Delegation of Nursing Functions in Dialysis Settings

​It has come to the Maryland Board of Nursing's (MBON) attention that the certified nursing assistant - dialysis technician (CNA-DT) has been taking call or has been called in to perform an acute dialysis treatment independent of the physical presence of an experienced renal dialysis registered nurse (RN). The provision of renal dialysis treatment is considered a nursing function. As such the nurse may choose to delegate selected aspects of the dialysis treatment to the appropriately trained and clinically competent CNA-DT. 

In dialysis, whether in the acute or chronic setting, the registered nurse is always held responsible as the delegating nurse for the CNA–DT. The RN is held to the Standards of Practice for the Registered Nurse (COMAR 10.27.09). These standards require that RN:
  1. ​delegate only to competent individuals;
  2. provide instruction, direction, and supervision
  3. regularly evaluate the performance of the person the RN is delegating to.
  4. rectify a situation when the nursing function is performed incorrectly; and
  5. prohibit delegation when the task(s) is performed incorrectly.
The Delegation of Nursing Function regulations (COMAR 10.27.11) require that the RN be readily available when delegating a nursing task. Readily available is defined in a structured setting as, physically present on the patient unit of care. The structured setting is defined as a hospital, ambulatory care setting or any other acute or chronic care facility, etc. The following clarifies the role of the RN and the CNA-DT in Dialysis: 
  1. ​The CNA–DT is an individual who performs delegated nursing functions, (see Occupations Article 8-6A-01).
  2. In the chronic dialysis settings the patient is generally chronic and stable and the treatment may be of a routine nature. In this setting the CNA-DT must be supervised by a RN who has six months of full time of dialysis experience as a RN (not LPN or CNA-DT); and who is physically present on the unit of care where the patient is receiving dialysis, (see regulations from the Maryland Kidney Commission COMAR and the Office of Health Care Quality COMAR and COMAR
  3. In the acute dialysis setting the patient is generally medically fragile, hemodynamically unstable and the treatment may not be considered routine in nature. In this setting the CNA-DT must also be supervised by a registered nurse who is an experienced dialysis nurse who is also physically present on the unit of care where the patient is being dialyzed, (see COMAR 10.27.09 and COMAR 10.27.11). 
  4. In both chronic and acute dialysis, the CNA-DT can not be considered as an independent care provider with a defined scope of practice. Instead it is the RN who is responsible and accountable for delegating and supervising the CNA-DT in compliance with the Standards of Practice for the Registered Nurse (COMAR 10.27.09) and the Delegated Nursing Functions Regulations (COMAR 10.27.11) when delegating aspects of the dialysis treatment to the CNA who also has the additional certification of DT.
The Board currently has a dialysis workgroup meeting to discuss how to meet these requirements in the dialysis setting.

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