Building a Dialysis Center

Building a Dialysis Center     By Gary Heathcote, AIA, NCARB  

A dialysis center is a lifeline for patients with final stages of renal failure, also known as kidney failure. The patient’s kidneys are not able to perform the function of removing toxins and disposing of excess water through the normal urination process. There usually is a small percentage of normal functions of the kidney, somewhere around 10%. The rest of the process must be done through dialysis.
  The Kidneys have important roles in maintaining normal health. When healthy, the kidneys maintain the body’s internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium and sulfate). ]1]  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 calcitriol. Erythropoietin is involved in the production of red blood cells and cacitriol plays a role in bone formation [3] 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). [3] 
  There are two types of dialysis available Hemodialysis and Peritoneal dialysis..  Hemodialysis circulates the patient’s blood through a chemical and filtration system with a dialysis machine. This method is performed either in a medical facility or can be done at home. The patient has either a catheter or a permanent site for needles that exchange the blood. The catheter is usually a temporary thing until the patient has a permanent site for exchange. The typical treatment time is 3 hours, three times per week.  Peritoneal dialysis is a different method that uses the body as a filtration unit through the stomach. This method can take between 10 hrs to 12 hrs per day. It is a method that can be done in the home. It requires strict guidelines to be followed by the patient making this method a bit more difficult to be done safely

 The Design of Dialysis Centers

The focus of this article is to provide basic information regarding the Architectural Design and needs of a dialysis center. There is no attempt to provide medical or business information here.

Dialysis centers can be a part of a hospital. All hospitals have a need to provide dialysis to their patients. Typically the patient is given treatment in the patient room. However if the patient is mobile there may be a dialysis center in the hospital. Such a center can serve outpatient needs as well as inpatient needs.

Other dialysis centers can be independent units or part of a larger patient care center.

Exterior Drop Off Area

The independent dialysis center design should have a patient drop off area that is weather protected and well lit. It is common for patients to arrive in wheel chairs or they have some difficulty walking. Some patients arrive in an ambulance transport and are on a gurney. There is a need in that area to accommodate emergency personnel such as EMT or ambulance or fire department crews. There are emergencies with the patients because of the acute nature of their illness. They are susceptible to having respiratory and heart problems as well.

Lobby Space

Just inside the front doors should be a lobby space. In cold weather areas the lobby space should be protected by a transitional space as the patients may have to wait awhile either for treatment or for transportation. Some patients are ambulatory and drive themselves to and from the dialysis center. The waiting area needs to be well lit and spacious for the waiting patients. There should be seats and plenty of space for wheel chairs. Just off the lobby there should be an accessible toilet room. Many facilities have a television in the lobby to keep the waiting patients occupied. In the lobby there should be a receptionist to assist with scheduling and assisting patients to the treatment area.

Patient Treatment Room

Adjacent to the lobby is the patient treatment area. Directly inside of the treatment area is a weight scale to weigh the patients prior to treatment. The weight is taken before and after treatment to determine how much water weight has been removed from the patient. This scale should be designed with handrails to assist the frail patients and to accommodate wheel chair patients to be weighed in their chairs. The treatment area is usually a large room with treatment stations along the perimeter. The nurse’s stations are to have a central location to observe all patient stations at an easy glance. Patients need constant observation. Within a few minutes time patients can develop a problem due to the serious nature of their illness. There are various alarms on the dialysis machines that have audio alert systems and the staff monitor them regularly. Also, the patient is susceptible to having instant and severe leg cramping. This is another reason why the staff needs to visually see that the patient is in distress. In addition, the patients should have an emergency call button for when they are having a problem. Staff often will discuss with the patients how well they are feeling. The blood pressure on each patient is generally checked each ½ hour automatically. It is registered directly on the dialysis machine. Patients change their blood pressure as a part of this process. During the removal of water and the filtering of the blood the heart rate can go too high and often it can go too low. This is equalized by how much saline is injected into the patient through the machine.

Adjacent to the treatment areas there should be storage cabinets that are within easy reach of staff to obtain gauze, tape, needles, protective gloves, masks, gowns, dialysis filters, tubing for the machine and other supplies. The sink tops should have should have sinks everywhere as the staff needs to wash their hands frequently. The sinks should be well distributed in the patient treatment area so that staff with use them often allowing sanitary procedures for hand washing.  There should be multiple eye wash fixtures at most sinks. Sanitizing foam dispensers should be well distributed throughout the treatment area. Glove dispensers should be located in all of those areas. Computer stations are needed for staff to input patient data right at the patient treatment area. The data on the dialysis machines needs to be entered in the patient records right at the machine.

