ASSIGNMENT -3

DIALYSIS CENTRE

SUBMITTED TO SUBMITTED BY
SORABH LAKHANPAL SIR GAURAV OJHA

Prof.(LPU) 1907A02

MBA(HHM)

Overview and organization:

Overview of dialysis unit

 In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaning

through, and "lysis", meaning loosening) is primarily used to provide an artificial
replacement for lost kidney function in people with renal failure.

 Dialysis may be used for those with an acute disturbance in kidney function (acute
kidney injury, previously acute renal failure) or for those with progressive but chronically
worsening kidney function a state known as chronic kidney disease stage 5 (previously
chronic renal failure or end-stage kidney disease).

 The latter form may develop over months or years, but in contrast to acute kidney injury
is not usually reversible, and dialysis is regarded as a "holding measure" until a renal
transplant can be performed, or sometimes as the only supportive measure in those for
whom a transplant would be inappropriate.
Haemodylysis machine

 The kidneys have important roles in maintaining health.

 the kidneys maintain the body's internal equilibrium of water and minerals (sodium,
potassium, chloride, calcium, phosphorus, magnesium, sulfate).

 Those acidic metabolism end products that the body cannot get rid of via respiration are
also excreted through the kidneys.

 The kidneys also function as a part of the endocrine system producing erythropoietin and
1,25-dihydroxycholecalciferol (calcitriol).

 Erythropoietin is involved in the production of red blood cells and calcitriol plays a role
in bone formation.

Dialysis is an imperfect treatment to replace kidney function because it does not correct
the endocrine functions of the kidney. Dialysis treatments replace some of these
functions through diffusion (waste removal) and ultrafiltration (fluid removal).

Principle

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across a
semi-permeable membrane. Diffusion describes a property of substances in water. Substances in
water tend to move from an area where they are in a high concentration to an area of low
concentration. Blood flows by one side of a semi-permeable membrane, and a dialysate, or
special dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of
material that contains various sized holes, or pores. Smaller solutes and fluid pass through the
membrane, but the membrane blocks the passage of larger substances (for example, red blood
cells, large proteins).

The two main types of dialysis,

1. Hemodialysis (HD)

2. Peritoneal dialysis (PD),

 There are two primary types of dialysis and another two types in addition, they are
namely hemodialysis , peritoneal dialysis, and thirdly investigational type and finally
intestinal dialysis.

Hemodialysis

In hemodialysis, the patient's blood is then pumped through the blood compartment of a dialyzer,
exposing it to a partially permeable membrane.

The dialyzer is composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the
semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the
outside the fibers, and water and wastes move between these two solutions.

The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by
increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by
applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient
causes water and dissolved solutes to move from blood to dialysate, and allows the removal of
several litres of excess fluid during a typical 3 to 5 hour treatment.

In the US, hemodialysis treatments are typically given in a dialysis center three times per week
(due in the US to Medicare reimbursement rules); however, as of 2007 over 2,500 people in the
US are dialyzing at home more frequently for various treatment lengths.

Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours.
These frequent long treatments are often done at home, while sleeping but home dialysis is a
flexible modality and schedules can be changed day to day, week to week. In general, studies
have shown that both increased treatment length and frequency are clinically beneficial.
Peritoneal dialysis

In peritoneal dialysis, a sterile solution containing glucose is run through a tube into the
peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal
membrane acts as a semipermeable membrane.

The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines
and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs (stomach,
spleen, liver, and intestines).

The dialysate is left there for a period of time to absorb waste products, and then it is drained out
through the tube and discarded. This cycle or "exchange" is normally repeated 4-5 times during
the day, (sometimes more often overnight with an automated system).

Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of
glucose, and the resulting osmotic pressure causes fluid to move from the blood into the
dialysate.

As a result, more fluid is drained than was instilled. Peritoneal dialysis is less efficient than
hemodialysis, but because it is carried out for a longer period of time the net effect in terms of
removal of waste products and of salt and water are similar to hemodialysis.

Peritoneal dialysis is carried out at home by the patient. Although support is helpful, it is not
essential. It does free patients from the routine of having to go to a dialysis clinic on a fixed
schedule multiple times per week, and it can be done while travelling with a minimum of
specialized equipment.

Hemofiltration

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle.

The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A
pressure gradient is applied; as a result, water moves across the very permeable membrane
rapidly, "dragging" along with it many dissolved substances, importantly ones with large
molecular weights, which are cleared less well by hemodialysis. Salts and water lost from the
blood during this process are replaced with a "substitution fluid" that is infused into the
extracorporeal circuit during the treatment. Hemodiafiltration is a term used to describe several
methods of combining hemodialysis and hemofiltration in one process.

Intestinal dialysis

In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is
digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is
eliminated in fecal waste. An alternative approach utilizes the ingestion of 1 to 1.5 liters of non-
absorbable solutions of polyethylene glycol or mannitol every fourth hour.

Starting indications

The decision to initiate dialysis or hemofiltration in patients with renal failure depends on
several factors. These can be divided into acute or chronic indications.

