An Exemplar Dialysis Unit
Firstly, this blog is not specifically a home dialysis blog but, rather, it offers my musings in response to a request from a British colleague, who recently asked me to “dream up” an exemplar dialysis unit. He asked me to “come up with a few dot points,” so what follows is how I imagined things could be, as I thought through the dialysis service design we currently and repeatedly churn out—and the recurrent shortcomings of that design. There are clear nuts and bolts issues that I think are essential … like:
- Building orientation
- External access to light, sun and shade
- Heating and cooling utilising passive building principles
- Elimination of thermal bridging
- Alternate power sourcing (sun and wind)
- Flat roof design for roof garden/horticulture
- Re-direction of RO reject water for internal uses
- Waste management
- And, there are many more …
While I will flesh all that essential stuff out a bit later, the first question that needs to be answered is: Who is the unit for? For now, I will assume the unit is to provide dialysis care for an outpatient population, i.e., non-hospital-services-dependent, non-hospitalised patients.
- Note: I often worry about the use of the word “patient” or “patients,” as that word—through common usage—implies and/or confers “dependency.” I will therefore call the patients “dialysis users.”
As outpatient dialysis users are far from homogenous—they are a hugely pleomorphic group—any design for an “exemplar unit” should embrace pleomorphism, not homogeneity, and should allow for:
- Moderate user dependency on nursing services – NB: high dependency likely implies the need for hospital-based services
- Self-care (partial or complete)
- Home training
- Home respite/re-training/problem-solving
As each of these user groups has a different need set, this, then, demands a pod design.
Pod 1: Low-moderate nursing dependency
- These chairs need to face inwards towards the central nurse core
- They must be ‘observable’
- Users may need intermittent intervention(s) during treatment
The design disadvantage for this Pod is that the users must face inwards towards the nursing station…and must also face each other. However, from a safety perspective, this is essential. Dialysis unit design has invariably used an inward-oriented model for all patients: illness facing illness, the dilemma(s) of one feeding on the dilemma(s) of others. We should ask: Why?
Most users do not need this level of “supervision” during their dialysis and, if supervision is required, modern technology easily uses cameras, video, or CCTV surveillance. Based on the twin P’s of Positivity and Privacy, there can be nothing more intrusive or negative for a user than to stare – for hours at a time – at a mirror image dialysis user, suffering through the same tribulation(s) as oneself.
Pod 2: Self-care (partial or complete)
- These chairs could and should face outwards, away from the central core.
- Users in these chairs can be observed—if it is felt necessary—by camera, video, or CCTV.
- Their view should be towards floor-to-ceiling, one-way glass windows that open out onto external plantings, distant views, or areas of activity or interest. One such unit in Melbourne, Victoria, opens directly to a view of an airport, the constant activity providing users with a sound proofed yet welcome activity scene to pass the time.
- These outward-oriented chairs should avoid direct vision of other users.
- Each station should have button-operated privacy screens on either side.
- Each station should have user-operated dimmer switches and a simple, individual DVD deck, TV and access to the Internet, and Internet-based entertainment, like Netflix.
- It may be possible to orient individual chairs to different interest areas or views, etc.
- Nursing help would be button-summoned from an in-arm console, as is used for aircraft seating.
- Internal green spaces planted should be within vision, or if concerns arise with live green spaces (spores, mold, fungi, etc.), artificial greenery could be deployed as a fallback.
Pod 3: Home training, re-training, problem-solving, and home respite
- This should have an in-facing pod design, but structured into a conversation pit, rather than having a nurse-station “observational” format – as in Pod 1.
- The central space would feature a demonstrator station with a pull down white-board, and video-screen access.
- Each station would also have button-operated privacy screens to allow seclusion between group training activities.
- Each station would have patient-operated dimmer switches and a DVD deck, Internet access and Internet channels, as in Pod 2.
- But, as these stations are not intended for long-term use but are oriented to home training and/or home relief, views and privacy should be subservient to training technology.
Unit design should take into account the intended user population. If the group is homogenous, the design model should provide for the needs of that user group (as above). But, if the user group is pleomorphic, as is commonly the case for any service of more than 6 - 8 chairs, far greater design imagination is essential.
CLEARLY, I am not an internal designer, but I have included a line diagram—drawn off the top of my head—as a sketch sample of a potential pleomorphic model.
Many things are givens:
- A roof-space solar and/or wind-augmented power plant is essential.
- LED lighting should be used throughout. (Note: there is now some evidence to suggest that ambient lighting—and especially fluorescent lighting—can activate oxidative pathways in blood subjected to light, as it is 4 hours three times a week in dialysis tubing) and contribute to the chronic inflammatory state so commonly seen in dialysis users.
- Reject water created by the reverse osmosis (RO) plant should be directed to an on-site SteriMed™, Celitron™ (or like system) and used to generate autoclave steam for the sterilization of post-dialysis plastic consumables. This is not patient effluent fluid, but is potable-grade, filtered water. In addition, reject water is ideal for roof top farming, toilet flushing, floor cleaning, and other landscaping uses.
