Download Specific Peritoneal Dialysis Facility Standards

New Zealand
Dialysis Standards and Audit
2005
Report for New Zealand Nephrology Services on behalf of the
National Renal Advisory Board
Kelvin Lynn
Chair, Audit and Standards Subcommittee
March 2007
Establishment of a national quality assurance framework to improve the delivery of dialysis
services to the New Zealand dialysis population.
Members of the Standards and Audit Working Party
Kelvin Lynn, Chair
Anne de Bres (resigned Nov 2003)
Adrian Buttimore
Brenda Clune (resigned Nov 2004)
Mark Marshall
Jenny Walker
Tafale Maddren
2
Table of Contents
Acknowledgments ....................................................................................................................... 4
Introduction ................................................................................................................................ 5
The process of data collection .................................................................................................... 6
Commentary ............................................................................................................................. 33
Appendix A: Circulation list .................................................................................................... 36
Access to Dialysis Treatment ................................................................................................... 37
Recommendations ................................................................................................................ 37
Audit standards ..................................................................................................................... 38
Vascular Access for Haemodialysis (HD) ............................................................................... 38
Recommendations ................................................................................................................ 38
Audit standards ..................................................................................................................... 38
Peritoneal Dialysis (PD) ........................................................................................................... 40
Recommendations ................................................................................................................ 40
Audit standards ..................................................................................................................... 40
Dialysis facilities standards ...................................................................................................... 41
Lighting ................................................................................................................................ 41
Controlled environment........................................................................................................ 41
Oxygen and suctioning ......................................................................................................... 42
Security................................................................................................................................. 42
Vinyl floors .......................................................................................................................... 42
Telephones ........................................................................................................................... 42
Dialysis and emergency service access ................................................................................ 42
Toilets ................................................................................................................................... 42
Emergency spills .................................................................................................................. 42
Clean and dirty utility........................................................................................................... 42
Ancillary facilities ................................................................................................................ 43
Other facilities ...................................................................................................................... 44
Specific Haemodialysis Facility Standards .............................................................................. 44
Haemodialysis chairs............................................................................................................ 44
Dialysis Machines ................................................................................................................ 44
Dialyser Re-Use ................................................................................................................... 44
Hand basins .......................................................................................................................... 45
Treatment areas .................................................................................................................... 45
Isolation Facilities ................................................................................................................ 46
Specific Peritoneal Dialysis Facility Standards ....................................................................... 46
Peritoneal Dialysis Training Room ...................................................................................... 46
Peritoneal Dialysis Clinic room / Interview room ............................................................... 46
Storage .................................................................................................................................. 46
Technical standards for dialysis ............................................................................................... 47
General ................................................................................................................................. 47
Electrical............................................................................................................................... 47
Dialysate ............................................................................................................................... 47
3
Acknowledgments

Associate Professor John Collins and the staff of the New Zealand Peritoneal Dialysis
Registry

Professor Graeme Russ, Dr Stephen McDonald of the Australian and New Zealand
Dialysis Registry

New Zealand Ministry of Health

DHBNZ

Clinical Directors, data collectors and staff of the Renal Units in New Zealand

Peter Dini, Department of Nephrology, Christchurch Hospital
4
Introduction
The National Renal Advisory (NRAB) is proud to present the second audit report of the New
Zealand dialysis care standards. The background to this process is summarised in the 2004
report sent to you last year. It is regretted that you have not received this report earlier. The
delay is the result of the ANZDATA Registry receiving renal unit data returns late and further
delays in some data analysis. In addition, not all New Zealand Units have been able to provide
information in regard to provision of vascular access before the start of dialysis treatment and
the rates of vascular catheter related blood stream infections. This all reflects the difficulties
that many units have in getting sufficient support for audit and practice improvement.
The Department of Nephrology at Christchurch Hospital provides support for the production
of this report and I am indebted to the help of Peter Dini, Systems Manager.
Included in this report are the standards for dialysate and water and facilities which we hope
will be of use to dialysis units and DHBs in planning and maintenance (See Appendix B).
The standards developed by the Working Party on Standards and Audit have been reviewed
by the Service Specification Project Team for the DHB Funding and Performance Directorate
of the Ministry of Health and now form an appendix of the Tier 2 Renal Service
Specifications which can be found in the National Service Framework library URL.
www2.moh.govt.nz/nsfl
The ANZDATA Registry has recently published analyses of the effects of haemodialysis
treatment duration and frequency, haemoglobin concentration and urea reduction ratio (URR,
a measure of dialysis efficiency) on patient outcome. These analyses [1,2] showed that patient
survival was worse if:

