosage on the label, and give the pill to a patient in a hospital facility if the medication has been prescribed by a licensed physician. The opinion noted that "the clear intent of the (second) paragraph of G.S. 90-167 is to permit certain acts to be performed by unlicensed persons if the act is (1) a specified mechanical act, (2) performed in the physical care of the patient, and (3) does not require the knowledge and skill of a registered nurse or licensed practical nurse or is performed under orders or directions of a licensed physician, licensed dentist or registered nurse."

"The term (mechanical) is frequently defined as meaning employment in manual labor; engaged in manual labor; of, pertaining to, or concerned with manual labor." 57 C.J.S. Mechanical. The inquiry is therefore whether the following tasks of a dialysis technician or home dialysis aide may be classified as mechanical. The technician or aid:

a.

Rinses, primes dialyzer; attaches and installs all required tubing; positions dialyzer; prepares fluid delivery system for dialysis; connects dialyzer and all pumps; calibrates and checks alarms; sets monitors; tests dialyzer if required.

b.

Assembles all necessary supplies and equipment at bedside.

c.

Weighs patient and obtains baseline vital signs.

d.

Inspects and evaluates vascular and peritoneal access (sites).

e.

Obtains blood samples and culture specimens as ordered.

f.

Initiates dialysis utilizing established access routes (with fistula venipuncture, shunt or peritoneal catheter).

g.

Determines clotting times and adjusts heparin dosage according to a prescribed protocol.

h.

Measures and adjusts blood flow rates.

i.

Monitors and records dialysis treatment measurements, e.g., vital signs, weight changes.

j.

Observes fluid delivery unit for correct functioning during dialysis, responds to alarms and makes appropriate adjustment during treatment.

k.

Returns blood and discontinues dialysis utilizing established procedures.

l.

Cleans and dresses access site using appropriate techniques.

m.

cleans and sterlizes equipment; disposes of expendable supplies.

n.

Performs preventive maintenance of equipment.

o.

Administers oxygen as necessary by cannula or mask.

p.

Institutes basic emergency measures in the event of cardiac and/or pulmonary arrests.

Clearly, the tasks listed above are more complicated than taking a pill from a bottle but the tasks are nevertheless "mechanical." The tasks require manual dexterity, knowledge of the operation of the dialysis apparatus, and adherence to a defined procedure with modifications based on predetermined protocol. For example, connection of the machine to the patient is accomplished by means of established access routes and the heparin is administered according to a prescribed protocol via the tube connecting the machine and patient. A "technician" is defined by Webster’s New Collegiate Dictionary as "a specialist in the technical details of a subject or occupation." "Technical" is defined as "having special and usu. practical knowledge esp. of a mechanical or scientific subject." (Emphasis added.) Herein, the dialysis technician is a "technician" as defined by Webster in that he is a specialist in operating a specific machine performing a specific function in the overall process of delivering health care to the patient. The application and operation of the dialysis machine requires adherence to pre-established, detailed instructions. In our opinion, this is the decisive factor in determining that the application and operation of the machine is a mechanical act because the tasks performed by the technician or aide are stipulated by the physician and are not entrusted to the judgment of the technician or aide. The tasks are limited in scope and directed to a specific need of the patient. The practice of nursing, on the other hand, cuts across the broad spectrum of services in the health care delivery system in order to administer to the needs of the patient, notwithstanding the nature of the illness or injury.

The second requirement, i.e. relating to the physical care of a patient, is satisfied herein. Dialysis treatment is certainly related to the physical care of the patient. Finally, the second part of the third requirement is satisfied in that the dialysis technician and home dialysis aide perform under the orders or directions of a licensed physician or registered nurse. the dialysis technician and the home dialysis aide do not act independently but rather act upon the orders of a physician and within the framework of activities defined by the physician. The supervising physician has either supervised their training or examined their knowledge and capabilities to insure that they are able to perform their assigned tasks in the care of patients with end-stage renal disease.

The importance of the supervising physician in this matter cannot be over-emphasized. He is the one who will determine the qualifications of the technician and the aide. He is the one who will prescribe the protocol under which the technician and aide will operate. The physician is also the one who must review periodically the progress of the patient. Having concluded that the tasks of the dialysis technician and the home dialysis aides satisfies the requirements of the second paragraph of G.S. 90-167, it is the opinion of this Office that such technicians and aides may perform the tasks listed above without violating the provisions of the Nurse Practice Act.

Rufus L. Edmisten Attorney General

Robert R. Reilly Assistant Attorney General