 Indications for dialysis in the patient with acute kidney injury are:
1. Metabolic acidosis in situations where correction with sodium bicarbonate is
impractical or may result in fluid overload.
2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined
with AKI.
3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or
aspirin.
4. Fluid overload not expected to respond to treatment with diuretics.
5. Complications of uremia, such as pericarditis, encephalopathy, or gastrointestinal
bleeding.
 Chronic indications for dialysis:
1. Symptomatic renal failure
2. Low glomerular filtration rate (GFR) (RRT often recommended to commence at a
GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier.
3. Difficulty in medically controlling fluid overload, serum potassium, and/or serum
phosphorus when the GFR is very low

Functional relationships

A satellite dialysis unit contains three zones: patient-treatment stations, associated support
facilities, and staff areas. There are key functional relationships both within and between these
zones which should be taken into account when designing accommodation. Details of these
relationships are described below.

 Staff-base/patient-treatment stations: staff at the staff base must be able to see and
hear patients in the dialysis area. A balance should be struck between providing adequate
observation for staff and privacy for patients.
  Patient-treatment stations/utilities and equipment storage: utility areas and
equipment storage and maintenance areas should be located to provide ease of access to
patient-treatment stations.
 Patient-treatment stations/staff areas: staff rest rooms and offices should be separate
from, but close to, patient-treatment stations.
 Treatment station/treatment station: the layout of the multi-station dialysis area should
enable patients to talk to one another, and nurses to call for assistance from one station to
another, but care must be taken to allow sufficient space between dialysis stations to
prevent the risk of cross-infection and for a degree of privacy (a preferred minimum of
900 mm between stations is required in this guidance).

Staffing and Organisation

Doctors

 The physician in charge of a dialysis centre must be registered with the

Singapore Medical Council’s Register of Specialists in Renal Medicine and
have experience in Nephrology in a recognised centre, including at least 1
year’s experience in dialysis.

 The physician in charge of the dialysis centre must practise holistic medicine
and be responsible for overall management of the patients in the Centre. The
responsibility of the physician in charge of the centre must cover dialysis
access care (perform or arrange for insertion of vascular catheters, arrange
for creation of AVF and insertion of tenckhoff catheters).
 The physician in charge of the dialysis centre shall in the management of
patients, ensure the following:
(a) that the need for dialysis treatment and choice of modality shall be
based on sound clinical principles and a thorough clinical evaluation of
medical condition and co-morbids.
(b) that the attending renal physician shall clearly recommend to the endstage
renal failure patient the modality that is best suited to him. This
shall be based on the patient’s renal and other co-morbid conditions,
ability to comply with treatment, available family support and other
social factors.
(c) that the patient shall be allowed to make a fully-informed choice of
dialysis modality, after receiving adequate counselling from his renal
physician on the different modalities available and the modality that is
most appropriate for the patient’s need

 There shall be a 1:150 doctor-dialysis patient ratio at any one time, for total
patient care, which includes work in hospital and work related to vascular
access problems and medical complications.
  There shall be a documented Quality Assurance Programme (QAP) to ensure
quality patient care through objective and systematic monitoring, evaluation,
identification of problems and action to improve the level and appropriateness
of care. The QAP shall include:
(a) documented policies and procedures related to the safe conduct of all
patient care activities.
(b) documented regular reviews of the policies and procedures.
(c) documented reviews of deaths, accidents, complications and injuries
arising from dialysis treatment.

Nursing Staff

 The nurse in charge of a dialysis centre must be a qualified registered nurse:-

(a) certified in Renal Nursing (or its equivalent) and at least 2 years
experience in dialysis nursing in a dialysis unit in a major hospital,
(b) at least 3 years in an institution based/affiliated dialysis unit if they do
not have a course certificate.
 A minimum of 1 trained nurse (registered/enrolled nurse) or 1 nurse-aide with
at least 6 months training/experience in dialysis is required for every 5 dialysis
patients per dialysis shift in a nurse-assisted dialysis facility
 The nurse in charge shall possess appropriate training in handling
resuscitation equipment and dealing with cardiac emergencies. All nursing
staff shall have undergone formal certified training in cardiopulmonary
resuscitation. The certified training in basic life support shall be current and
up-to-date.

OTHERS

Lab technicians
Ward boys
Trainers
Clericals

Planning and design considerations

The design of new dialysis centres will have to take into account some absolute needs one of
which is the assurance of high microbiological quality of the dialysis fluid.

The following items are to be considered as indispensable:

a) Water treatment with reverse osmosis. A double reverse osmosis is now considered as a
safer system along the line of the "double safety" philosophy.

b) Ring "distribution" installation with circulation and continuous backflow system

upwards and two intakes for each dialysis site. Water tubing connecting device feeding the
dialysis machine is of critical importance in this context. This zone of stagnation represents the
ideal zone for proliferation and seedling media during the interdialytic period sowing regularly
the dialysis machine. It is worth the effort to design an ultrashort connecting tubing device
feeding directly the dialysis machine thereby preventing water stagnation.

c) Automatic disinfection of the equipment. Hemodialysis machine is clearly identified as the

source of bacteria proliferation. The degree of contamination depends on the complexity of
hydraulic circuit, the dialysate content, the presence of stagnation zones and dead spaces, the
frequency and the efficacy of disinfection procedures.

