Building Resilience in Hemodialysis Care: A Program Report on the British Columbia Hemodialysis Emergency Support Team

Abstract

This program report describes the development and implementation of the Hemodialysis Emergency Support Team (HEST) in British Columbia, an initiative led by BC Renal in partnership with the province’s 5 health authorities. The HEST was created in response to the growing risk of climate-related emergencies such as wildfires, floods, and water shortages, with the goal of ensuring continuity of care for patients receiving maintenance dialysis during service disruptions. The report outlines the provincial strategy behind HEST, including capacity building during non-emergency periods, strengthening of routine operations, and insights gained through simulation-based evaluations. Key outcomes include the achievement of provincial consensus, development of standardized staffing models, integration with existing emergency response frameworks, and the creation of rapid mobilization protocols. Beyond emergency response, HEST nurses also serve as mentors and clinical resources during non-emergency times, supporting local teams, sharing best practices, and helping build capacity within the hemodialysis unit. This dual role contributes to both emergency preparedness and long-term workforce sustainability.

Sources of information

Data from the provincial Ministry of Environment and Climate Change Strategy was used to identify the most likely climate risks BC is facing. An internal needs assessment was completed to inform key areas of focus when developing the HEST strategy, including a review of past emergencies handled by BC Renal, while consultation with experts was done to produce the guidelines.

Methods

A needs assessment revealed staff were already working at over capacity, suggesting that additional staff and funding would be needed to create an effective HEST. A project manager worked to oversee the development of HEST, consulted relevant experts in emergency response, and developed the novel framework. Twelve nurses from each in-center dialysis unit across BC were hired by their respective health region, with a matrix reporting structure to the BC Renal during emergencies.

Key findings

BC Renal’s novel HEST strategy enhances continuity of care for maintenance dialysis patients during climate-related emergencies by mitigating service disruptions and improving outcomes. The initiative strengthens emergency preparedness through patient education, staff training, evacuation protocols, contingency planning, and advanced data management. Provincial tabletop exercises and virtual mock drills identified gaps and validated team readiness, informing ongoing improvements. Beyond emergencies, HEST supports renal program sustainability by reducing operational burdens and boosting workforce resilience through mentorship and unit support. A 6-month survey of 98 novice dialysis staff showed over 85% agreement on improved clinical confidence, workplace communication, and team belonging, demonstrating positive impacts on staff retention and skill development.

Limitations

BC Renal has not yet encountered a climate crisis since the HEST was established, and therefore, it has not yet been possible to evaluate the effectiveness of the approach in a real-world setting.

Further evaluation during live events is needed to validate its impact on patient outcomes and emergency response efficiency.

Implications

The HEST initiative demonstrates how a proactive, coordinated approach to emergency preparedness can protect vulnerable dialysis populations during climate-related crises. Beyond emergency response, HEST also strengthens the dialysis workforce by fostering mentorship, staff and patient training, and system-wide collaboration. This model may be adapted by other jurisdictions seeking to enhance clinical readiness and workforce sustainability in the face of increasing environmental and health system challenges.

Introduction

The intersection of climate change and health care poses unprecedented challenges, particularly in specialized areas such as kidney care. ¹ Renal care systems, characterized by their dependence on specialized equipment, treatment schedules, and highly trained personnel, are acutely vulnerable to climate-related disruptions. ²

Interruptions in hemodialysis services can have significant adverse effects on patient health, particularly for those with complex medical conditions and clinical instability. For instance, a study reported a 9% increase in hospitalizations following the closure of 521 dialysis clinics in the United States. ³ The vital role of uninterrupted hemodialysis was also demonstrated following Hurricane Katrina, where patients missing 3 or more maintenance dialysis sessions were significantly more likely to be hospitalized within the first month compared to those who missed none. Approximately 23% of study participants reported hospitalization during this period. In addition, inadequate awareness of dialysis unit evacuation plans contributed to higher rates of missed sessions. These findings underscore the importance of addressing missed hemodialysis sessions, particularly in disaster or triage scenarios, to mitigate adverse outcomes and enhance patient resilience. ⁴

Of note, disasters can not only interrupt the delivery of maintenance dialysis for patients with chronic kidney failure but also increase the number of people requiring acute dialysis, as seen by the increase in people with acute kidney injury (AKI) following the 2023 earthquake in Turkey. ⁵ This increase in the demand for care further emphasizes the need for coordinated responses to manage dialysis delivery in a time of crisis. Having a trained task force capable of dealing with such a crisis has been shown to save lives. ⁶

Program Report: A Dual Strategy for Emergency Readiness and Workforce Retention

Building resilience requires more than preparedness; it demands a coordinated, cross-sector workforce. ⁷ This includes not only having emergency plans in place but also ensuring that the right people, with the right training, tools, and support, are available and mobilized effectively across renal systems. Integrated coordination enables rapid, informed responses during disruptions while maintaining continuity of care.

