NKF Campaigns Zone:
Dialysis

What a New Dialysis Centre should include in order to meet patient needs

If your patient group is not involved with the specifications being drawn up to supply a new Dialysis Centre, or has not been asked to take part in contract negotiations – you are recommended by the NKF to get involved immediately. It is vital that you make early representation and be included from the very beginning.

To help you in this task the NKF has produced the specification that follows – it is essential reading and will assist you to ensure that all the things that patients need in a Dialysis centre are included – it is too late after it is built!

RENAL SERVICES SPECIFICATION

A PATIENT CENTRED SERVICE

Renal services of the future should be centred on the needs of people with established renal failure and designed to facilitate their “journey of care”. Wherever possible, haemodialysis treatment should be delivered at a time and place convenient for patients, in an environment that is clean, comfortable and conducive to treating them with respect and dignity. It is essential that all stakeholders and particularly patients are consulted at all stages in the development, expansion or any other changes affecting renal services provision.

DEMOGRAPHICS AND CHOICE OF SITE

Before consideration of the siting of a renal unit or satellite the current and projected population, disease demographics, ethnic mix, transport links, case mix etc. of the area to be served should be studied to maximise service provision and ease of access for the patients. The renal unit should then be placed on a site that will best serve the needs of access for the majority of the renal patient population in its catchment area. A site should not be chosen because it is conveniently available or cheap because of location or lack of facilities e.g. parking.

A main unit should be attached to an acute hospital as this allows the unit easy access to the hospital services and departments that the patients (particularly those with multiple co-morbidities) and renal medicine require. Services should particularly include radiology, cardiology, Diabetology, vascular, surgery, critical care and urology.

The location of Satellites should be given particular consideration as it is now increasingly recognised that more innovation is required in taking “dialysis to the patient” The location of satellite dialysis units within existing or planned community service buildings should be considered, as this may enable patients, carers and the community to feel more integrated and may allow for other activities unrelated to the dialysis day to be incorporated with least effort. Smaller dialysis facilities at the Cottage Hospital and Heath centre level should also be considered as part of the regions dialysis provision strategy.

In consideration of any regional dialysis strategy patient needs and choice should be considered paticularly the choice of time and place of dialysis and type of modality. All dialysis modalities should be used in the design and provision of renal strategies with programmes, workforce planning, equipment needs and facilities designed to meet these requirements.

Capacity planning and resource

Patients recognise lack of capacity and resource as the main reason for lack of choice and the basis for many of their treatment problems Although Dialysis capacity has improved over the last few years it is still a serious problem. Unless we have a continuity of funding, skilled capacity management and planning of renal requirements patient needs will not be met.

Transplantation

Transplantation should not be overlooked in the provision of renal care as it is considered by many as the treatment of choice. A transplant unit will always be on the overall campus of an acute hospital and be intimately linked to that hospital’s main renal unit and its facilities. As a result, some of the facilities needed by the transplant unit can be shared with both the main renal unit and the hospital. As with the renal unit all stakeholders including patients should be involved in the any new build, expansion or development of the unit. Project / design teams should ensure that the design of a new-build transplant unit is flexible enough to accommodate future expansion of the service.

CKD and early detection

CKD and the early detection of the disease is already having an affect on patient refferal and on “in the community treatment”. Although it is early days the affect of this programme cannot be ignored in the renal planning process e.g. increased community treatment programmes, increase Unit clinic demands, Conservative management requirement, palliative care and end of life care requirements in the community and at the renal unit.

UNIT SPECIFICATION AND DESIGN

The National Kidney Federation has been involved during the period of the NSF development in many of the aligned area ensuring that patients needs and requirements were integrated in the recommendations.

The NHS estates development of specifications for new build main Renal units, Satellites and Transplant units are three areas where NKF Patient members were involved in determining the patients needs in the specification of such units.

It is accepted that the standards of requirement may be difficult to achieve in some of the existing older renal unit buildings due to physical restrictions e.g no further land next to the unit for parking extentions building improvements. The standards stipulated should be regarded as minimum requirements and where old buildings are restricting the quality of services delivered to patients planning action put in place to replace the facilities. This type of strategy is already being carried out in various parts of the country and is also covered in the standards.

