An Exemplar Dialysis Unit

This blog post was made by Dr. John Agar on October 5, 2017.
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:

  1. Moderate user dependency on nursing services – NB: high dependency likely implies the need for hospital-based services
  2. Self-care (partial or complete)
  3. Home training
  4. 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.


  • Malcolm S Macdonald

    Jan 10, 2018 7:04 AM

    I am a dialysis home user, and I think this should be considered in my response to John Agar's article.

    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.
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
    • John Agar

      Jan 10, 2018 8:26 PM

      Thanks for those suggestions/additions. In my out-facing chairs, the in-pod dividers would be able to be raised/lowered at patient preference to permit socialising or privacy. I havent thought through user-driven chair choices or selection, but it shouldnt be set in stone that each user always has to occupy the same chair. As for CCTV ... point taken ... though some form of staff surveillance seems likely necessary, if only for medico-legal safety. That said, we dont monitor home patients at home, so the argument stands - why then the need to monitor self-care patients in a centre? If ever such a unit were to be mooted, that would prove a clear decision point.
      Reply to a Comment
      *All fields are required.
      Your email will not be displayed publicly
  • Surendra Kumar Mehta

    Oct 13, 2017 4:13 PM

    My wife aged 75 ,DM/ESRD is on twice a week Dialysis at Jaipur,Rajasthan,India since March 2015.Life expectancy as per literature is 3.6 years.
    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.
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
    • John agar

      Oct 13, 2017 10:26 PM

      Surendra ... i am sorry, but I dont think this is the right place to arrange personal bookings for international travel. This should be arranged, renal service to renal service, in the usual way. Your renal team in India shoukd be able to do this for uou.
      Reply to a Comment
      *All fields are required.
      Your email will not be displayed publicly
      • Surendra

        Oct 14, 2017 2:14 AM

        A big Thank you.Yes it is not a right platform for these problems.
        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.
        Reply to a Comment
        *All fields are required.
        Your email will not be displayed publicly
  • Summer Foovay

    Oct 08, 2017 5:58 PM

    It's nice to dream isn't it?
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
  • Pat Ligon

    Oct 06, 2017 9:55 PM

    May I suggest that the dialysis users be the ones to control their chairs. There are a lot of issues we are unable to control. It would be nice to CHOOSE view - the garden, the tv, a friend, or other patients.
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
    • 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 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.
      Reply to a Comment
      *All fields are required.
      Your email will not be displayed publicly
  • John agar

    Oct 05, 2017 10:24 PM

    Damn,you are spot on, Mel. That was a bad miss @ to forget sleep-over nocturnal ! ... and me of all people! I think Pod 2 could be easily used for that, but the description should include a conversion statement, I agree.

    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 ...
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
  • Mel Hodge

    Oct 05, 2017 7:52 PM

    An impressive design... two suggestions -- the chairs and LED lighting should be adjustable for optimized in-center nocturnal dialysis sleep and the center should be designed for seven days/week operation -- nobody on less than alternate day dialysis.
    Reply to a Comment
    *All fields are required.
    Your email will not be displayed publicly
Leave a New Comment
*All fields are required.
Your email will not be displayed publicly