Dedicated teams with appropriate training are better equipped to adapt to complex and evolving emergency situations, whereas reliance on untrained volunteers can introduce critical vulnerabilities. ⁸ Trained clinical staff bring both technical competence and situational awareness that are essential for making safe, timely decisions under pressure. In contrast, ad hoc or insufficiently prepared personnel may lack familiarity within emergency protocols, increasing the risk of errors, inefficiencies, and stress on existing staff. As such, investments in structured training and cross-jurisdictional collaboration are central to achieving operational readiness and long-term system resilience.

The Hemodialysis Emergency Support Team (HEST) program was developed as a comprehensive strategy to support both emergency preparedness and long-term workforce sustainability in renal care. From the outset, the program recognized the dual need for clinical surge capacity during crises and for sustained support of daily operations in a specialized high-acuity setting. As such, HEST was designed with a dual focus: ensuring immediate provincial response capability while simultaneously strengthening local workforce capacity through targeted support, mentorship, and knowledge sharing.

A key feature of the HEST model is its mentorship component, which was deliberately integrated to promote clinical development and team resilience. When not responding to emergencies, HEST nurses continue to work in their designated units, where they serve as mentors, support an inclusive workplace, and contribute to staff development and cohesion.

By embedding mentorship into the broader framework of emergency readiness, the HEST program reinforces the principle that sustainable workforce development is essential to system resilience. It illustrates how investing in experienced nurses and fostering a culture of peer support can enhance both everyday clinical capacity and the ability to respond to emergencies. Ultimately, HEST demonstrates that a resilient kidney care system must prioritize both preparedness and the ongoing development of its workforce.

While the benefits of having a dedicated team to enhance system resilience emergency response strategies are clear, there are fewer resources outlining how to create these strategies. However, insights gained from the COVID-19 pandemic are pointing to some factors that contribute to successful emergency response strategies. For instance, a systemic review of 40 studies following the pandemic suggests that effective emergency response strategies often involve: dedicated and trained teams for emergency response, clear lines of communication, and recruiting and redeploying health care workers for tasks within their skillset, rather than reassigning them to tasks outside of their expertise; as well, having a supportive work environment, including continuous support from more experienced health care workers, was identified as a factor for successful redeployment and training. ⁹

Sources of Information

Along with factors that support meaningful emergency response strategies, it is important to take local climate risks into consideration. The type of climate change disasters, and thus disruptions to care, can vary greatly depending on geographic location. British Columbia is increasingly experiencing the impacts of climate change, including rising temperatures, increasing water shortages, and more frequent extreme and variable weather events. These changes are projected to accelerate and intensify in the coming years and decades. Proactively understanding and managing these climate-related risks is essential to safeguard the well-being of both patients treated with dialysis and health care staff in the province.

Figure 1 presents an overview of the risk assessment findings for 15 illustrative climate risk scenarios affecting British Columbia. A detailed summary of each risk event is provided in the Ministry of Environment and Climate Change Strategy. ¹⁰

Figure 1.

This risk matrix highlights the outcomes of assessing 15 climate-related scenarios that could impact British Columbia. For more details on each scenario, refer to the Ministry of Environment and Climate Change Strategy’s summary.

As outlined in Figure 1, the increasing threat of climate-related hazards, such as wildfires, extreme heat, and seasonal water shortage, underscores the urgency of emergency preparedness in hemodialysis care (Ministry of Environment and Climate Change Strategy, 2019).

Natural disasters, such as the British Columbia wildfires, frequently necessitate the declaration of a state of emergency, triggering widespread evacuations and significant disruptions to health care services. Among the most vulnerable populations during these crises are patients dependent on life-sustaining hemodialysis treatments. Such emergencies require rapid and coordinated responses involving health authorities, medical teams, and evacuation services to ensure continuity of care and timely access to appropriate facilities and resources.

