Date of Adoption: February 5, 2002.

     Purpose: The proposal implements the provisions of 2001 legislation (chapter 22, Laws of 2001). WAC 246-826-100 is being amended to include a seventh category of health care assistants, category G, to perform hemodialysis. The proposed rules will establish definitions, health care assistants, category G, minimum requirements to perform end-stage renal dialysis, core competencies and minimum training standards for the certification of hemodialysis technicians.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-826-100.

     Statutory Authority for Adoption: RCW 18.135.030.

     Other Authority: RCW 18.135.020.

      Adopted under notice filed as WSR 01-23-099 on November 21, 2001.

     Changes Other than Editing from Proposed to Adopted Version: WAC 246-826-302 Minimum training standards for mandatory hemodialysis technician training programs, to include, "or accredited academic institution." The proposed rule includes minimum training standards from an accredited academic institution. There may be nationally accredited academic institutions that have a training education program in place or they are in the process of creating and establishing a training education program in hemodialysis.

     WAC 246-826-302, stakeholders were concerned with "accepting documentation from another facility" and their liability incurred should one of their former employees make a mistake with a subsequent employer. The proposed rule includes the language, "The dialysis facility that accepts the documentation assumes responsibility for confirming the core competency of the hemodialysis technician."

     WAC 246-826-303 (2)(c), stakeholders were concerned that the rule would limit the health care assistant from performing diagnostic and therapeutic agents as authorized in statute. The proposed rule amends the language, "Prepare and administer heparin and sodium chloride solutions and intradermal, subcutaneous, or topical administration of local anesthetics during treatment in standard hemodialysis doses."

     WAC 246-826-100(5), "and administer skin tests" was added to category E assistants. This makes the rule consistent with WAC 246-826-170.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 4, Amended 1, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 4, Amended 1, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

March 5, 2002

Mary C. Selecky

Secretary

OTS-5208.5

AMENDATORY SECTION(Amending Order 121, filed 12/27/90, effective 1/31/91)

WAC 246-826-100   Health care assistant classification.   Effective ((September 1, 1988)) December 2001, there ((shall be six)) are seven categories of health care assistants:

     (1) Category A assistants may perform venous and capillary invasive procedures for blood withdrawal.

     (2) Category B assistants may perform arterial invasive procedures for blood withdrawal.

     (3) Category C assistants may perform intradermal, subcutaneous and intramuscular injections for diagnostic agents and administer skin tests.

     (4) Category D assistants may perform intravenous injections for diagnostic agents.

     (5) Category E assistants may perform intradermal, subcutaneous and intramuscular injections for therapeutic agents and administer skin tests.

     (6) Category F assistants may perform intravenous injections for therapeutic agents.

     (7) Category G assistants may perform hemodialysis.

[Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-826-100, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.135.030. 87-23-022 (Order PM 689), § 308-175-075, filed 11/12/87.]

     (1) "Hemodialysis technician" means a person certified as a health care assistant, category G, by the department of health, who is authorized under chapter 18.135 RCW and these rules to assist with the direct care of patients undergoing hemodialysis and to perform certain invasive procedures under proper delegation and supervision by health care practitioners.

     (2) "Competency" means the demonstration of knowledge in a specific area and the ability to perform specific skills and tasks in a safe, efficient manner.

     (3) "Hemodialysis" means a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane.

     (4) "Dialysis facility or center" means a place awarded conditional or unconditional status by the center for Medicaid/Medicare services to provide dialysis services. This does not include in the home setting.

     (5) "Direct supervision" means the licensed health care practitioner, as required by or authorized by RCW 18.135.020, is physically present and accessible in the immediate patient care area and available to intervene, when necessary.

     (6) "Preceptor" means the licensed health care practitioner, as required by or authorized by RCW 18.135.020, who supervises, trains, and/or observes students providing direct patient care in a dialysis facility or center.

     (7) "Training monitor" means the certified hemodialysis technician who with limited accountability mentors skill building and monitors for safety. The training monitor does not replace or substitute for the preceptor.

     (8) "End-stage renal disease" (ESRD) means the stage of renal impairment that appears irreversible and permanent, and requires either the replacement of kidney functions through renal transplantation or the permanent assistance of those functions through dialysis.

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     (1) Minimum qualifications for hemodialysis technician, category G assistants to perform hemodialysis, the applicant must have:

     (a) A high school education or its equivalent;

     (b) The ability to read, write and converse in the English language;

     (c) Basic math skills including the use of fractions and decimal points; and

     (d) Adequate physical ability, including sufficient manual dexterity to perform the requisite health care services.

     (2) Documentation of the satisfactory completion of a skills competency checklist equivalent to, or exceeding the competencies required by these rules.

     (3) Training and experience. The hemodialysis technician, category G assistant shall receive training, evaluation(s), and assessment of knowledge and skills to determine minimum level competency, as required by WAC 246-826-302.

     (4) The dialysis facility forwarding an application for certification as a hemodialysis technician must verify the applicant has satisfactorily completed all of the core competencies and minimum training standards for hemodialysis training programs required by chapter 18.135 RCW and these rules. The dialysis facility must verify that the applicant is sufficiently qualified, skilled, and knowledgeable to perform all procedures to be delegated to the applicant upon certification.

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     (2) Training program record retention requirements: The training program shall maintain the orientation checklists and any appropriate training documentation while the hemodialysis technician is employed with the health care facility or health care practitioner.

