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Chapter-1
Setting up of Hemodialysis Unit
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.
1. The dialysis area should be air conditioned so as
to achieve 70°F–72°F temperatures and 55%–60%
humidity
2. Each 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 privacy
3. Nursing 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/disposables
4. Floor 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
stations
5. The 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 m
6. Isolation 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:
© 2020 Indian Journal of Nephrology | Published by Wolters Kluwer - Medknow
• For hepatitis B virus (HBV) patients, rooms/linen
shall be color coded with blue
• For hepatitis C virus (HCV) patients, rooms/linen
shall be color coded with yellow
• This should not be considered a substitute for
universal precautions observed in the dialysis facility
7. 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 facility
8. The 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 pumps
9. All 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 desirable
• Skirting 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 infiltration
• Walls: Wall finishes must be scrubbable and should
be smooth and water resistant
• Ceilings: 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 pipes
• Window 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 ceilings
• Natural 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
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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.
1. We suggest that the reprocessing area should be
equipped with a hood and an exhaust fan
2. We 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 effluent
3. We 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 compartment
4. We recommend the use of a 316 SS or medical-grade
polyvinyl chloride (PVC) for fittings
5. We recommend a physically separate reprocessing area
for processing dialyzers of patients with HCV infection
6. We suggest that space should also be provided for
dialyzer reprocessing machine(s)
7. 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 [Figures 2a, 2b, 3 and 4].
Storage Areas
1. We recommend two separate storage areas: one for
new supplies (dry storage) and another for reprocessed
dialyzers (wet storage)
2. 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 records
3. The wet storage is for reprocessed dialyzers and tubings
4. We recommend a separate area with a workbench for
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preparation of sterile trays for dialysis startup kit and
preparation of injections
5. We suggest that there should be designated places
for storage of emergency equipment and keeping
wheelchairs/trolleys and weighing scale
6. Clean and dirty utility
7. We 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):
1. 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 room
2. The following equipment are suggested for the
procedure room:
a. Operating table
b. Operating lights
c. Ultrasound: Preferably with a vascular probe for
localizing and puncturing central veins
d. C-Arm imaging system (optional)
e. Instrument storage facility.
3. Consultation/examination room (120 sq. ft. desirable)
for examining patients
4. Recovery room (to manage postdialysis complications
such as bleeding from access-site hypertension [HTN]
and hypotension)
5. Administrative areas – Multiuse rooms for meetings,
health education, and clerical work and to store files
and other documents of the unit
6. Area for staff
7. Doctors’ room
8. Common rooms (with toilet) for staff – male and female
9. Pharmacy
10. We 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 area
11. Audio–visual entertainment, educational booklets, and
magazines for the patients (desirable) may be provided
within this area
12. We recommend that there should be adequate number
of toilets for patients and accompanying persons,
preferably separately for males and females
13. We 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 areas
14. We recommend that if the MHD unit is a part of a general
hospital setup, then the areas for reception, waiting, records,
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consulting room, and storage could be shared. The above

recommendations have been summarized in Table 1.

Power Supply and Plumbing

1. 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’ electronics
2. A minimum of six plugs per station is recommended
3. Online 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 area
4. In units having >25 machines, we suggest that 1
UPS backup unit is capable of supplying 20 to 25 Figure 1: Typical hemodialysis machine area. Black dots: electricity outlets,
green dots: oxygen outlet, yellow dots: vacuum outlet, blue dots: treated
machines water inlet, ash dot: drainage outlet
5. We recommend a generator of adequate capacity where
power supply is erratic
6. We recommend the use of SS-grade 316 or medical-
grade PVC for treated water pipelines.

Austenite steels make up over 70% of the total SS

production. They contain a maximum of 0.15%
carbon, a minimum of 16% chromium, and sufficient
nickel and/or manganese to retain an austenitic
structure at all temperatures from the cryogenic region
to the melting point of the alloy. The most widely used
austenite steel is the 304 grade or A2 SS (not to be
confused with A2 grade steel, also named Tool steel, a
steel). The widely used austenite steel is the 304 grade
or A2 SS. The second most common austenite steel is the
316 grade, also called marine-grade SS, used primarily
Figure 2a: Spout with appropriate elevation and gradient
for its increased resistance to corrosion.

SS does not corrode, rust, or stain with water as

ordinary steel does, but despite the name, it is not fully
stainproof. It is also called corrosion-resistant steel when
the alloy type and grade are not detailed, particularly
in the aviation industry. There are different grades and
surface finishes of SS to suit the environment the alloy
must endure. SS is used where both the properties of
steel and resistance to corrosion are required. 300
series, SSs, has an austenitic crystalline structure, which
is a face-centered cubic crystal structure.

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. Figure 2b: Push-pull connector for machine water inlet

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

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Table 1: Summary of designated areas in the dialysis unit

Designated areas
HD area [Figure 5a]
Nursing station
Dialyzer reprocessing area [Figure 5b]
Storage areas: Two separate storage
areas
Separate area for preparation of sterile
tray and dialysis startup kit/injections
Clean and dirty utility
Space for emergency equipment,
wheelchairs, trolley
Minor operation/procedure room
Examination/consultation room
Recovery room
Administrative areas [Figure 5b]
Common rooms for doctors and staff
Pharmacy (desirable)
Waiting area
AVF: Arteriovenous fistula, HD: Hemodialysis
Suggested dimensions (desirable) Functions of the space
11 ft × 10 ft Accommodate dialysis machine, chair/couch,
resuscitation equipment as and when required,
and working room for two dialysis personnel
Sufficient space for on‑duty nurses, Unobtrusive view of all patient treatment
technicians, a computer terminal, and a areas. Constant monitoring of patients and
working desk timely action in case of emergency
Sufficient space for two persons to work Reprocessing the dialyzers
simultaneously
Space should be in conformity with the Storage of disposables and consumables (dry)
size of the dialysis unit (number of dialysis Storage of reprocessed dialyzers and
performed/day) tubings (wet)
Sufficient space
Sufficient space
Sufficient space
Sufficient space (120 sq.ft.) (desirable) Insertion of dialysis catheters, AVF creation,
etc.
‑DO‑
Sufficient space To manage the complications post dialysis,
medication administrations, etc.
Sufficient space For meetings, health education clerical work,
and storage of documents
Sufficient space (with toilet) separate for
males and females
Sufficient space
Sufficient space (with toilets) in conformity For the stay and relaxation of the patients and
with the workload of the facility their attendants

Figure 3: Spout capped with aperture to accommodate machine effluent

pipe snugly

Figure 4: Conventional Drainage system

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.

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Figure 5b: Dialysis support area

Figure 5a: Typical dialysis unit

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