Patient requirements are mentioned throughout the specifications and cover

• Patient involvement in all renal strategy developments
• Car parking requirements for the unit – this must be related to No of dialysis beds
• Covered access / dropoff and pickup points
• Wheelchair access and wheelchair storage area
• Hotel style (comfortable) reception and waitng areas (with refreshment facilities)
• Patients’ changing areas that promote privacy and dignity
• Patients sanitary facilities, including a WC accessible to the disabled
• Patients’ monitoring area – for monitoring and recording patients’ general health, weight and blood pressure before each treatment.
• Multifaith/quiet room which can be used, for example, as a religious/cultural-observance room.
• Dialysis area (containing a number of treatment stations) – this area could be open-plan or could be divided into appropriately-sized bays according to design options, bed spacing standards and patients’ choice.
• Isolation room – where medically stable patients may be dialysed in isolation if necessary. This is often overlooked.
• Staff base – preferably with separate air conditioning/temperature controls.
• Resuscitation trolley bay.
• Separate private Consulting/examination room.
• Treatment room – where staff may insert and change the lines and cannulae required by CAPD and haemodialysis patients, and carry out a range of other clinical procedures
• Patient-training facilities where staff can teach patients how to perform tasks appropriate to their mode of dialysis. Exactly what these facilities should be will depend on the tasks being taught and may vary from satellite to satellite.
• Counselling Room or available use of room for such purposes.
• Renal Manager’s office.
• Multidisciplinary office/interview room.
• Administration office.
• Renal Seminar room.
• Water treatment plant room – this is a critical haemodialysis area – Standards are critical.
• Maintenance room – for the maintenance and repair of dialysis machines.
• Equipment room – for storing spare machines.
• Separate store room for machines and equipment requiring repair or maintenance.
• Clean utility.
• Dirty utility.
• Disposal room.
• Staff rest room.
• Pantries: patients and staff.
• Staff change/locker room.
• Equipment storeroom
• Fluid store.
• Clean linen storage.
• Cleaners’ room.
• Electrical distribution cupboard
• IT room – integrated patient records with main units / Satellites, Primary Care - Patient view implementation
• Air conditioning plant room – air conditioning design is critical to patient and staff comfort – Staff areas will usually require different temperature settings to patient areas – care is required in designing the air diffusion outlets to avoid patients sitting in cold air – this is a serious patient problem.
• Stand-by Generator to cover electrical supply interruption – not always provided and can cause considerable disruption.

This is a brief outline of what patients would see as basic requirements. The detail and standards that must be adhered are laid down in the following publications.

Facilities for renal services

1. HEALTH BUILDING NOTE 53 VOLUME 1: SATELLITE UNITS
2. HEALTH BUILDING NOTE 53 VOLUME 2: MAIN RENAL UNITS
3. HEALTH BUILDING NOTE 53 VOLUME 3: TRANSPLANT UNITS

Transport

I believe that it is important that a transport contract specification should be part of any renal unit specification so that the final cost per head for dialysis also covers the transport cost to get to the unit. The recent Cheshire and Merseyside Learning set publication in which the NKF was involved gives examples of good practice. We can supply a typical working specification if it is required.

TREATMENT STANDARDS

I am sure it does not need to be pointed out that there are many treatment standards already clearly defined in the following Documents They are used regularly in NHS dialysis bid assessment requirements and in ISP contracts if the standards indicated were applied they would meet the requirements of patients. Some of the main documents are

• Renal National Service Framework
• BRS Criterior for success
• UKCKD Guidelines (RA)
• Renal Association Haemodialysis – Clinical practice guidelines 4th Edition ( still in draft)- covers CKD, Acute RF, Haemodialysis, Peritoneal Dialysis, Transplantation.
• Anaemia Management Guidelines
• Home Haemodialysis guidelines and standards
• BBV guidelines – Isolation requirements hepatitus etc often not implemented fully
• The DOH delivery programme to reduce Healthcare Associated Infections (HCAI) including MRSA – renal one of the most at risk areas
• BTS Guidelines for transplantation (also inc in the RA guidelines)
• BTS living donation guidelines – Living donation could overtake cadevaric donation in the next 2 yrs
• Living donor expenses reimbursement – Guidelines
• Medicines management

Health Care Commission Audit

This is an important area all units and perhaps particularly Independent Sector Programme Units should be inspected on a regular basis by the Health Care Commission with the results published. In the case we are looking at of a complete regions going over to ISP we should be considering perhaps a closer / more frequent level of scrutiny in the beginning.

Continuity of treatment

There must be continuity in treatment types in circumstances where contract change takes place. e.g needling methods, dialysis fluids in CAPD, Drug type etc. Patients must be consulted before changes of this type are implemented. Patient preference/ choice must be given consideration.