- Roof top farming (horticulture) of vegetables in season, both as a recreational option and as a nutritional supplementation for staff and patient diets.
- An elevator is essential, especially for users, to access roof top recreational and horticultural areas.
- Roof top alternative power sources through an inverter +/- a Tesla (or similar) battery storage system, can be used to augment or fully power (depending on geographical location) the chosen sterilization system, and the internal power needs of the unit.
- Free visitor access must be permitted to the self-care chair area.
- Electric transporters (power augmented by the alternative power plant) should facilitate user transport.
- Subsidized transport drivers can be sourced from among user relatives/families, potentially using a roster system.
- Small, fast turn-around, snap-and-go dialysis systems (eg: the Quanta SC+) would minimise between-shift changeover time, and thus would permit longer dialysis shifts.
- Smart, flexible rosters would help to optimize dialysis duration. See my previous blog on this topic.
These are some of the ideas that might underpin a compassionate, forward-looking, dialysis unit model. It would be fun if readers could think on these issues, add and subtract as they see fit, and hone the model – if it is seen as a useful start – into a more patient-sympathetic option than most currently on offer. Have a go!
Finally, I have (purposefully) made no attempt at an estimated cost of a unit built along these lines, though on the surface, I see no major additional expense. Most of these dot-points simply use what we currently have, but in a more humane and effective way, recognising that most out-of-hospital facility users are users, not patients, and should be treated as a consumer, and not as a disease.
Comments
Malcolm S Macdonald
Jan 10, 2018 7:04 AM
I love going to Peter James in Burwood (Eastern Health). The environmental aspects take in many of the aspects, such as large windows, a native garden coming right up to those windows. It always feels light and leafy and give a real sense of space. I am sure many of the other aspects could be implemented there.
Re "patients", I quite jokingly refer to myself as "an inmate", a "prisoner of the machine". Whatever we choose to call it, whether we like or not, I am still dependent. But I am still planning my escape!
The answer is very much the move to self care. To take control, and be in control of your own destiny healthwise. It would be good to see more onsite assistance by nursing staff. And home respite, It's nice to have someone else take responsibility for your dialysis every now and then. I know of one unit that has this as part of their program.
In reference to Pod 2, I prefer a bit of company while unit dialysing, but I can understand those who may wish to opt out. I do like the idea of facing out, with maybe a control, and alert chair arm control, and facilities, but would hate to be CCTV monitored.
Many of your ideals for the 'perfect' unit will come with the push for a better quality of human life.
John Agar
Jan 10, 2018 8:26 PM
Surendra Kumar Mehta
Oct 13, 2017 4:13 PM
Her daughter is in Melbourne. RMIT University. She wants to visit Melbourne once before D.
In India Home hemodialysis is a century away dream. You mentioned one Dialysis center in Melbourne suitable as per your specifications. Will you please send the complete address. Also please advise as to who/which organization can financially fund me for minimum 8, maximum 12 in center Dialysis.Here we pay Rs 1260.OO per dialysis for single use FX 8 Dialyzer. Thanking you for very useful and informative blog on Dialysis.
mehtasurendra117@gmail.com
John agar
Oct 13, 2017 10:26 PM
Surendra
Oct 14, 2017 2:14 AM
Soon I will be posting certain problems very important for life expectancy of a elderly ,diabetic
Patient art to duration of dialysis time I.e
8 hours vs 12 vs 18 (3 hr. Daily for 6 days vs 48 hours 8 hours nocturnal for 6 days.
Summer Foovay
Oct 08, 2017 5:58 PM
Pat Ligon
Oct 06, 2017 9:55 PM
John agar
Oct 07, 2017 5:34 AM
That is implicit in Pod 2.
Pod 1 is where - due to instability, frailty, whatever, a user needs to be ‘observed’ ... but the ‘n’ is limited ... at most, may 1:4 or 1:5 really fit that need. Most should either be in Pod 3 ...ie: being trained for home, then sent home (also 1:4 to 1:5 or so of the prevalent user population at any moment in time), while the remainder are Pod 2 (likely numerically the biggest group) where user-controlled dividers, arm rest controls that dim lights, change tv channels, select music or games, operate window and adjoining chair view/privacy controls, call a nurse (just like in business or first class aircraft seats), and are fully user-determined.
John agar
Oct 05, 2017 10:24 PM
As for 7 day a week Rx and a minimum of alternate day use, absolutely, but the design should accommodate that without modification.
Thanks for showing up my error on the nocturnal aspect, Mel ... and perhaps a drop-down curtain of sorts behind the Pod 2 chairs might make the semicircular Pod 2’s seem more private at night. That might be an answer ...
Mel Hodge
Oct 05, 2017 7:52 PM