The duration of individual dialysis treatments was less <4.5 hours/session
5

Patients received less than 3 dialyses each week

The haemoglobin concentration was <110 g/L

The urea reduction ratio (URR), a measure of dialysis efficiency, was < 65%
This report includes information on the first three parameters. Data for URR have not been
included because most units have incomplete data sets.
The International Society of Peritoneal Dialysis (ISPD) recommends that renal units aim to
reduce the incidence of peritoneal dialysis related peritonitis to less than 1 episode every 18
months (0.67 episodes per year at risk)[3]. Peritonitis-free survival is another useful way to
present the rates of peritonitis in peritoneal dialysis patients. Data in this format analysing the
effects of age and ethnicity for the period 2001-2005 are included in this report courtesy of
Associate Professor John Collins of the New Zealand Peritoneal Dialysis Registry.
The data for central venous catheter use in patients who had haemodialysis for up to 90 days
before starting on peritoneal dialysis have been reanalysed by the ANZDATA Registry
because of discrepancies noted between the 2004 and 2005 analyses. The aim of this audit
standard is to identify poor planning of peritoneal dialysis catheter placement for patients
intending to start peritoneal dialysis as their first dialysis treatment modality. The data for
2004 in this report differ from those presented in the previous report.
The process of data collection
The 2005 Report includes data from the 2005 ANZDATA and NZ PD Registry Reports and
from some renal units’ audit programmes. The timing of data collection and reporting for
these two Registries means that the New Zealand Audit Report cannot be distributed until
their work is completed in the second half of the year following original data collection. Once
the ANZDATA Registry has complete unit data the reports of enquiries related to the New
Zealand audit programme can be produced quickly.
6
The National Renal Advisory Board would appreciate feedback on this report. Comments can
be sent to Johan Rosman, Chair of NRAB, [email protected] or Kelvin Lynn,
[email protected]
The audit data is shown in tabular and graphic form in the following pages
7
Treatment modality of incident patients in New Zealand in 2004
100%
90%
80%
70%
Percentage
60%
Satellite HD
Hospital HD
CAPD
APD
50%
40%
30%
20%
10%
0%
Northland
Auckland
Starship
Middlemore
Hamilton
Palm Nth
Unit
8
Taranaki
Wellington Christchurch
Dunedin
Treatment modality of incident patients in New Zealand in 2005
100%
80%
Percentage
60%
Satellite HD
Hospital HD
CAPD
APD
40%
20%
0%
Northland
Auckland
Starship
Middlemore
Hamilton
Palm Nth
Unit
9
Taranaki
Wellington Christchurch
Dunedin
Treatment modality of prevalent patients in New Zealand in 2004
100%
60%
HHD
Satellite HD
Hospital HD
CAPD
APD
40%
20%
Unit
10
in
D
un
ed
rc
h
C
hr
is
tc
hu
gt
on
ra
Ta
W
el
lin
na
ki
th
N
Pa
lm
on
am
ilt
H
M
id
dl
em
or
e
ip
St
ar
sh
Au
ck
la
nd
or
th
la
n
d
0%
N
Percentage
80%
Treatment modlaity of prevalent patients in New Zealand in 2005
100%
90%
80%
60%
HHD
Satellite HD
Hospital HD
CAPD
APD
50%
40%
30%
20%
10%
C
Unit
11
in
D
un
ed
rc
h
is
t
ch
u
n
hr
ra
Ta
W
el
lin
gt
o
na
ki
th
N
Pa
lm
ilt
am
H
dl
em
M
id
on
or
e
ip
rs
h
St
a
Au
ck
la
nd
or
th
la
n
d
0%
N
Percentage
70%