There are also patient records kept in locked cabinets for the Nephrologist to

review the progress of patients. All surfaces of floors, walls and cabinets need to be washable and capable of being sanitized. Patients can bleed after treatments and create a biohazard mess at times. A janitorial closet needs to be directly adjacent to the area. In addition to blood other dialyzing fluids can leak onto the floor creating a slippery condition. Floor surfaces need to be slip resistant. A space next to the main nurse’s station needs to have area for a resuscitation “Crash Cart”.

Patient Treatment Stations

There are two types of patient stations for Hemodialysis. The most common is the treatment chair. In some cases a bed is supplied to the patients. In some facilities there are isolation rooms for those patients that might have special problems or needs. The isolation room needs to have sliding glass doors that allow visibility to the patient at all times.

Dialysis Patient Stations

The chair type patient station has several components. The chair itself needs to have hinged components for easy cleaning. The chair finish material should be washable. There are times when blood gets on the chair. This can happen with the removal of the needles, and occasionally a needle location will bleed without the patient or nurse noticing a large quantity of blood. The patients may also vomit as a result of built-up toxins in their stomach. The chair also should be able to recline and have a foot and leg support. Typically there is a flat screen television hooked to an armature so the patient can watch television. The regular amount of time for most patients is a 3 hour treatment. Television is a great distraction. Patients generally bring headphones so that the sound of their television is private to them. Having a Wi-fi service for laptop computers is also needed.  
 

Typical Dialysis Machine next to patient

The dialysis machine is directly to the left or right of the patient. Each time a patient is hooked up to the machine new tubes for blood transfer is installed along with a new filter. The nurse hooks up the patient with large scale needles or attaches to catheters. If there is a permanent access it is modified and readied by a vascular surgeon. This allows for best flow of blood with the patient. The technician or nurse will need to have close access to tapes and gauze to hold the tubing and needles in place.  Directly adjacent to the dialysis machine is a bio waste container which should have a foot pedal so the tech does not need to touch it. There is also a sharps  needle disposal container to dispose of the needles after treatment. Some patients need oxygen during treatment for a variety of reasons. Oxygen generators should be able to be plugged into standard electrical outlets. It is not uncommon for the patient to have water in his/her lungs as a result of fluid buildup. Many patients need a back counter to store bags that they brought with blankets and other things they need during the dialysis. Care should be taken to not have air-conditioning blow directly on to the patients while getting treatment. Directly adjacent to the patient treatment area there needs to be a patient restroom. It is important because the patients are sitting still for 3 hours of treatment without breaks and often need to use a restroom after the treatment is completed.

Exam Rooms

Generally there are one to two private exam rooms for patient review and other tests that may need to be performed. These exam rooms have a sink and an exam table. These rooms must be wheelchair accessible.

Conference Room

A small conference room is needed for patient consultations and staff meetings.

Physician office

A private office is needed for a physician or a shared office with visiting physicians.

Dietician Office

An integral part of patient treatment is the monitoring of blood tests, weight gain and the diets of patients. A renal dietician meets with patients on a regular basis to review various results of renal health and to make changes in the patient’s diet routine and monitor various medications. The dietician needs an office to review records and ready his recommendations for the patient interviews. Records need to be in locked cabinets for patient confidentiality.

Billing office

Generally there are several work stations for billing personnel. Insurance coding is a primary activity for keeping the cash flow of the dialysis facility. The size and number of workstations will depend the size and patient load of the facility.

Administrator’s Office

There should be a private office for the facility administrator. This office should be in direct connection to the patient treatment area.

Social Worker’s Office

The Social Worker is a representative that works with the patient to answer many questions regarding dialysis and to help the patient understand their insurance or governmental issues while receiving dialysis. This office is usually small because most of the interaction is either in the conference room or at the treatment chair.

Training Room

A training room should be for both patients and staff. Home dialysis training can be a part of the entire program. Audio visual equipment and computer work station should be included.

Staff Break Room

The staff break room should accommodate several employees at once. It should include a kitchen table, refrigerator, ice dispenser, sink, hot and cold water dispenser, counter space, coffee machine and other snack machines or soda machines. An adjacent outside patio is also nice to have.

Ultra water purification Plant

The water used for dialysis is specifically prepared by an onsite water purification plant. This water is often referred to as RO water or reverse osmosis water.  City water is used for the plant. It is then processed to remove particulates, chorine, minerals and other chemicals present.  Bacteria and other disease micro organisms are filtered through a .05 micron filter membrane at the end of the process. There are 3 types of water that are used in the process of making RO water; Bicarbonate water and IV Saline bags.  The quality of the water is critical to the patient. It has been shown that mortality rates in End Stage Renal patients can be affected by the quality of the process. The design of the plant should be planned by an experienced engineering firm that specializes in dialysis water plants. The whole system needs to be constantly monitored and cleaned on a regular basis. The water system includes a loop piping system that goes to each patient dialysis station. The water plant room should be located close to the patient treatment area. There should be reduced amount of turns in the piping as these are areas for bacteria to build up in the piping. Tests on the water quality are done on a daily basis.