The challenges associated with maintaining dialysis care during emergencies are often exacerbated during summer months, when many dialysis units face staffing shortages, further straining health care providers. In addition, dialysis services are frequently overlooked in regional emergency preparedness plans due to their outpatient nature, resulting in gaps in resource allocation and logistical planning. Establishing a dedicated hemodialysis emergency support nurse with specialized expertise in renal care can play a pivotal role in streamlining the organization and execution of emergency response efforts.

The 2021 Fraser Valley flood in British Columbia exemplified these challenges, over 50 patients without access to dialysis treatment, while others were without proper medical supplies or power to dialyze, placing further strain on an already overburdened system. ¹¹ The uncertainty surrounding the continuity of care during this event heightened patient stress and underscored deficiencies in emergency response frameworks.

These experiences highlight the critical need for comprehensive disaster preparedness frameworks that explicitly address the unique needs of patients treated by hemodialysis and other vulnerable populations. Such frameworks must ensure equitable access to care while minimizing the physical and psychological impact of service disruptions during emergencies. Proactive measures, including designated hemodialysis emergency support nurses, resource allocation frameworks, detailed contingency plans, and a network built on mutual support and collaboration, are essential to mitigate the risks posed by future disasters.

In response to the growing challenges posed by climate-induced emergencies and systemic pressures within the hemodialysis workforce, BC Renal, a provincial organization responsible for the planning and resourcing of kidney care in British Columbia, developed a comprehensive framework to enhance emergency preparedness. This framework addresses both acute service demands and underlying systemic vulnerabilities.

A key component of this initiative is the establishment of the HEST, a provincially coordinated model designed to ensure continuity of facility-based hemodialysis care during climate-related emergencies. The HEST provides a scalable approach to mitigating service disruptions, supporting workforce resilience, and safeguarding patient outcomes in the face of escalating climate risks.

Methods

Program Design and Rationale

A province-wide needs assessment identified substantial deficiencies in staffing levels, operational capacity, emergency response protocols, and resource allocation. Many renal programs were functioning beyond their intended capacity and experiencing persistent challenges in staff recruitment, retention, and vacancy management. These findings highlighted the urgent need for a sustainable, system-level strategy to ensure the continuity of dialysis care during crises.

Initial consideration was given to traditional approaches, such as developing guidance documents or relying on staff volunteers. However, these strategies proved inadequate. Documentation alone could not resolve issues related to workforce sustainability, scalability, or resource planning. Similarly, dependence on volunteer staff was deemed unreliable due to fluctuating availability, competing personal commitments, and the already strained workforce. These limitations reinforced the need for a dedicated, trained, and regionally integrated emergency response workforce specifically tailored to the unique demands of dialysis care.

Program Development and Implementation

The HEST program was developed using a multi-phase approach involving key partner consultation, document analysis, and leadership engagement:

• 1. Needs Assessment and Informal Interviews

•  To validate the central hypothesis that a centralized, cross-regional team of trained nurses would enhance emergency response, we conducted informal interviews with experienced emergency management and hemodialysis administration and staff. Participants had firsthand experience managing care during emergencies and consistently reported that reliance on volunteerism was ineffective due to chronic understaffing and routine overcapacity. These insights confirmed the need for a dedicated and structured emergency response team.

• 2. Systematic Review of After-Action Reports

•  A program review of after-action reports from prior emergency events within renal programs revealed significant inconsistencies in documentation and preparedness. Many units lacked updated emergency protocols, and numerous reports were unavailable or incomplete. These findings emphasized the need for standardized emergency planning and systematic documentation across all renal programs.

• 3. Leadership Engagement and Cross-Jurisdictional Barriers

•  Expert consultation interviews were conducted with health region leaders to identify barriers to the redeployment of nursing staff across jurisdictions. Challenges included union regulations, variations in classification and compensation, and limited alignment between health authorities. To address this, a standardized provincial job description for HEST nurses was developed to ensure role clarity and consistency across regions. Leadership commitment was instrumental in resolving these systemic challenges.

Drawing on the findings from the above phases, the HEST program was designed to address emergency response gaps in a structured and sustainable manner. A dedicated project manager collaborated with renal administrators, emergency planning experts, and executive leadership to align objectives and create a coordinated framework. External consultation with other provincial programs (eg, BC Centre for Disease Control, BC Transplant, Trauma Services BC, Health Emergency Management BC) informed the planning and modeling process.