 Location
The unit should preferably be located on the ground floor and, ideally, have its own dedicated
entrance. (Units based away from hospital sites are likely to have dedicated entrances by nature
of their location.) Where the unit is based on a hospital site, this is to facilitate the comfort and
passage of patients, especially at shift changes, during which congestion might occur if only a
shared entrance is available.

 Design
 Many patients attending a satellite unit are likely to arrive by their own transport.
However, they may also travel to the unit by public transport or by NHS patient-transport
services including taxis or ambulance.
 Where possible, therefore, satellite units should be located near public transport routes. It
is also important to provide dropping-off points for ambulances and designated patients’
car-parking spaces immediately adjacent to the unit.
 Based on a 12-station dialysis unit, it is recommended that there is one dedicated space
for every three dialysis stations, of which one of the four should be a disabled-width bay.
 The entrance to the unit should be covered so that patients transferring from a vehicle
into the unit are not exposed to the weather.
 The entrance should be easily accessible to people using wheelchairs or walking aids.
 There should be access for large vehicles so that they can off-load at the various storage
facilities without disturbing the unit’s operation or traversing through patient or treatment
areas.

The satellite unit will require large volumes of clinical and non-clinical supplies to be delivered
and off-loaded routinely (see also 'Support/utility'). This will lead to large volumes of clinical
waste and non-clinical waste that will need to be removed daily. Thus, the eventual location of
the unit and plantroom must be considered carefully, as waste fluids in such volume require
correct disposal.

Access to storage facilities, technical support facilities, workshops and the plantroom must be
considered and adequate provision must be made:
 access from the outside of the building should be via separate, lockable double doors, and
security camera surveillance should be considered;
 attention should be paid to access to allow removal or replacement of the units and for
delivery of heavy goods such as salt for the water softeners;
 for the deliveries of goods and supplies (particularly as renal goods are delivered in bulk),
a separate – possibly remote – entrance is required, as some deliveries are impromptu and


LOCATION AND DESIGN OF DIALYSIS UNIT

Space recquirement
 A room for nephrologist
 A room for assistant manager
 Treatment room for non Hepatitis patients with enough space for 6 beds. (24’ x 20’)
 Treatment room for Hepatitis C+ve patients with enough space for 4 beds (24’ x 20’)
 A nursing station (16’ x 16’)
 A room for the water filtration plant (10’ x 10’)
 A waiting area for relatives of the patients (16’ x 12’)
 Separate staff and patient toilet facilities
 A room for emergencies
 Intensive care room
 24 hour medical cover for the Dialysis Centre
 Access to Pathology laboratory with specific facilities for kidney patient blood chemistry
 Hospital electrical backup generator to ensure machines run during electrical failures.

Infection Control Practices

General Precautions

 Standard Precautions1 shall be used on all patients regardless of whether the

Hepatitis B, Hepatitis C and HIV status is known. During dialysis, blood is
often spilt. It is therefore vital for staff to be adequately protected using
impervious gowns/aprons, gloves and eye protection
 Disposable gloves shall be worn by staff members for personal protection
when performing procedures which are potentially biohazardous. Staff shall
also wash their hands and use a fresh pair of gloves with each patient to
prevent cross-transmission. Gloves shall be removed when such procedures
are interrupted (e.g. answering telephone calls, called away for other duties)
to prevent contamination of surfaces uninvolved with the aforesaid procedure.
 Hepatitis B vaccination of all staff who have contact with blood and body fluids
is strongly recommended. This applies also to helpers of self-care dialysis
patients. Routine screening of staff for anti-HCV may be done where necessary.
 Screening for Methicillin Resistant Staphylococcus Aureus nasal carriers
among staff, patients and helpers of self care dialysis patients shall be done in
the context of an outbreak in the Centre and appropriate action taken to track
carriers and to prevent infection of patients.
 Blood samples for analysis shall be carefully taken, put in plastic vials and
then placed in separate plastic bags. Individual vials shall be labelled and
carefully checked after each blood sample is taken.
 Only blood and blood products screened and found negative for HBsAg, anti-
HCV and HIV shall be given.
 Draining, disinfection and rinsing procedures shall be performed after each
dialysis. If a blood leak occurs in a recirculating system, the usual rinsing and
disinfection procedure shall be performed twice before the system is used on
a different patient.

Dialysis Centre’s Responsibility to Patients

 The dialysis centre is responsible for the medical care of the patients including
the management of complications arising from dialysis and end stage renal
failure.
 The physician in charge must ensure adequate monitoring of patients during
dialysis, and subsequent outpatient aftercare.
 The dialysis centre is responsible for registering all suitable patients for
cadaveric renal transplantation

Safety
 There must be provision for emergency electric power supply for life-saving
equipment in case of power failure.
Fire precautions must be taken and fire escapes shall be clearly visible.

Death of Patient
 All deaths occurring whilst on dialysis or as a consequence of dialysis or any
procedure related to dialysis must be reported immediately to the main head.