Comments and suggestion invited from members. For any comments and suggestions, write the page number & Section of the draft and email to [email protected] SETTING UP OF HD UNIT Setting up of maintenance HD (MHD) unit is a major challenge for an uninitiated nephrologist. The purpose of this guideline is to help design a new unit. Dialysis (HD) Area We recommend that the 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 70–72°F temperatures and 55– 60% humidity. 2. Each machine should be in the centre of sufficient area [Figure 1] to allow easy movementof 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 warning sounds from the machines for taking appropriate timely actions. Nursing station should have enough space for on duty nurses/technicians working;a computer terminal, and working desk/bench. There should be a cupboard /space to store emergency medicines/disposables 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 2 dialysis personnel. There should be adequate clearance space between dialysis stations. 4. Head end of each bed should have stable electrical supply with at least 6 sockets of 5/15 amps, oxygen and vacuum outlet, treated water inlet, and drainage.The wires from electric sockets should be in such a way that they do not pose a threat to the patient or staff during the 1 | P a g e dialysis. The minimum door opening width (desirable-1.12m)should be sufficient for easy transport of patient on trolleys /wheel chair to the dialysis station. The minimum ceiling height shall be 2.4-2.7metres 5. 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 dialyse patients with known blood-borne pathogens shall have at least 2 separate rooms to use for those patients as follows For HBV patients rooms/linen shall be colour coded with blue. For HCV patients rooms/linen shall be colour coded with yellow. This should not be considered a substitute for universal precautions observed in the dialysis facility 6. Facilities for hand washing and alcohol-based hand rub/ sterilent dispensers should be available in all patient areas, and should be easily accessible. Hand washing basins (an area of the basin 1 sq.m) usually made of porcelain, stainless steel, or solid surface materials should also be available in the facility 7.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 unitdaily . All surfaces should be free from seams and creases which may harbour 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 may be chosen in such a way that it is easy to maintain, readily cleanable and resistant to disinfection procedures. Epoxy flooring is desirable Skirting should be coved to prevent dirt congregating in corners. It should extend all the way up the wall upto 20 cm or upto30 cm (desirable) to protect all potentially wet areas from infiltration. 2 | P a g e 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 fall out 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 andare easier to clean and non-flammable. Washable paint should be applied for all walls and ceilings Natural light contributes to a sense of wellbeing, assists orientation to building locations and improves service outcomes. The use of natural light should be maximized throughout the unit Dialyzer Reprocessing Area 1. We recommend an independent area for reprocessing the dialyzers. This should have a workbench and sink withside-board and drainage. The workbench should have separately marked treated as well as untreated water supplies at 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 labelling) of the dialyzer. We suggest that the space should be sufficient for two persons working simultaneously. 2. We suggest that reprocessing area should be equipped with a hood and an exhaust fan. 3. 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. 4. We recommend that 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. 5. We recommend the use of 316 SS, or medical grade polyvinyl chloride (PVC) for fittings. 6. We recommend a physically separate reprocessing areafor processing dialyzers of patients with hepatitis B virus(HBV) and hepatitis C virus (HCV) infection. 7. We suggest that space should also be provided for dialyzer reprocessing machine(s). 8. We recommend stabilized electrical supply and drainage for the work bench. DRAINAGE SYSTEM 3 | P a g e Services that facilitate the drainage of waste fluids from the haemodialysis machines must be ventilated to prevent condensation and the subsequent growth of mould. This fact should be kept in mind when designing covers or screens for the drainage systems. Drainage 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. 6. We recommend that all drainage should be connected directly to the main drainage line in a straight line without bends or blind loops.(please refer to the photographs below) . STORAGE AREAS 1. 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, IV fluids, and other consumables. It should also have space for stationery, linen and records. The wet storage is for reprocessed dialyzers and tubings. 2. We recommend a separate area with a workbench for preparation of sterile trays for dialysis start-up kit, and preparation of injections. 3. We suggest that there should be designated places for storage of emergency equipment, keeping wheelchairs/trolleys and weighing scale. 4. Clean and dirty utility. 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 independant 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(120sq.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. 4 | P a g e The following equipments are suggested for the procedure room: • Operating table • Operating lights • Ultrasound: preferably with a vascular probe for localizing and puncturing central veins • C-Arm imaging system (optional) • Instrument storage facility 2. Consultation/Examination room(120sq.ft.desirable): for examining patients 3. Recovery Room (to manage post dialysis complications like bleeding from access site hypertension, hypotension etc.) 4. Administrative areas -Multiuse rooms for meetings, and health education,clerical work and to store files and other documents of the unit 5.Area for staff Doctors’ room 6.Common rooms (with toilet)– staff-male 7- female 8.Pharmacy 9.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. Audio-visual entertainment, educational booklets and magazines for the patients(desirable) may be provided with in this area. We recommend that there should be adequate number of toilets for patients and accompanying persons, preferably separate for males and females We recommend that if the MHD unit is a part of a generalhospital set-up then the areas for reception, waiting,records, consulting room, and storage could be shared. 5 | P a g e POWER SUPPLY AND PLUMBING 1. We recommend stable and continuousvoltage supply. The supply should be stable and uninterrupted, pure sinewave, both voltage and frequency regulated. The use of electrical surge protectors is recommended to protect dialysis machine’s electronics.