Staffing and Role Definition

Given their central role in dialysis delivery, registered nurses with 3 or more years of experience in a hemodialysis setting were hired as the primary HEST team. Funding was provided by BC Renal to hire 1 HEST nurse for each of the 12 in-center outpatient hemodialysis units across the province. Clear expectations for emergency response responsibilities were embedded within the HEST nurse job descriptions.

Training Framework

A structured program framework was developed, integrating evidence-based practices and the expertise of key contributors. This framework established clear priorities for resource allocation, outlined training requirements, and defined operational protocols. The BC Renal designed a comprehensive training curriculum to prepare HEST nurses to deliver dialysis care beyond normal capacity, operate effectively in unfamiliar or resource-limited settings, support crisis management efforts, and serve as mentors and clinical leaders during non-emergent periods within the hemodialysis unit.

Simulation-Based Evaluation

To evaluate the effectiveness of the HEST pilot, a tabletop exercise and virtual mock drill were conducted across provincial health regions. The tabletop exercise provided a structured, discussion-based forum for key participants to examine roles, responsibilities, and decision-making pathways within a simulated emergency scenario. This exercise was instrumental in identifying critical information gaps, refining communication protocols, verifying the accuracy of patient demographic records, and ensuring access credentials and emergency system passwords were functional and up to date. In addition, it enhanced inter-provincial coordination by promoting shared understanding and alignment of emergency response strategies across jurisdictions.

Following the tabletop exercise, a virtual mock drill was conducted to simulate the deployment process in real time. This exercise allowed teams to assess escalation protocols, evaluate operational readiness, and test workflow execution under pressure. It also provided an opportunity to identify logistical challenges, such as travel arrangements and coordination across health regions, in a controlled but realistic setting. Insights gained from both the tabletop and mock drill exercises informed targeted refinements to the HEST framework, ultimately strengthening the emergency response strategy and contributing to a more resilient, scalable, and practice-ready model for future implementation.

Non-Emergent Role and Preparedness Activities

Beyond emergency deployment, preparedness is a critical component of hemodialysis care, involving a comprehensive strategy to ensure patient safety and care continuity during crises. This role includes patient education on emergency planning, covering emergency diet and medication management, verification of up-to-date demographics and emergency contacts, and familiarization with emergency takeoff procedures. In addition, patient data are continuously updated and maintained in relevant database systems to ensure readiness for emergencies.

Staff training and simulated code scenarios within the hemodialysis unit are foundational to preparedness efforts, driving ongoing improvements in emergency response protocols. The program also emphasizes the continuous revision of evacuation and emergency plans in collaboration with emergency support teams, ensuring that renal care is prioritized during regional evacuations due to its life-supporting nature.

These coordinated efforts are designed to mitigate risks and improve patient outcomes during emergencies, ensuring that hemodialysis remains a top priority in regional emergency and evacuation planning.

Table 1 presents the stepwise components essential for developing a responsive, equitable, and sustainable emergency response system for hemodialysis care services across diverse health regions.

Table 1.

Essential Steps to Build a Responsive and Equitable Emergency Response System for Hemodialysis Services for B.C. Health Regions.

Step 1: Establish Strategic Alignment Establish alignment between key kidney service medical and administrator leaders and external partners, to ensure coordinated program development.

Step 2. Define and Develop Resource Allocation Protocols and Contingency Plans Define and develop resource allocation protocols12,13 and contingency plans14,15 to optimize the distribution of workforce and resources.

Step 3: Conduct Capacity Gap Assessments Assess and identify capacity gaps within existing infrastructure to address anticipated service demands in emergency scenarios.

Step 4: Achieve Cross-Provincial Consensus Establish a shared framework and achieve consensus across health regions to ensure a unified understanding of roles, responsibilities, and operational expectations.

Step 5: Implement Comprehensive Scheduling Systems Develop and implement a comprehensive scheduling system to ensure uninterrupted coverage throughout the year, including weekends and holidays.

Step 6: Standardize Staffing Structures Design standardized provincial job description accompanied by equitable compensation structures and consistent classification criteria across all health regions to promote uniformity and equity in staffing practices. Ensure union and labor relations endorse the proposed strategy.

Step 7: Develop Targeted Interview Guides Create an interview tool tailored to identify candidates capable of responding to emergencies, working in new environments, ability to travel to unfamiliar site, and mentoring others.

