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Year : 2020  |  Volume : 30  |  Issue : 7  |  Page : 1--5

Setting up of hemodialysis unit

 

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How to cite this article:
. Setting up of hemodialysis unit.Indian J Nephrol 2020;30:1-5

How to cite this URL:
. Setting up of hemodialysis unit. Indian J Nephrol [serial online] 2020 [cited 2020 Aug 5 ];30:1-5
Available from: http://www.indianjnephrol.org/text.asp?2020/30/7/1/289769

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Setting up of maintenance hemodialysis (MHD) unit is a major challenge for an uninitiated nephrologist. The purpose of this guideline is to help design a new unit.

 Dialysis (Hemodialysis) Area



We recommend that the hemodialysis (HD) treatment area (dialysis machine + bed or chair) should have the following features:

The dialysis area specifications and requirements shall include enough space to accommodate the number of provided dialysis stations.

The dialysis area should be air conditioned so as to achieve 70°F–72°F temperatures and 55%–60% humidityEach machine should be at the center of sufficient area [Figure 1] to allow easy movement of personnel and resuscitation equipment whenever needed. The layout should have facilities for protecting patient's privacyNursing station (counter): This requires an unobtrusive view of all patient treatment areas. The nursing station should also be within the range of hearing alarms from the machines for taking appropriate timely actions. The nursing station should have enough space for on-duty nurses/working technicians, a computer terminal, and a working desk/bench. There should be a cupboard/space to store emergency medicines/disposablesFloor covering in the dialysis area shall be monolithic and joint free. The floor occupied by each dialysis station shall be large enough to accommodate the dialysis chair/couch, dialysis machine, as well as working room for two dialysis personnel. There should be adequate clearance space between the dialysis stationsThe head end of each bed should have stable electrical supply with at least six sockets of 5/15 A, oxygen and vacuum outlet, treated water inlet, and drainage. The wires from the electric sockets should be in such a way that they do not pose a threat to the patient or staff during the dialysis. The minimum door-opening width (desirable – 1.12 m) should be sufficient for easy transport of patient on trolleys/wheelchair to the dialysis station. The minimum ceiling height shall be 2.4–2.7 mIsolation room: There should be separate areas for dialyzing patients with conditions that require isolation (desirable) to ensure safety to patients and staff in the dialysis room. This area should have independent water supply and drainage facilities. Facilities that dialyze patients with known blood-borne pathogens shall have at least two separate rooms to use for those patients as follows:{Figure 1}

For hepatitis B virus (HBV) patients, rooms/linen shall be color coded with blueFor hepatitis C virus (HCV) patients, rooms/linen shall be color coded with yellowThis should not be considered a substitute for universal precautions observed in the dialysis facility

Facilities for handwashing and alcohol-based hand rub/sterilant dispensers should be available in all patient areas and should be easily accessible. Hand-washing basins (an area of the basin 1 m2) usually made of porcelain, stainless steel (SS), or solid surface materials should also be available in the facilityThe dialysis room should contain additional equipment that is required for regular use in the unit such as a weighing scale and stadiometer, cardiac monitors, defibrillator, and infusion pumpsAll surfaces and fixtures are to be designed to enable easy and thorough cleaning on a regular and repeated basis to ensure a high level of infection control in all aspects of practice. High levels of cleaning are to be conducted in the unit daily. All surfaces should be free from seams and creases which may harbor bacteria. Vinyl that requires a warm water wash and does not require daily polishing should be included in all treatment areas.

Floors: This must be covered by ceramic or flooring surfaces which may be chosen in such a way that it is easy to maintain, is readily cleanable, and is resistant to disinfection procedures. Epoxy flooring is desirableSkirting should be covered to prevent dirt congregating in corners. It should extend all the way up the wall up to 20 cm or up to 30 cm (desirable) to protect all potentially wet areas from infiltrationWalls: Wall finishes must be scrubbable and should be smooth and water resistantCeilings: All exposed ceilings and ceiling structures must be easy to clean. All areas where dust fallout would present a potential problem must have finished ceilings that cover all conduits and pipesWindow furnishings: Washable blinds are preferable to curtains as they retain less dust and are easier to clean and nonflammable. Washable paint should be applied for all walls and ceilingsNatural light contributes to a sense of well-being, assists orientation to building locations, and improves service outcomes. The use of natural light should be maximized throughout the unit.

 Dialyzer Reprocessing Area



We recommend an independent area for reprocessing the dialyzers. This should have a workbench and a sink with a sideboard and drainage. The workbench should have separately marked treated as well as untreated water supplies at a water line pressure of 1.3 kg/cm2 (20 psi). There should be two sinks (one for initial cleaning and the other for filling sterilent, packing, and labeling) of the dialyzer. We suggest that the space should be sufficient for two persons working simultaneously.

