Blog Post on Home Dialysis Central by Beth Witten on Self-Cannulation

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.

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 carethat 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:

• Fistula First Change Concept 8: Cannulation training for AV fistulas: Site Rotation and Buttonhole Techniques
• Stuart Mott’s Overcoming a Barrier to Home Dialysis: The Art of Teaching Buttonhole 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.