Step 8: Standardize HEST Nurse Training Programs Develop and implement standardized training program for the HEST nurses to ensure preparedness for emergency deployment and working in unfamiliar areas.

Step 9: Integrate Data-Sharing Platforms Integrate data-sharing platforms to facilitate communication and coordination across different levels of care.

Step 10: Establish Rapid Mobilization Protocols Establish protocols for the rapid mobilization of resources and personnel in response to emerging needs.

Step 11: Regularly Update Operational Plans Regularly update and revise operational plans to reflect changes in patient demographics, care needs, and external factors.

Step 12: Implement Real-Time Monitoring and Evaluation Create mechanisms for continuous monitoring and evaluation of program effectiveness and system responsiveness in real-time operational contexts.

As shown in Table 1, the HEST strategy was developed through a comprehensive, phased process to support cross-provincial alignment, contingency planning, and workforce readiness. This structured approach supports both emergency preparedness and long-term sustainability.

Workforce Resilience and Mentorship Impact

The hemodialysis workforce has been significantly strained by persistent nursing shortages (nationally and worldwide), the increasing complexity of patients treated with maintenance dialysis, and the broader aging population requiring kidney replacement therapies. These challenges have been compounded by the issue of dialysis clinics operating at overcapacity, which further exacerbates the strain on health care resources. These challenges reached a critical point due to multiple emergent situations in recent years. Through a comprehensive needs assessment, administrators identified key issues with the renal workforce, including staff retention, burnout, high vacancies, and escalating sick leave.

In addition to their pivotal role in emergency response, HEST nurses play a crucial role in promoting a supportive and resilient work environment. During non-emergent periods, HEST nurses contribute to the hemodialysis workforce by focusing on mentorship, staff development, and fostering a positive workplace culture. These efforts are vital in improving staff satisfaction, reducing turnover, and enhancing patient care outcomes. The HEST initiative’s impact extends beyond emergency response, demonstrating significant benefits for both workforce resilience and care quality.

Table 2 describes the workforce resilience and benefits from the Hemodialysis Emergency Support Team initiative in hemodialysis units.

Table 2.

Workforce Resilience Outcomes and Advantages of the Hemodialysis Emergency Support Team Initiative.

Categories	Benefits
Mentorship and Training	• Supportive Environment: the HEST Mentorship Program promotes a welcoming, inclusive workplace for new staff. • Skill Development: hands-on training and continuous mentorship enhance confidence and reduce turnover.
Staff Support	• Task Assistance: eases workload by aiding with complex procedures like vascular access, hemodialysis complications, and patient management. • Team Cohesion: regular check-ins foster trust and camaraderie. • Onboarding: supports orientation and mentoring for new hires, alleviating senior staff workload. • Clinical Educator Support: collaborates with Clinical Nurse Educators to mentor and develop novice staff.
Career Development	• Professional Growth: supports education, skill-building, and leadership opportunities, increasing job satisfaction. • Retention Incentives: clear pathways for advancement encourage long-term staff commitment.
Stress Reduction	• Administrative Relief: handles emergency planning and patient education, reducing stress for other staff. • Workplace Morale: creates a safer, more organized environment that supports staff well-being. • Elbow-to-Elbow Support: provides a safety net for novice nurses by staying alongside them as they tackle new and challenging tasks. • Supernumerary: staff coverage during periods of late arrivals, appointments, or staff training. • Leadership: supports staff during codes and other emergencies
Improved Patient Outcomes	• Infection Control: evaluates and enhances practices to improve care quality. • Vascular Access Training: ensures staff proficiency, benefiting both patient outcomes and staff satisfaction. • Community Dialysis Patient Support: ensures patients in community dialysis units benefit from emergency education. • Emergency Planning: in times of crisis, patients are prepared and informed on emergency practices and plans.

As outlined in Table 2, internal feedback from hemodialysis staff indicates that HEST contributes to a more resilient and supported workforce by addressing key areas such as mentorship, task sharing, career development, and workplace morale, factors critical to sustaining specialty-trained staff in high-paced environments.

