Abstract
When outpatient dialysis care began to grow in the early 1970s, technicians focused mainly on biomedical tasks. In the 1980s, dialysis patient care technicians (PCT) joined nurses in an expanded role as caregivers. Today, PCTs often outnumber nurses in a typical dialysis clinic.

The Medicare Conditions for Coverage (CfC), which took effect a year ago, require that PCTs pass a nationally recognized certification exam by spring of 2010. While required PCT certification has long been a goal of the nephrology community, another goal has been to improve training. Currently, there is no standardized education and training curriculum on specific, outcome-related competencies. The recently published "Identifying Best Practice" study associated competent technician and nurse proficiency with improving outcomes in patients on dialysis. This article discusses the lack of standardized education for PCTs, and the opportunity the dialysis community again has to ensure that certification is preceded by standardized education, training and transitioning of knowledge into identified core competencies. Only when thorough standardized education for PCTs is available will the required certification be meaningful.

Introduction
Currently, dialysis clinics train the majority of dialysis personnel using a unit-established training program. The training program usually consists of didactic education on theory by the staff educator and then procedural training by preceptors using the "see one, do one, teach one" method.

As there are no minimum knowledge requirements for entering the dialysis caregiver arena, there is no consistency in content of training programs. In fact, the education often varies from facility to facility within the same dialysis provider. With the frequent turnover of staff, experienced role models often are not available to serve as preceptors. In fact there is no assurance that preceptors are good teachers. Additionally, preceptors often are required to carry their usual patient load while attempting to devote their undivided attention to the trainee. It appears critical components of the education and training of dialysis personnel are indeed at risk.
 
Included in the Conditions for Coverage for End Stage Renal Disease facilities published April 15, 2008 (42 CFR Parts 405, 410, 413, et al., Medicare and Medicaid Programs) is a new condition, Subpart D 494.140, requiring that all newly hired and employed patient care technicians (PCT) be certified. Certification is required no later than 18 months after hire or if employed on Oct. 14, 2008, the deadline is April 15, 2010.1 Previously only 15 states had regulated PCTs by requiring competency testing or certification.2 With the new requirements, all PCTs will now be required to obtain certification and maintain that certification through continuing education or retesting. While certification is the primary motivator, many in nephrology clinical practice have longed for improved and standardized education for the PCTs, the front line caregivers of patients with ESRD. Is not the cart (certification) before the horse (standardized education)?

The role of the PCTs in providing care in dialysis facilities has expanded since they first became a significant presence in the late 1970s. Staffing of dialysis units has always been affected by reimbursement, and as reimbursement has declined, the proportion of registered nurses (RN) has decreased while the number of PCTs has increased.3 Additionally the consolidation of smaller, privately owned, and hospital-based dialysis units into large proprietary companies has forced more cost saving tactics as these publicly owned companies strive for profits. The bottom line is that while PCTs are integral to dialysis care, their basic educational background coupled with inconsistent educational programs and on-the-job training may result in inadequate skills to care for patients on dialysis.
 
In the early 1990s, the American Nephrology Nurses' Association (ANNA), the Council of Nephrology Nurses and Technicians (CNNT) and the National Association of Nephrology Technicians (NANT) identified the increased use of PCTs and the lack of training as a growing concern, particularly with an impact on quality of care. A task force was formed to obtain consensus regarding dialysis technician's roles and the training necessary to function in the dialysis unit. In addition, the task force identified problems confronting the renal community concerning PCTs. This included the lack of standardized training and education as well as the absence of an official program to certify technicians.
 
From that task force a patient care technician role description was published by the National Kidney Foun-dation (NKF). Duties or tasks of the PCT were identified. The description of educational training was "on-the-job, employer sponsored training programs, or vocational schools/community college programs." Certification was also cited and a description of the certifying organizations was listed.4

In 1994, NANT issued an updated position paper regarding the importance of education and training programs for PCTs. The paper stated that on-the-job training programs do not adequately prepare technicians to deliver safe and effective hemodialysis treatments and that education should be accomplished through more formal educational approaches. The NANT position paper stated that formalized education and certification should be the standard.5



Fast forward to 2009. While the Conditions of Coverage now require certification by one of three certifying bodies for PCTs (see Table 1), the lack of a standardized training and education for PCTs still exists. The Conditions indeed list basic subjects for PCT training (see Table 2); however, the number of PCT education programs is limited.1 While the intent of CMS to improve the quality of care delivered by the PCTs in dialysis is evident by the requirement for certification, how can the community ensure that the testing meets the required knowledge and core competencies that support quality of care delivery and a safe treatment environment?



The nephrology community must again come together and identify core knowledge and competencies that each dialysis patient care technician should have and demonstrate in order to be certified. Indeed, to ensure patient safety and reduce risks from hemodialysis devices "...the operators of the techniques must be aware of the risks, well educated and consciously acting..." 6  In a study, Roy examined the cause of death among 47 patients on dialysis, reported between 1992 and 1996, and found 34% of the deaths were related to human error. Only 10% were related to technical equipment failure. He concluded that "risk awareness must be heightened and education of the operator of the equipment is indispensable."7

Human interface with machines increases the risk for error
Although today's dialysis operating systems are much improved over years past, with many safety features, there remain potential hazards where only operator knowledge and vigilant monitoring can prevent tragic incidents. Here are some examples:

• The accidental dislodgement of the venous needle. post blood pump can cause significant blood loss. The dialysis system addresses this potential problem with extracoporeal pressure monitors. However, the venous needle may dislodge without causing a change in the venous pressure, which would not cause an alarm. The person monitoring the patient and dialysis system must be knowledgeable and alert to the potential for needle dislodgement and able to prevent the potentially fatal occurrence by ensuring the access site and connections remain uncovered and visible.
• Trouble-shooting alarms requires thorough operator knowledge. While personnel may be tempted to devise mechanisms to over-ride alarms they feel are merely nuisance alarms, this may lead to patient harm. One example is the practice of clamping an arterial transducer line when the prescribed blood flow cannot be achieved. Hemolysis may occur, or air may be introduced into the system.
  

