Renal unit design: focus on the patient

Many dialysis patients spend three or more days a week in renal units, so where they are located, and how they are designed, can impact greatly on their quality of life. KATHLEEN ARMSTRONG reports

A RENAL dialysis unit is not just another treatment centre. For many patients, it is almost like a second home – a place where they spend almost half their week, every week, and will do for the rest of their lives unless they are among the lucky few who receive a transplant.

Therefore, the design of the dialysis unit impacts greatly on the quality of life for this group of patients – patients whose quality of life is already very poor.

“Dialysis needs to be as pleasant an experience as possible – more like going to a hotel than a hospital,” says Timothy Statham, chief executive of the National Kidney Federation (NKF). “What they need are premises that take care of the small things.”

The renal unit and its patients is very much a community – that is what the unit needs to foster

This includes thinking about what might have an impact on patients as they are undergoing, or waiting for, treatment. For example, are they sitting under an air conditioning unit? Do they have adequate access to food and drink? Do they have something to do while they are undergoing dialysis?

Adequate nourishment while they are there is essential, as is access to entertainment, such as a television, radio or the internet. The introduction of Patientline, where patients were charged to use television and WiFi, was a real concern, Statham says.

“Patients are strapped to the machines for four hours, so they need something to do; to be able to watch television or use WiFi without charges. When Patientline came in, patients couldn’t afford to watch TV, and the televisions NKF had originally supplied had been dumped.”

Attention also needs to be paid to the environment in which patients wait for treatment. Many may have been on a long journey to get there, sitting in a vehicle while it picks up other patients. If the journey is delayed for any reason, they could miss their allocated dialysis slot, which means they may have to wait for a few hours for the next one. According to Statham, dialysis treatment can take up to 12 hours of a patient’s day – three or more days a week.

“It is often the stress of the experience that kills them,” Statham says. “The renal unit and its patients is very much a community – that is what the unit needs to foster.”

Where the unit is located is also important and the NKF has welcomed the development of satellite dialysis units which aim to bring dialysis closer to the patient’s home. The organisation suggests that satellite dialysis units could be set up within existing or planned community service buildings in order to help patients and carers feel more integrated in the community. In addition, it says, this may allow for other activities unrelated to the dialysis day to be incorporated with least effort. Smaller dialysis facilities at the cottage hospital and health centre level should also be considered, it advises, as part of the region’s dialysis provision strategy.”1

The location of the unit should be ‘a site that will best serve the needs of access for the majority of the renal patient population in its catchment area’. The guidance also states that a site should not be chosen because it is conveniently available or cheap because of location or lack of facilities, eg parking’.

The Government has developed a number of guidelines for the planning and design of both main and satellite renal units, which are available on the Department of Health’s Space for Health website as online manuals. They provide guidance on the location, size and layout of the units, as well as other functional and design requirements. And, perhaps more importantly, they recommend that patients should be consulted on the design of the unit and their suggestions included in any written design brief.

More specifically, the Space for Health online manual for the planning and design of a main renal dialysis unit states recommends:

  • Haemodialysis facilities should ideally be located on the ground floor on the fringe of the main renal unit and adjacent to the other areas within that unit, including peritoneal dialysis and renal outpatients, administration, transplant, technical services and the renal inpatient ward
  • It should have covered access to other hospital departments, particularly radiology, cardiology, urology, diabetology and the general wards
  • The area set aside for dialysis should consist of dialysis stations in increments of three
  • There should be sufficient space allowed for chairs to be fully reclined and for nurses to carry out procedures, with a slightly larger space allowed if beds are used instead of chairs
  • Patients should be involved in the choice of chairs
  • Facilities at each dialysis station should include storage space for medical items that can be easily reached by patients and staff, as well as other facilities that enable patients to carry out seated activities, including a mobile table for storing books, papers and other belongings; a communication and entertainment system with individual TV, radio, video and stereo headphone systems and telephone handset; and a computer point and network connection point
  • There should be one handbasin between two stations, as well as an alcohol hand rub dispenser, a wall-mounted soap dispenser, a towel dispenser, a clinical and non-clinical waste bin and a sharps container
  • The floor should be slip-resistant, easily cleanable and have an impervious finish with coved skirting, as the risk of spillage of body fluids and contaminants is high
  • There should be adequate adjustable lighting on walls and ceilings, with controls within easy reach of patients and staff, to enable staff to carry out procedures and for patients to be able to read and write
  • Air conditioning should ideally be installed from the outset in order to help keep rooms at a comfortable temperature for both patients and staff

For satellite dialysis units, the manual recommends one dedicated space for every three dialysis stations, based on a 12-station unit. The entrance should be covered so that patients arriving in a vehicle are not exposed to the weather. As with the main renal unit, the satellite unit should be located on the ground floor and have its own dedicated entrance, easily accessible to people using wheelchairs or walking aids.

Dialysis needs to be as pleasant an experience as possible – more like going to a hotel than a hospital

Furthermore, the manual for the planning and design of satellite dialysis units states that the layout of the unit must take into account the functional relationships between its three zones – patient treatment stations, associated support facilities, and staff areas. For example, staff must be able to see patients in the dialysis area; balancing adequate observation with patient privacy. Utility areas, equipment storage and maintenance areas should be located to enable ease of access from patient treatment stations, and the layout of the multi-station dialysis area should enable patients to talk to each other and for nurses to be able to call for assistance from one station to another.

However, there also needs to be sufficient space between dialysis stations to prevent the risk of cross infection and to allow a degree of privacy for patients – 900mm is the preferred distance. In addition, it suggests non-fixed demountable partitions be used to provide flexibility.

Baxter Healthcare is a major provider of dialysis products and manages seven dialysis centres. According to Catherine Holton, product manager for home haemodialysis (HHD), what is often overlooked in renal units is the area for training and education: “This usually takes place in areas that are often cramped – in the case of HHD there is often no area for HHD training at all – and this is done in the central unit, which is busy and distracting.”

Training needs to take place in a non-clinical environment that enables patients to undertake group learning and training, have discussions and nurture peer support. It should allow training for both types of home dialysis – peritoneal dialysis (PD) and HHD – to help patients make an informed choice about the type of home dialysis they want.

The design of the unit and its location will impact on this patient group perhaps more than any other. A patient-focused renal unit, whether a main unit based in a hospital or a satellite unit based in the community, needs to be sensitively designed, easy to access – for both ambulatory and wheelchair-bound patients – and needs to provide an unstressful community-like atmosphere for patients while also respecting their privacy.

References:

1 See ‘What a New Dialysis Centre should include in order to meet patient needs’

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