Evaluation of the Mentorship Experience

Six months after the HEST strategy was integrated into BC’s renal operations, a survey was conducted with 98 novice hemodialysis nurses (defined as having less than 1 year of experience) working within the in-center dialysis units alongside HEST nurses (Supplemental Material 1). The purpose of the survey was to evaluate the mentees’ experiences with the HEST nurse mentorship program. A 10-item questionnaire, adapted from the College Student Mentoring Scale ¹⁶ was used to assess perceived support and guidance. Items were rated on a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.”

The survey was distributed via QR code by HEST nurses and completed electronically through SurveyMonkey. Responses were collated within the platform and later analyzed by BC Renal. Responses were thematically grouped to identify key trends and insights related to mentorship effectiveness and clinical integration.

Over 85% of respondents agreed with all items; 88% reported increased clinical confidence, 89% felt a greater sense of belonging, and 88% noted improved communication around workplace challenges.

Table 3 demonstrates the responses to these items provided insights into the role of mentoring in the professional development of novice hemodialysis nurses in in-center clinical settings.

Table 3.

Mentoring and Its Role in Supporting Professional Growth of Novice Hemodialysis Nurses in Clinical Settings.

Statement	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Total
I can talk openly about social issues related to being in the workplace	58.59% (58)	28.28% (28)	3.03% (3)	8.08% (8)	2.02% (2)	99
Gives me clinical support and confidence to perform my nephrology duties	70.71% (70)	17.17% (17)	6.06% (6)	3.03% (3)	3.03% (3)	99
Encourages me to explore the expectations managers and nurses have of me in the workplace	59.60% (59)	25.25% (25)	10.10% (10)	4.04% (4)	1.01% (1)	99
Makes me feel that I belong in the unit/workplace	68.37% (67)	20.41% (20)	6.12% (6)	4.08% (4)	1.02% (1)	98
Encourages me to use him or her as a sounding board to improve my practice	64.65% (64)	21.21% (21)	7.07% (7)	6.06% (6)	1.01% (1)	99
Shares personal examples of difficulties they have had to overcome to accomplish professional goals	61.62% (61)	19.19% (19)	14.14% (14)	3.03% (3)	2.02% (2)	99
I can talk with openly about issues related to being a new nephrology nurse	65.31% (64)	17.35% (17)	9.18% (9)	5.10% (5)	3.06% (3)	98
Encourages me to discuss problems I am having in the workplace	61.62% (61)	25.25% (25)	6.06% (6)	6.06% (6)	1.01% (1)	99
Provides practical suggestions for improving my clinical performance	65.66% (65)	23.23% (23)	5.05% (5)	5.05% (5)	1.01% (1)	99

Table 3 presents the survey responses related to mentorship and its perceived impact on the professional development of novice hemodialysis nurses in in-center clinical settings. The findings reveal strong overall agreement with statements emphasizing the supportive role of mentors in both clinical and interpersonal dimensions of workplace integration.

Integration of the Hemodialysis Emergency Support Team Nurse Role Into Routine Clinical Operations

The HEST role is part of a strategic approach to workforce sustainability through the integration into routine clinical operations. This innovative role assumes key responsibilities in frontline support and staff training, effectively alleviating the workload of Clinical Nurse Educators (CNEs) and enabling them to focus on broader professional development initiatives.

The HEST Nurse enhances clinical competencies, fosters guidance to bedside nurses, and contributes to overall system resilience through targeted mentorship and capacity building. In collaboration with CNEs, the HEST nurse leads initiatives that support staff confidence, promote professional growth, and cultivate a cohesive, team-based care environment.

As a supernumerary team member, the HEST nurse plays a critical role in maintaining continuity of care, supporting staff coverage for breaks, late work arrivals, or absences, and facilitating participation in educational workshops. By providing real-time, elbow-to-elbow clinical support, the HEST nurse strengthens the learning environment and promotes team cohesion. A central aspect of the role involves the orientation and mentorship of novice nurses, reducing the burden traditionally borne by senior staff and enabling more sustainable, structured knowledge transfer.

Furthermore, the HEST Nurse delivers hands-on mentorship in essential hemodialysis practice areas, including vascular access management, complication response, machine alarm troubleshooting, and unit-specific procedures. These competencies are reinforced through direct demonstration, clear explanation, and the promotion of a culture of continuous learning.

Collectively, these contributions support the development of a resilient, adaptable workforce equipped to meet the evolving demands of kidney care. Future steps to evaluate the impact the HEST role has in strengthening workforce sustainability include evaluating the effect of the HEST role on staff turnover and retention and advancing a redesigned, scalable care model to ensure long-term workforce sustainability across provincial renal programs.