Personnel must be properly educated and tested to be sure they understand the ramifications of their actions. Desai and colleagues sought to identify "best practices" in dialysis facilities that may account for inter-facility variation in outcomes. The Identifying Best Practices study 8 was undertaken to identify "best practices" that may improve facility-level achievement of clinical performance measures and overall mortality reduction goals. Best practices in dialysis facilities were identified through a staged process, including systematic review of the literature, cognitive interviews with dialysis personnel, and a national focus group of dialysis providers. An inventory of the 155 best practices was created. A national survey asked randomly selected dialysis opinion leaders, nephrologists, and dialysis nurses from the Renal Physicians Association, the American Medical Association, and ANNA to rank-order the best practices by perceived importance. Two of the top five factors that respondents ranked as "best practices" most strongly related to outcomes were linked to PCT performance. Ranked second on the list was auditing the performance of PCTs proficiency in cannulation of vascular access, and ranked fourth on the list was random and blinded review of nurse and technician performance. Indeed the authors feel the findings from this study may define "best practices" and provide a roadmap for how to improve overall outcomes of dialysis.

Knowing patient care technician performance may in-deed be a critical component to improving outcomes in dialysis facilities, how does the nephrology community ensure that technicians are consistently trained in core competencies? CMS mandates only that required topics
be included (see Table 2) with course approval by the medical director and governing body of the dialysis provider. California is one of a handful of states that requires the Department of Public Health to approve the training and testing program of each dialysis facility, college or university; however,no specific content or knowledge re-quirements are cited. 9



While there are many publications available to educate dialysis personnel (see Table 3), there are only two comprehensive options for dialysis providers for consistent and standardized training.

1). The Core Curriculum for Dialysis Technicians (4th edition)
 
2). The Hemodialysis Review: 2009.

The "Core," published by the Medical Education Institute (MEI), provided the first and only consistent education for PCTs and has been available for many years. Supported by an unrestricted educational grant from Amgen, the Core is a collaborative effort by the nephrology community to provide a comprehensive review of hemodialysis. Its stated goal is to enhance the preparation of the patient care staff. It has been widely used and accepted as the curriculum for educating new PCTs. While the Core Curriculum does provide at least some consistency of training content there are some limitations to this written format, including its inability to provide up-to-date information when medical or technical advances occur or guidelines or regulatory requirements change. It is available for download at www.meiresearch.org/core_curriculum.php.

A second hemodialysis review course, Hemodialysis Review: 2009, is available on the Internet. This course,also a collaborative effort by experienced nephrology clinicians, was designed to respond to and to fill the need for up-to-date, accessible, and consistent PCT education. The HD Review: 2009, like the Core, covers the critical core competencies identified in best practices papers. It can be found at www.nephrologyclinicalsolutions.com.

Education before certification: the horse before the cart
In the 1990s, the nephrology community task force identified the lack
of standardized education and training and the absence of an official program to certify technicians as concerns that impact quality. Today, 18 years later, a 2008 review of best practices found ensuring technician performance is a key best practice to improve patient outcomes and reduce mortality. We have indeed put the cart-CMS's mandated certification for PCTs-before the horse of standardized education. We must find methods to help PCTs transition their knowledge into identified core competencies that will reduce the risks for patients on hemodialysis. With such an approach, we believe that patient outcomes will improve, mortality will decline, and required certification will be meaningful.

References
1. Conditions for coverage for end stage renal disease facilities: Final Rule. Federal Register 2008. www.hhs.gov/CFCsAndCoPs/downloads/ESRDfinalrule.0415.pdf Accessed August 1, 2009

2. VanBuskirk S. Time flies when there's a deadline. ASN Kidney News.
www.asn-online.org/publications/kidneynesw/archies/2009/mar/
KN_March09.pdf
Accessed August 1, 2009.

3. Held PJ. Garcia JR, Pauly MV and Cahn MA. Price of dialysis, unit staffing, and length of dialysis treatments. Am J of Kidney Dis 15(5); 441-450. 1990

4. Renal career fact sheet. National Kidney Foundation, 1992. www.kidney.org/PROFFESSIONALS/cnnt/techcnnt.cfm
Accessed August 1, 2009

5. Dunetz PS, Paret B. The role of nephrology nurses in training hemodialysis patient care technicians. ANNA Journal. 23(4): 389-395, 1996

6. Roy T. Patients' safety and haemodialysis devices. Nephrol Dial Transplant 16: 2138, 2001

7. Desai AA, Bolus R, Nissenson A, Bolus S, Solomon MD, Khawar O, Gitlin M, Talley J, Spiegal B. Identifying best practices in dialysis care: results of cognitive interview and a national survey of dialysis providers. Clin J An Soc Nephrol 3: 1066-1076, 2008

8. California Business and Professions Code Section 1247-1247.9. Hemodialysis Technician Training Act. 1995. www.leginfo.ca.gov/cgi-bin/calawquery?codesection=bpc&codebody=&hits=20
Accessed Aug. 20, 2009


Ms. McCarley is with the Diablo Nephrology Medical Group, Walnut Creek, Calif. Mr. Hudson (retired) was Chief Technician at the VA Medical Center in Palo Alto, Calif, and is past president of the National Association for Nephrology Technicians/Technologists. Ms. Kammerer is a nephrology consultant.