Dialysis Centre

8/8/2019 Dialysis Centre

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ASSIGNMENT -3

DIALYSIS CENTRE

SUBMITTED TO SUBMITTED BY

SORABH LAKHANPAL SIR GAURAV OJHA

Prof.(LPU) 1907A02

MBA(HHM)


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Overview and organization:

Overview of dialysis unit

In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaningthrough, 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 (previouslychronic 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 renaltransplant can be performed, or sometimes as the only supportive measure in those for

whom a transplant would be inappropriate.


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Haemodylysis machine

The kidneys have important roles in maintaining health.

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

y Those acidic metabolism end products that the body cannot get rid of via respiration are

also excreted through the kidneys.y The kidneys also function as a part of the endocrine system producing erythropoietin and

1,25-dihydroxycholecalciferol (calcitriol).

y Erythropoietin is involved in the production of red blood cells and calcitriol plays a rolein 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 thesefunctions through diffusion (waste removal) and ultrafiltration (fluid removal).

Principle

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across asemi-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 lowconcentration. 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 ofmaterial 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 bloodcells, large proteins).

The two main types ofdialysis,

1. Hemodialysis (HD)

2. Peritoneal dialysis (PD),

There are two primary types ofdialysis and another two types in addition, they are

namely hemodialysis , peritoneal dialysis, and thirdly investigational type and finallyintestinal dialysis.


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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 theoutside 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 gradientcauses water and dissolved solutes to move from blood to dialysate, and allows the removal ofseveral 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 theUS 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.


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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 peritonealmembrane acts as a semipermeable membrane.

The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that linesand 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 outthrough 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 ofglucose, 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 ofremoval 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 fixedschedule 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 membranerapidly, "dragging" along with it many dissolved substances, importantly ones with large


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molecular weights, which are cleared less well by hemodialysis. Salts and water lost from theblood 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 severalmethods 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 onseveral factors. These can be divided into acute or chronic indications.

y Indications for dialysis in the patient with acute kidney injury are:

1. Metabolic acidosis in situations where correction with sodium bicarbonate isimpractical or may result in fluid overload.

2. Electrolyte abnormality, such as severe hyperkalemia, especially when combinedwith AKI.

3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, oraspirin.

4. Fluid overload not expected to respond to treatment with diuretics.5. Complications of uremia, such as pericarditis, encephalopathy, or gastrointestinal

bleeding.y

Chronic indications for dialysis:1. Symptomatic renal failure2. 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 theserelationships are described below.

y Staff-base/patient-treatment stations: staff at the staff base must be able to see andhear patients in the dialysis area. A balance should be struck between providing adequate

observation for staff and privacy for patients.


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y Patient-treatment stations/utilities and equipment storage: utility areas andequipment storage and maintenance areas should be located to provide ease of access to

patient-treatment stations.y Patient-treatment stations/staff areas: staff rest rooms and offices should be separate

from, but close to, patient-treatment stations.y

Treatment station/treatment station: the layout of the multi-station dialysis area shouldenable patients to talk to one another, and nurses to call for assistance from one station toanother, 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 of900 mm between stations is required in this guidance).

StaffingandOrganisation

Doctors

y The physician in charge of a dialysis centre must be registered with theSingapore Medical Councils Register of Specialists in Renal Medicine andhave experience in Nephrology in a recognised centre, including at least 1

years experience in dialysis.

y The physician in charge of the dialysis centre must practise holistic medicineand be responsible for overall management of the patients in the Centre. Theresponsibility 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).y 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 ofmedical condition and co-morbids.

(b) that the attending renal physician shall clearly recommend to the endstagerenal failure patient the modality that is best suited to him. This

shall be based on the patients 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 ofdialysis modality, after receiving adequate counselling from his renalphysician on the different modalities available and the modality that is

most appropriate for the patients need

y There shall be a 1:150 doctor-dialysis patient ratio at any one time, for totalpatient care, which includes work in hospital and work related to vascularaccess problems and medical complications.


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y There shall be a documented Quality Assurance Programme (QAP) to ensurequality patient care through objective and systematic monitoring, evaluation,

identification of problems and action to improve the level and appropriatenessof 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

y 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 yearsexperience 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.y 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 dialysispatients per dialysis shift in a nurse-assisted dialysis facility

y The nurse in charge shall possess appropriate training in handlingresuscitation equipment and dealing with cardiac emergencies. All nursingstaff shall have undergone formal certified training in cardiopulmonary

resuscitation. The certified training in basic life support shall be current andup-to-date.

