Dialysis access has seen an enormous multiplication of options for dialysis patients; specialised fistulas, endovascular fistulas, and new graft materials. This has brought the focus onto allied health members that carry out cannulation in the dialysis unit, namely nurses and technicians. Yet, this poses challenges such as identifying what kind of fistula does a patient have, how do they make it ‘cannulatable’, what is their graft material, and what is their direction of flow, all of which represent skills that may need further development to give a safe patient experience and make access last longer.
This was the message from Dirk Hentschel (Brigham and Women’s Hospital, Boston, USA) when he spoke to Renal Interventions at the most recent Hamburg Dialysis Access symposium and Masterclass (8–9 September 2023, Hamburg, Germany) about what he feels is needed to ensure that dialysis patients are receiving the best possible standard of care whilst under the care of dialysis units.
“If you look at it, [there are] 10,000 dialysis units or so in the USA, with tens of thousands of nurses, and then tens of thousands of technologists, who actually have the day-to-day contact with the patients,” Hentschel stated. The problem arises, however, when you try to introduce the new technologies that are being developed, because, as he put it, “we’re creating all these new devices and accesses, yet they may not be usable,” because the training to match is not being introduced alongside the technology.
The solution, Hentschel feels, lies in education. “VASA [Vascular Access Society of America] is working on organised collaboration with allied health members—nurses, technologists, and physician assistants—that are in the dialysis units to carry the concepts that we’re all working on at the moment into the unit.” The issue that needs addressing, he averred, is that most technologists, technicians and nurses “look at a catheter and they connect, but they have no idea if it’s a symmetric catheter, if it’s a split catheter, or a step catheter. What that means is they feel they have to reverse the lines, and this could be bad for the patient, but if they have a symmetric catheter, it’s not bad for the patient, but that knowledge is often not there”.
That, according to Hentschel, is something that VASA is working on, with a specific committee that looks at the allied health education. “We’re going to visit the ANNA [The Association of Nephrology Nurses of America],” he said, “and so we hope that that will blossom kind of into a broader, vascular access-specific effort that maintains this line of communication” in the long term. “There are so many nurses, and we can create one or two new ‘fistula maven’, but in the end, we need hundreds of thousands of nurses in the dialysis units that are better educated.”
The first step to address this is, as Hentschel proposed, is “[VASA] will participate in the next ANNA conference; we actually have a session that they have graciously allowed us to talk about bringing VASA surgical and interventionist expertise and have a forum. In addition, we’ve proposed forming a joint working committee that develops standards and guidelines. In the UK for instance, they have this gold, silver, bronze cannulation proficiency,” which is exactly the type of certification that Hentschel, along with VASA, is hoping to introduce. “We’ll hopefully get there; we’re not there yet, but that would be the goal.”
Another aim of introducing more education and training, according to Hentschel, is creating more ‘careers’ from roles that are currently ‘jobs’. “If you become a dialysis tech, not technician,” he stated, “that’s a job, it’s not a career. But if you have certain levels of expertise that you can document, all of a sudden it’s kind of a mini career. It also gives the opportunity to get education, to certify education, to say: Okay, I have this, I know this, and I know about this. So there’s self-esteem on their side.” Not only are there improved career prospects for allied health members, but from the patient’s experience, which is what VASA is trying to improve, this accreditation provides quality assurance.
“The biggest thing,” Hentschel concluded, “is there was a recent KHI [Kidney Health Initiative] video which featured patients talking about their dialysis accesses. The number one thing that patients [highlighted] was the pain they experienced with failed needle insertions. So that’s where we—as physician leaders—may have an opportunity to help,” Hentschel suggested. He continued, saying that “you don’t want to come in and take over, that doesn’t work well, but we should act as [a partner], because there are certain things that we can provide to nurses [and technicians] and then they can take [this guidance] and they can educate others.”