Treatment consumables

Although consumables may not be part of the main contract many ISP providors will want to use their own. In cases where the change in a consumables has implications that effect patients full consultation must take place. e.g types of dialysis needles used (pain)

Patient specific areas

The majority of patients are satisfied with their treatment from a medical standpoint at the last check. The main areas of patient concern come from the non medical areas. It is often difficult however to establish if the satisfaction with treatment is qualitive or gratitude based since without treatment regardless of quality patients will die. The following is a listing of prioritised patient problem areas that need to be addressed in renal services specification.

• Transport
• Psychosocial Support
• Temporary dialysis away from Home
• Holistic care /Consistent care management
• Choice
• Care plans (fully integrated)
• Training - Education
• Capacity / resource problems
• Drugs and Pharmacy
• Infection control
• Staff shortages /communication

Psychosocial Support

The impact of renal failure on patients goes beyond the clinical aspects of their condition. This type of support is rated as the number two problem by the majority of patients. This area should not be underated in its importance since it covers most of the personal, family, financial, employment and social aspects of patient lifestyles. It is an essential part of the service delivered by the Multi Disciplinary Team

Holistic care

Patients have clearly identified the need for a holistic approach to their care – treating the patient not the disease – cultural needs / considerations – emotional / psychosocial – drugs management - advice-information – staff & patient training - staff communication - dietetics - integrated careplans - holiday – finance / benfits- counselling – employment – environment ( unit) – transport. All are part of the essential service delivered by the Multi Disciplinary Team.

Communication

Doctor patient – between health care sectors (no silos) – between healthcare and other agencies (social services) – effective feedback high quality feedback on diagnostic tests, treatment etc

Co Morbidity and integrated careplans

Integrated careplans and treatment across morbidities – no silos

Choice

Choice both with a capital “C” as in the Governments plans and choice with a small “c” in the patients day to day treatment is implicit in the Renal National Service Framework.

Choice means

• Choice of modality
• Choice of time of Dialysis
• Choice of place of Dialysis
• Choice to take a holiday
• Choice of consultant
• Choice named nurse
• Choice of when and where to die

National Service Framework

All units must commit to the implementation of the requirements of the Renal National Service Framework as determined at national, regional levels and the implementation of national guidence where applicable.

WORKFORCE REQUIREMENTS

Patients recognise the necessity for correct staffing of units with renal specific trained staff. Without a clearly defined Multi Disciplnary Team (MDT) carrying out their treatment the level and quality of that treatment will suffer. Integrated working between the renal healthcare professionals, close working relationships with primary care teams and liaison with other healthcare teams and outside agencies is essential for the delivery of high quality renal care.

Staffing problems result in

• Not having a named Consultant / Nurse or named unit contact
• Not seeing their Consultant regularly – Consultant too busy to listen – too busy to help
• Uncaring Staff attitudes due to work pressures
• Bad needling due to pressures/lack of time/ lack of experience
• Neglect in treatment due to staff shortages and pressures – less articulate and older patient (perhaps more difficult) tend to suffer more.

Any renal unit specification must include staffing requirements, type, skills mix, clinical practice and training requirements etc. In the past on independent sector unit contracts the staffing arrangements of the Units were subject to external Regulation under Part II of the Registered Homes Act (1984)49 and the Care Standards Act 200050.

In simple terms the most recent guidance and work done on renal workforce requirements is the BRS Workforce Confederation document of 2002. If nothing else it was comprehensive in its considerations. (The predictions on renal Growth are interesting 4years on.)

The growth predictions in staffing requirements in this document are as shown in section 5.1.5(a). To fully understand the qualifications I suggest reading the documents conclusions.

This Work Force Plan table 5.1.2 below is based on patient centred care, integrated multi-professional working and the current best practice. The recommendations for each professional group have been reviewed together to ensure consistency. Where possible the impacts of developments in practice and technological advances have been considered. Three scenarios of future dialysis and transplant patient numbers have been modeled using different assumptions with regard to the starting stock, acceptance rate, transplant supply and survival on haemodialysis.

I think a patient to staff ratio qualified by a national regulation and if possible line management diagrams for those areas needing clarification would probably suffice.

TABLE 5.1.2
CURRENT AND RECOMMENDED SPECIALIST RENAL STAFF TO PATIENT ON RRT RATIOS

Table 5.1.5 (a)
Workforce requirement for England

GENERAL

Any Kidney Patient Association requiring further detail or assistance in respect of any local proposal or negotiation should contact the Advocacy service at the NKF Helpline 0845 601 02 09

R W Dunn January 2007