     (3) The training program for new hemodialysis technicians must be a minimum of six to eight weeks. The hemodialysis technician shall complete training in both didactic and supervised clinical instruction. The training program shall (a) extend over a period of time sufficient to provide essential, sequenced learning experiences, which enables the trainee to develop competence and shall (b) show evidence of an organized pattern of instruction consistent with principles of learning and sound educational practices.

     (4) Supervised clinical experience must provide opportunities for the application of theory and for the achievement of stated objectives in a patient care setting. Training through supervised clinical experience must include clinical learning experiences to develop the skills required by hemodialysis technicians to provide safe patient care. The preceptor must be physically accessible to the hemodialysis technician when the hemodialysis technician is in the patient care area.

     (5) The dialysis facility may accept documentation of a hemodialysis technician's successful completion of training objectives in another dialysis facility or accredited academic institution if it is substantially equivalent to the core competencies described in WAC 246-826-303. The dialysis facility that accepts the documentation assumes responsibility for confirming the core competency of the hemodialysis technician.

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     Patient care.

     (1) Data collection and communication. The hemodialysis technician must:

     (a) Verify patient identification and dialysis prescription.

     (b) Gather predialysis patient information necessary for treatment as required by facility protocols.

     (c) Accurately calculate patient fluid removal and replacement needs.

     (d) Monitor and verify treatment parameters during dialysis as required by facility protocols.

     (e) Gather post dialysis patient information necessary to conclude treatment as required by facility protocols.

     (f) Communicate and report patient, family or other care providers' concerns and/or needs to the nurse.

     (g) Provide written documentation to the patient's medical record related to both routine treatment and unusual events.

     (h) Recognize, report and document signs and symptoms related to:

     (i) Hemodialysis vascular access complications.

     (ii) Patient treatment complications.

     (iii) Complications due to operator or equipment error.

     (iv) Complications associated with allergic reactions.

     (v) Complications associated with treatment anticoagulation.

     (2) Basic hemodialysis treatment skills. The hemodialysis technician must be able to:

     (a) Set up dialysis related supplies and equipment as required by a licensed health care practitioner prescription and facility policies and procedures.

     (b) Prepare and mix additives to hemodialysis concentrates as required by facility procedure based on patient prescription.

     (c) Prepare and administer heparin and sodium chloride solutions and intradermal, subcutaneous, or topical administration of local anesthetics during treatment in standard hemodialysis doses.

     (d) Provide routine care for and cannulate hemodialysis vascular accesses for treatment as required by facility policies and procedures.

     (e) Initiate hemodialysis treatment as required by facility policies and procedures.

     (f) Provide routine care for, initiate, and terminate hemodialysis treatments using central catheters as required by facility protocols.

     (g) Terminate hemodialysis treatment as required by facility policies and procedures.

     (h) Provide routine care for equipment post dialysis including rinsing, disinfecting and shutting down as required by facility policies and procedures.

     (i) Draw required samples for laboratory testing as required by facility protocols and procedures.

     (3) Hemodialysis treatment interventions. The hemodialysis technician must be able to:

     (a) Administer oxygen to patient by cannula or mask.

     (b) Initiate CPR.

     (c) Provide initial response to patient complications and emergencies during treatment per facility procedures, including, but not limited to, the administration of normal saline per facility protocol.

     (d) Respond to equipment alarms and make necessary adjustments.

     (4) Education and personal development for hemodialysis technicians: The hemodialysis technician should be able to demonstrate a basic understanding of the following subjects:

     (a) General orientation subjects for the new hemodialysis technician.

     (i) Common manifestations of renal failure.

     (ii) Principles of dialysis.

     (iii) Dialyzer and concentrate use and prescription.

     (iv) Basic concepts of hemodialysis water treatment and dialyzer reuse.

     (v) Principles of fluid management.

     (vi) Hemodialysis treatment complications and emergencies.

     (vii) Standard precautions and the use of aseptic techniques.

     (viii) Hazardous chemical use in the hemodialysis setting.

     (ix) Use and care of hemodialysis vascular accesses.

     (x) Common laboratory testing procedures and critical alert values.

     (xi) Basic concepts related to dialysis patient dietary/nutrition requirements.

     (xii) Common psychosocial issues related to aging, chronic illness and dialysis therapy.

     (b) Facility requirements as required by written policies and procedures. The hemodialysis technician must:

     (i) Maintain current CPR certification.

     (ii) Demonstrate an understanding of facility requirements related to infection control and the use of hazardous chemicals.

     (iii) Demonstrate knowledge of facility disaster plans and emergency evacuation routes.

     (c) The hemodialysis technician must be able to demonstrate a basic understanding of the proper body mechanics for patient and self.

     (d) Maintaining patient confidentiality related to medical and personal information.

     (e) The hemodialysis technician must be able to demonstrate a basic understanding of the patient's rights and responsibilities per facility policies.

     (f) The hemodialysis technician must be able to demonstrate a basic understanding of the Uniform Disciplinary Act of the state of Washington, chapter 18.130 RCW.

     (g) The hemodialysis technician must be able to demonstrate a basic understanding of the role of hemodialysis technician patient care as it relates to professional interactions with:

     (i) Patients, family members and other care providers.

     (ii) Supervisory and administrative health care providers.

     (iii) Peers and other facility employees.

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