We suggest that the reprocessing area should be equipped with a hood and an exhaust fanWe recommend the use of sinks with a depth of at least 45 cm with a drainage mesh at a depth of around 20 cm to prevent the dialyzer and tubing resting in the effluentWe recommend that the washing area be equipped with two outlets or a “T” connection. Two different fittings should be provided on the water line at each reprocessing area, a standard tubing to clean the blood compartment, and a Hansen connector for backwashing the dialysate compartmentWe recommend the use of a 316 SS or medical-grade polyvinyl chloride (PVC) for fittingsWe recommend a physically separate reprocessing area for processing dialyzers of patients with HCV infectionWe suggest that space should also be provided for dialyzer reprocessing machine(s)We recommend stabilized electrical supply and drainage for the workbench.

 Drainage System



Services that facilitate the drainage of waste fluids from the HD machines must be ventilated to prevent condensation and the subsequent growth of mold. This fact should be kept in mind when designing covers or screens for the drainage systems. Drainage systems should be constructed of a chemically resistant material such as high-density polyethylene. The dialysate and the reprocessing effluent should drain into a separate drainage system/tank with adequate capacity to handle the volume.

We recommend that the number of bends in pipelines be kept to a minimum and blind loops be avoided.

We recommend that all drainage systems should be connected directly to the main drainage line in a straight line without bends or blind loops [Figure 2]a, [Figure 2]b, [Figure 3] and [Figure 4].{Figure 2}{Figure 3}{Figure 4}

 Storage Areas



We recommend two separate storage areas: one for new supplies (dry storage) and another for reprocessed dialyzers (wet storage)The dry storage area should have sufficient space to store adequate supply of dialyzers, tubings, dry powder HD concentrate solutions, intravenous (IV) fluids, and other consumables. It should also have space for stationery, linen, and recordsThe wet storage is for reprocessed dialyzers and tubingsWe recommend a separate area with a workbench for preparation of sterile trays for dialysis startup kit and preparation of injectionsWe suggest that there should be designated places for storage of emergency equipment and keeping wheelchairs/trolleys and weighing scaleClean and dirty utilityWe suggest that there should be an area for dirty utility. The area should be designed in such a way that once personnel and material enter this area, they do not have to come back to the clean dialysis area.

Other areas (applicable to independent units. In case such facilities are available in any other area of the hospital, the HD unit can share it):

Minor operation room/procedure room (120 sq.ft desirable) – We suggest that all activities not directly related to a HD procedure including creation (not puncture) of vascular access be done in a separate procedure roomThe following equipment are suggested for the procedure room:

Operating tableOperating lightsUltrasound: Preferably with a vascular probe for localizing and puncturing central veinsC-Arm imaging system (optional)Instrument storage facility.

Consultation/examination room (120 sq. ft. desirable) for examining patientsRecovery room (to manage postdialysis complications such as bleeding from access-site hypertension [HTN] and hypotension)Administrative areas – Multiuse rooms for meetings, health education, and clerical work and to store files and other documents of the unitArea for staffDoctors' roomCommon rooms (with toilet) for staff – male and femalePharmacyWe recommend provision of sufficient designated area for the stay and relaxation of attendants accompanying the patients. Patients waiting to go on dialysis and those who have recently completed dialysis could also utilize the same areaAudio–visual entertainment, educational booklets, and magazines for the patients (desirable) may be provided within this areaWe recommend that there should be adequate number of toilets for patients and accompanying persons, preferably separately for males and femalesWe suggest that the waiting area be connected by some form of communication with the dialysis unit in order that communication can be carried out without the need for physical movement between the two areasWe recommend that if the MHD unit is a part of a general hospital setup, then the areas for reception, waiting, records, consulting room, and storage could be shared. The above recommendations have been summarized in [Table 1].[Figure 5]{Table 1}{Figure 5}

 Power Supply and Plumbing



We recommend stable and continuous voltage supply. The supply should be stable and uninterrupted, of pure sine wave, and both voltage and frequency regulated. The use of electrical surge protectors is recommended to protect dialysis machines' electronicsA minimum of six plugs per station is recommendedOnline uninterrupted power supply (UPS) with at least 30-min backup is suggested. The power capacity of the UPS should be able to support all functions of the dialysis machine and water treatment system if located in the same areaIn units having >25 machines, we suggest that 1 UPS backup unit is capable of supplying 20 to 25 machinesWe recommend a generator of adequate capacity where power supply is erraticWe recommend the use of SS-grade 316 or medical-grade PVC for treated water pipelines.

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We recommend that the area should be brightly lit to facilitate the performance of procedures. If possible, provision should be made for dimming the lighting.

 Others



We recommend that there should be an established system for record keeping. We suggest the use of an electronic system for patient as well as unit records. The records system should have adequate security to ensure the protection of privacy of the patients.

We recommend that all statutory precautions are taken against fire. Fire escapes should be clearly visible.

N.B. Dialysis machines may be kept in two rooms in the ratio of either 20/80 or 50/50, with independent water treatment and drainage facilities, as disinfection process often done in the weekends could be carried out without causing disturbance to emergency dialysis, the need of which may arise at any time.