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.