Key Findings

The HEST project has addressed critical vulnerabilities in dialysis service delivery during emergencies. These included staffing shortages, limited surge capacity, inconsistent emergency protocols, and fragmented operational planning across health authorities. A dedicated team of trained hemodialysis nurses was established to replace volunteer-based response models, which had proven unreliable. Implementation across jurisdictions was supported through a standardized provincial job description, leadership engagement, and resolution of workforce barriers related to classification, deployment, and compensation. Simulation exercises such as tabletop scenarios and mock drills identified gaps in communication, data accuracy, and logistics. Targeted improvements followed, enhancing provincial emergency response coordination. Beyond deployment, HEST nurses supported preparedness by leading patient education, updating emergency records, facilitating staff training and mentorship, and promoting evacuation planning. The HEST framework demonstrated scalability, flexibility, and relevance for other clinical services requiring reliable emergency response capacity.

Limitations

While the HEST initiative offers promising solutions to the challenges faced by hemodialysis care providers, it is important to acknowledge that several barriers may hinder its successful implementation. One significant barrier is the limited staffing within renal systems in Canada, where taking experienced nurses out of their regular clinical roles may disrupt the functioning of established programs. This highlights the need for solutions that can be integrated into existing infrastructures without causing disruption to routine care. Thus, it is essential to design programs that utilize current resources and staff in a manner that optimizes both operational capacity and patient care.

Although the program has been in place for over a year, it has yet to face a large-scale emergency, and as a result, mock drills and tabletop exercises have served as the primary means of evaluation. These simulations provide valuable insights into potential challenges and areas for improvement; however, they cannot fully replicate the complexities of an actual emergency. Therefore, it is crucial to continue monitoring the program’s effectiveness, particularly in real-world scenarios, to ensure that it is adequately prepared to meet the needs of both patients and staff during crises.

The effectiveness of nurse training, particularly regarding the operation of various dialysis machines, emergency protocols, and ongoing competency development, is a critical area that requires continuous attention. As hemodialysis care needs evolve and new dialysis technologies emerge, it is imperative that the training program adapts to ensure that HEST nurses are equipped to manage a diverse range of clinical situations. Moreover, the recruitment and retention of specialized renal nurses, particularly those willing to engage in travel-based assignments and work in unfamiliar settings, may present a challenge, as this type of role may not be suitable for all renal nurses.

The sustainability of the HEST initiative relies on a mutual agreement between health regions to deploy nurses across various hemodialysis settings as needed, with the caveat that HEST nurses should not be utilized as a substitute for permanent staff in units. To ensure the continued success and responsiveness of this model, it is essential for health regions to invest in the HEST program as an integral part of emergency response infrastructure, thus supporting the evolving demands of renal care while maintaining the program’s integrity and operational effectiveness.

The HEST initiative represents a significant advancement in addressing the complex challenges facing renal care in British Columbia. By focusing on staff retention, emergency response and preparedness, and operational efficiency, the program offers a scalable model that can be adapted to other regions grappling with similar issues. As the health care landscape continues to evolve in response to the rising incidence of climate emergencies and the pressures on the health care workforce, initiatives like HEST provide a framework for addressing these challenges while ensuring that patient care remains at the forefront. The long-term success of such programs will rely on ongoing feedback, strategic adaptations, and a commitment to both the needs of patients and the well-being of the health care workforce.

Implications

The Hemodialysis Emergency Support Team illustrates an evidence-based approach to integrating emergency preparedness with systemic workforce development in hemodialysis care. By addressing system vulnerabilities intensified by climate change, HEST contributes to operational resilience and sustainable staffing models in hemodialysis care. Its structured and scalable framework offers a potential model for other jurisdictions seeking to enhance the continuity of care during climate-related disruptions and strengthen long-term sustainability in hemodialysis services.

Conclusion

The Hemodialysis Emergency Support Team represents an innovative response to the intersecting challenges of climate-related emergencies and workforce instability in hemodialysis care. Grounded in evidence and designed for adaptability, HEST demonstrates how targeted, proactive strategies can mitigate service disruptions while reinforcing the human infrastructure essential to care delivery. As the impacts of climate change intensify, the HEST model offers a replicable framework for health systems aiming to enhance preparedness, protect patient care continuity, and invest in sustainable workforce solutions.