The final dialysate solution has a bicarbonate additive and other chemicals as well that are added to the water after it is filtered. These are attached directly into the patient dialyzer filter unit. The concentration of the additives needs to be carefully monitored.  In addition, there is a second fluid, acetic acid dialysate. This acid is mixed in the water that is generated from the filtration system to be used in the dialysis machine into the patient blood filter.

Emergency Generator

A standby emergency generator is a good idea, but not a requirement. The generator should be operational so that patients can be unhooked and their blood returned to them. Otherwise the technical staff will need to hand crank the blood back into the patient manually. In some emergencies this can take too much time.

Repair Shop-Equipment Maintenance Room

The repair shop handles dialysis machines repairs and television repairs. The technician may be part-time or full-time.

Machine Storage Room

Dialysis machines that are ready for use and serve as backup units are stored in this room. A clean environment and sanitary surfaces are important. The machines should be ready to be moved at a moments notice to a patient treatment area.

Medical Storage Area

There is a considerable storage area needed for all supplies for the dialysis unit. If the center is in an area that has difficulty receiving supplies there may need to be storage for up to 3 months of operations.

Fluid Store Room

Fluids such as IV saline solutions are stored and are used each day. Understanding of the quantities that would be stored is important.

Bio waste storage area

The bio waste storage area is a room that keeps bio waste until it is picked up by a specialized disposal company. This room will keep all bio waste and needles in containers. The room’s surfaces should be all washable and sanitary.

Clean Linen area

If the facility uses beds as part of the treatment for certain patients, a clean linen storage area will be needed. It is assumed that an outside linen company will pick up and deliver linens for the beds. If not, then an on-site laundry will need to be added to the facility.

Dirty Linen StorageIf beds are used, a separate dirty linen room will need to be included; all surfaces in the room to be easily cleaned.

Janitor/Cleaning Room

The janitorial room is more than a janitor closet. It will need to include sanitizing supplies, mop sink, vacuum cleaners, wet/dry vacuum and other materials.

Electrical/Telephone Room

The electrical room needs to contain the main switch gear for the facility including main sub-panels. The room should contain a telephone connection back board. If the facility has cable TV or satellite TV, they are connected through this room. A separate outside entrance door is important for this room.

Computer Room

The computer room should have separate air conditioning controls with after hours air conditioning. The server units for all data should be in this room. Telephone server racks may be needed. Wi-fi system would be installed there this would serve patients and staff. The patients can have a laptop or other device to “surf” the web during treatments which the wifi would be helpfull. Television cable distribution for individual patient treatment areas so that each patient can have a television. The television is a great distraction for a patient being hooked up to the dialyser for 3 or more hours.

Plant air conditioner Room

There are multiple choices in HVAC design and the need for a room dedicated to a system may or may not be needed. Some of the choices may come from the climate zone the project is in.

When constructing a new facility it is important to involve qualified professionals that are capable of instructing others to provide a state of the art facility. Contractors need quality control throughout the construction process. In some countries quality of construction is a big problem. The quality of life for a renal patient starts with the quality of the facilities.

1. Internet Wikipedia “Dialysis” , September 10, 2011 
2. Brundage D. Renal Disorders. St. Louis, MO: Mosby; 1992
3. "Atlas of Diseases of the Kidney, Volume 5, Principles of Dialysis: Diffusion, Convection, and Dialysis Machines". http://www.kidneyatlas.org/book5/adk5-01.ccc.QXD.pdf. Retrieved 2011-09-02

 

Additional References

Pontoriero G, Tetta C, Wratten ML, Locatelli F. Design and Quality Assurance of New Dialysis Centers. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2011 Nov 19];12:413-9. Available from: http://www.sjkdt.org/text.asp?2001/12/3/413/33566

Water Filtration and Distribution Systems

Internet article

http://www.vdt.org/downloads/V31N10~1.PDF

Philip Andrysiak,BS,MBA, CHT; Philip M. Varughese,BS, CHT

“Design requirements for Water Distribution System in a Hemodialysis Center”

South Carolina Renal Dialysis Licensing Facility Regulation 61-97

Comparison to other basic needs of other states, countries or governing authorities similar.   http://www.scdhec.gov/administration/regs/docs/61-97.pdf

National Kidney Federation of the UK

Article on new dialysis centers

http://www.kidney.org.uk/campaigns/Dialysis/dialysis-centre-spec.html