Self-Cannulation: A Patient Right and CMS Expectation for Interested and Trained Patients

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on July 20th, 2017.
Self-Cannulation: A Patient Right and CMS Expectation for Interested and Trained Patients

I recently heard through the grapevine that some dialysis clinics do not allow patients to cannulate their own vascular accesses. I thought I’d share some arguments in support of patients being allowed and encouraged to participate in this aspect of care.

The preamble to the ESRD Conditions for Coverage which were published in the Federal Register on April 15, 2008 includes comments from the community and CMS’ response:

  • On page 20373-20374, a comment was to add language to the CfC to state that a facility can teach a patient how to self-cannulate without certification as a self-dialysis unit. The CMS response was: “We agree with the commenters that any dialysis facility that is Medicare-certified to provide outpatient dialysis services may include instruction in self-cannulation in its dialysis program. We do not require any additional certifications, nor is a separate ‘‘self-dialysis’’ certification category available.”

  • On page 20389, a comment was that patients should be allowed to refuse a staff member’s cannulation after having problems with that staff’s cannulation. CMS’ response was: “‘‘Fistula First’’ is a nationwide initiative that promotes the adoption of recommended ‘‘best practices,’’ including cannulation methods, in dialysis facilities. Facilities are encouraged to implement these practices,including increased self-cannulation. The initiative encourages self-cannulation with the appropriate course of training, as part of an emphasis on broader patient involvement in care.”

The text of the ESRD Conditions for Coverage, includes these Conditions/Standards related to patient self-cannulation:

  • 42 CFR 494.70(a)(5) which states that the patient has the right to: “Be informed about and participate, if desired, in all aspects of his or her care...”

  • 42 CFR 494.80(a)(9) which states that the patient’s assessment includes, but is not limited to the following: “Evaluation of the patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process…”

  • 42 CFR 494.90 in the Condition statement it says: “The interdisciplinary team as defined at § 494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition…”

Since CMS ESRD regulations and Fistula First encourage facilities to allow patients to self-cannulate after appropriate training, any facility that refuses to allow a patient to self-cannulate may find itself the subject of a patient complaint, a state survey, and citation. The ESRD Interpretive Guidance Version 1.1 published October 3, 2008, provides guidance to surveyors to help them interpret whether the dialysis clinic is complying with the regulations. Surveyors could cite any or all the following tags in the Statement of Deficiencies and Plan of Correction (Form CMS-2567):

  • V456 states: “Self-cannulation may be performed by the patient in any facility upon receiving appropriate training and demonstrating competence, should they so choose.”

  • V512 states: “If patients express a desire for enhanced participation in their own care (e.g., weighing themselves, monitoring blood pressure, holding needle sites, self-cannulation), the facility staff should evaluate and plan for applicable self-care training.”

  • V585 that describes components of home dialysis training states: “Specific (step-by step) instructions in home dialysis procedures (e.g. self-cannulation, peritoneal dialysis exchange) to facilitate adequate dialysis as prescribed by the physician…” Patients doing

On the other hand, teaching a patient how to self-cannulate can save staff time and patient accesses. Here are some resources to teach self-cannulation:

I hope this blog dispels any concerns that a dialysis clinic might have about a patient’s right to be trained and perform self-cannulation and to provide evidence that CMS does not limit any dialysis clinic providing training and allowing trained patients to self-cannulate.

Comments

  • Sandy Beck

    Aug 17, 2:56 PM

    I was on dialysis for over ten years and learned self-cannulation within months of my start date. The staff were more than happy to teach me. I also set up my machine and maintained every aspect of my dialysis. I eventually moved on to nocturnal dialysis and subsequently a transplant.

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    • Beth Witten

      Aug 18, 8:58 AM

      That's the way it should be. Dialysis clinics don't have to be certified for home dialysis to teach patients to do self-care in-center (self-cannulation, machine setup/tear down, monitoring vital signs before, during and after treatment, recording treatment, etc.). I'm glad that your clinic supported you in your desire to be in charge of your treatment.

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  • Diane McRae, LICSW

    Jul 28, 11:56 AM

    We also have spouse/partners who have been trained to cannulate our patients. It's been wonderful for patients who want the same person to always cannulate, and for patients who travel. It can also be a gateway to full home dialysis!

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    • Beth Witten

      Jul 31, 9:40 PM

      If a patient is unable to self-cannulate, teaching a care partner how to do this can provide a patient with a sense of security. It's important for patients to feel safe and secure on dialysis and in other healthcare settings. The more that healthcare providers can do to achieve that goal, the better.

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  • Kevin Abrams

    Jul 20, 7:02 PM

    I asked my facility many times to do it and they wouldn't allow me to stick myself. So now I know my rights, thank you.

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    • Beth Witten

      Jul 21, 10:07 AM

      Show them your clinic my blog, which cites to the ESRD regulations and its preamble (the text before the regulations as well as the Interpretive Guidance. I'd be interested to know what the reason is why the clinic won't teach you to stick yourself.

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  • Joan Balla

    Jul 20, 4:55 PM

    I read with interest your comment on self cannulation. I would like to know if a spouse can be certified to do the treatment. What is involved? How long is the training? This is for possible future reference as my husband is currently stage 4 KF. Thanks.

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    • Beth Witten

      Jul 21, 10:25 AM

      Dialysis clinics that are certified to offer home training & support can teach patients and care partners how to do the entire home dialysis treatment (peritoneal and/or home hemodialysis). The training time depends in part on how quickly someone learns and the type of treatment. Most people can learn PD in a week, although Medicare will pay for 15 PD training sessions. Home HD patients typically get 3-6 weeks of training. Medicare will routinely pay for 25 training days...more if justified. Care partners may not need to attend every training session with the patient since it's best if the patient does most if not all of the treatment assuming he/she is physically and mentally able. Here's an article on home dialysis training that refers to other resources that may be helpful. http://www.homedialysis.org/news-and-research/blog/125-home-dialysis-training-and-back-up-patients-need-a-safety-net

      A resource that can help you and your husband decide which type of dialysis is best based on your values, lifestyle and what's important to both of you can be found at https://mydialysischoice.org/.

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