Vascular access of prevalent HD patients in New Zealand in 2004 & 2005 - percentage of AV fistulae
(number of patients show in columns)
100
90
Standard 70%
80
60
AVF only 2004
AVF only 2005
Standard
50
40
30
20
10
in
an
d
1028 1133
al
ed
Ze
un
ew
N
ch
u
is
t
hr
C
12
34 37
D
n
gt
o
W
el
lin
ak
ra
n
Ta
Units
48 61
rc
h
143 150
i
th
26 30
N
Pa
lm
ilt
am
dl
em
or
e
50 65
M
id
rs
h
133 152
on
292 312
H
2
ip
2
St
a
d
la
n
th
or
213 224
Au
ck
la
nd
83 100
0
N
Percentage
70
Vascular access in prevalent New Zealand HD patients at the end of 2004 & 2005 - use of catheters
(Includes tunnelled and non-tunnelled catheters - number of patients shown in columns)
60
Standard <10%
50
2004
2005
Standard
30
20
10
13
279 275
al
an
d
7
di
n
7
Ze
un
e
ew
N
tc
hu
hr
is
4
D
n
gt
o
C
Units
2
rc
h
46 39
W
el
lin
ki
Ta
ra
na
N
Pa
lm
ilt
on
am
H
dl
em
M
id
9 10
22 29
th
37 40
or
e
ip
94 82
rs
h
St
a
la
nd
th
or
1 0
48 46
Au
ck
la
nd
13 18
0
N
Percentage
40
Percentage of incident New Zealand HD patients starting HD with permanent vascular access in
2004 & 2005 - AV fistula or AV graft
(number of patients shown in columns)
80
Standard > 50%
70
60
2004
2005
Standard
40
30
20
10
Units
14
Ze
a
N
ew
D
un
rc
h
ch
u
is
t
273 279
la
nd
11 9
ed
in
26 25
hr
C
W
el
lin
ki
ra
na
Ta
43 44
gt
on
9 7
N
Pa
lm
on
ilt
am
H
dl
em
id
21 24
th
40 45
or
e
56 48
M
d
la
n
th
or
47 50
Au
ck
la
nd
20 26
0
N
Percentage
50
Percentage of non-late referred (<3 months) New Zealand HD patients starting HD with permanent
access in 2004 & 2005 - AV fistula or AV graft
(number of patients shown in columns)
90
Standard > 80%
80
70
2004
2005
Standard
50
40
30
20
10
nd
194 199
in
Ze
al
a
un
ed
ew
N
ch
u
is
t
hr
C
15
6 6
D
n
gt
o
W
el
lin
ak
ra
n
Ta
Units
23 21
rc
h
34 37
i
th
N
on
ilt
am
H
id
dl
em
St
a
5 5
(in
cl
.
11 12
M
rs
h
la
n
or
th
N
21 18
Pa
lm
47 40
ip
)
d
32 39
or
e
15 21
0
Au
ck
la
nd
Percentage
60
Percentage of incident New Zealand dialysis patients requiring HD for =<90 days via a temporary
CVC before starting PD in 2004 & 2005
(number of patients shown in columns)
120
Standard < 20%
100
2004
2005
Standard
60
40
20
16
nd
57 57
al
a
Ze
ew
N
ch
u
is
t
hr
5 2
in
n
C
Units
2
un
ed
4
D
4
gt
o
ra
n
Ta
W
el
lin
ak
i
3
rc
h
1 0
th
N
on
ilt
am
H
id
dl
em
St
a
(in
cl
.
3 1
M
rs
h
la
n
or
th
N
15 23
Pa
lm
15 10
ip
)
d
8 11
or
e
3 4
0
Au
ck
la
nd
Percentage
80
Percentage of first PD catheters in New Zealand PD patients that are functioning at one year for
2004 & 2005
(number of catheters inserted shown in columns)
100
Standard > 80%
90
80
60
2004
2005
Standard
50
40
30
20
10
17
246 246
in
an
d
13 11
N
ew
D
Ze
un
al
ed
rc
h
hr
C
Unit
18 27
is
tc
hu
gt
on
ra
Ta
43 39
W
el
lin
na
ki
th
NA 16
N
on
ilt
am
H
dl
em
St
a
cl
.
20 11
(in
M
id
rs
h
la
n
th
or
N
53 54
Pa
lm
41 44
ip
)
d
48 48
or
e
10 12
0
Au
ck
la
nd
Percentage
70
Peritonitis rates in New Zealand PD patients (months/episode) for 2004 & 2005
(number of prevalent patients shown in columns)
45
> 18 patient mths/episode
40
30
Percent 2004
Percent 2005
Standard
25
20
15
10
5
18
la
Ze
a
N
ew
D
un
ed
rc
h
is
t
C
hr
742 721
nd
35 30
in
61 64
ch
u
gt
on
ra
Ta
Unit
122 124
W
el
lin
na
ki
N
th
Pa
lm
on
ilt
dl
em
id
23 22
(in
cl
.
49 40
M
St
ar
sh
la
n
or
th
N
193 182
H
am
94 98
ip
)
d
140 137
or
e
25 24
0
Au
ck
la
nd
Months/episode
35