OTHERS

Lab technicians

Ward boysTrainers

Clericals

Planningand design considerationsThe 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 asafer 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


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dialysis machine is of critical importance in this context. This zone of stagnation represents theideal 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 devicefeeding directly the dialysis machine thereby preventing water stagnation.

c) Automatic disinfection of the equipment. Hemodialysis machine is clearly identified as thesource of bacteria proliferation. The degree of contamination depends on the complexity ofhydraulic circuit, the dialysate content, the presence of stagnation zones and dead spaces, the

frequency and the efficacy of disinfection procedures.

y Location

The unit should preferably be located on the ground floor and, ideally, have its own dedicatedentrance. (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 andpassage of patients, especially at shift changes, during which congestion might occur if only a

shared entrance is available.

y Designy 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-transportservices including taxis or ambulance.

y Where possible, therefore, satellite units should be located near public transport routes. Itis also important to provide dropping-off points for ambulances and designated patientscar-parking spaces immediately adjacent to the unit.

y 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.

y The entrance to the unit should be covered so that patients transferring from a vehicleinto the unit are not exposed to the weather.

y The entrance should be easily accessible to people using wheelchairs or walking aids.

y There should be access for large vehicles so that they can off-load at the various storagefacilities without disturbing the units 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 clinicalwaste 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 requirecorrect disposal.

Access to storage facilities, technical support facilities, workshops and the plantroom must be

considered and adequate provision must be made:


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y access from the outside of the building should be via separate, lockable double doors, andsecurity camera surveillance should be considered;

y attention should be paid to access to allow removal or replacement of the units and fordelivery of heavy goods such as salt for the water softeners;

y 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

y


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LOCATION AND DESIGN OF DIALYSIS UNIT

Spacerecquirement

y A room for nephrologist

y A room for assistant manager

y Treatment room for non Hepatitis patients with enough space for 6 beds. (24 x 20)

y Treatment room for Hepatitis C+ve patients with enough space for 4 beds (24 x 20)

y A nursing station (16 x 16)

y A room for the water filtration plant (10 x 10)

y

A waiting area for relatives of the patients (16 x 12)

y Separate staff and patient toilet facilities

y A room for emergencies

y Intensive care room

y 24 hour medical cover for the Dialysis Centre

y Access to Pathology laboratory with specific facilities for kidney patient blood chemistry

y Hospital electrical backup generator to ensure machines run during electrical failures.

Infection Control Practices

General Precautions

y Standard Precautions1 shall be used on all patients regardless of whether theHepatitis B, Hepatitis C and HIV status is known. During dialysis, blood isoften spilt. It is therefore vital for staff to be adequately protected using

impervious gowns/aprons, gloves and eye protection

y Disposable gloves shall be worn by staff members for personal protection


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when performing procedures which are potentially biohazardous. Staff shallalso wash their hands and use a fresh pair of gloves with each patient to

prevent cross-transmission. Gloves shall be removed when such proceduresare interrupted (e.g. answering telephone calls, called away for other duties)

to prevent contamination of surfaces uninvolved with the aforesaid procedure.

y

Hepatitis B vaccination of all staff who have contact with blood and body fluidsis strongly recommended. This applies also to helpers of self-care dialysispatients. Routine screening of staff for anti-HCV may be done where necessary.

y Screening for Methicillin Resistant Staphylococcus Aureus nasal carriersamong staff, patients and helpers of self care dialysis patients shall be done inthe context of an outbreak in the Centre and appropriate action taken to track

carriers and to prevent infection of patients.

y Blood samples for analysis shall be carefully taken, put in plastic vials andthen placed in separate plastic bags. Individual vials shall be labelled and

carefully checked after each blood sample is taken.

y Only blood and blood products screened and found negative for HBsAg, anti-

HCV and HIV shall be given.y Draining, disinfection and rinsing procedures shall be performed after each

dialysis. If a blood leak occurs in a recirculating system, the usual rinsing anddisinfection procedure shall be performed twice before the system is used on

a different patient.

Dialysis Centres Responsibility to Patients

y The dialysis centre is responsible for the medical care of the patients includingthe management of complications arising from dialysis and end stage renalfailure.

y

The physician in charge must ensure adequate monitoring of patients duringdialysis, and subsequent outpatient aftercare.

y The dialysis centre is responsible for registering all suitable patients forcadaveric renal transplantation

Safety

y 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

y

All deaths occurring whilst on dialysis or as a consequence of dialysis or anyprocedure related to dialysis must be reported immediately to the main head.

Dialysis Centre

Documents

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