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Northland)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Northland)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
500
1000
time in days
19
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Auckland)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Auckland)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
200
400
600
800
time in days
20
1000
1200
1400
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Middlemore)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Middlemore)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
500
1000
time in days
21
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age below 65 (Hamilton)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age >= 65 (Hamilton)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
500
1000
time in days
22
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (PalNorth)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (PalNorth)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
500
1000
time in days
23
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Taranaki)
(Tanaranki)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Taranaki)
(Tanaranki)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
200
400
600
800
0
time in days
200
400
600
800
time in days
24
1000
1200
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Wellington)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Wellington)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
500
1000
time in days
25
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Christchurch)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Christchurch)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
200
400
600
800
1000
0
time in days
500
1000
time in days
26
1500
Peritonitis free survival for renal units in 2001-2005
Survival to peritonitis by age and ethnicity
First Peritonitis Episode for Patients age >= 65 (Dunedin)
0.2
0.2
0.4
0.4
Survival
Survival
0.6
0.6
0.8
0.8
1.0
1.0
First Peritonitis Episode for Patients age below 65 (Dunedin)
Maori/PI
Other Races
0.0
0.0
Maori/PI
Other Races
0
500
1000
1500
0
time in days
200
400
600
time in days
27
800
1000
Percentage of HD patients - Treatment Frequency (< 3/week) for 2005
(number of patients shown in columns)
12
10
Percentage
8
6
4
2
0
4
0
1
1
2
0
Northland
Auckland
Starship
Middlemore
Hamilton
Palm Nth
Taranaki
9
0
4
21
Dunedin
New
Zealand
0
Units
28
Wellington Christchurch
Percentage of Hdpatients - Session Length (< 4.5h/session) for 2005
(number of patients shown in columns)
100
90
80
Percentage
70
60
50
40
30
20
10
42
126
2
144
52
21
20
Northland
Auckland
Starship
Middlemore
Hamilton
Palm Nth
Taranaki
30
5
15
457
Dunedin
New
Zealand
0
Units
29
Wellington Christchurch
Dialysis frequency and duration of session
New Zealand 2005
Duration of dialysis treatment
Dialysis frequency
< 4 hours
> 4 hours
Total
< 3/week
3
18
21
3 x weekly
32
1,010
1,042
> 3/week
16
54
70
Total
51
1,082
1,133
30
Percentage of dialysis patients with Hb Concentration (< 110g/l) at 31 Dec 2005
(number of patients shown in columns)
100
90
80
60
HD
PD
All
50
40
30
20
10
Units
31
la
nd
14 6 20
ew
N
449 267 719
Ze
a
di
n
un
e
35 25 60
D
rc
h
hr
is
57 39 96
C
8 5 13
tc
hu
W
el
lin
gt
on
i
na
k
31 13 44
Ta
ra
Pa
lm
H
am
N
th
ilt
on
or
e
dl
em
107 43 150 77 89 166
id
2 4 9
M
92 40 132
St
ar
sh
ip
26 3 29
Au
ck
la
nd
or
th
la
nd
0
N
Percentage
70
32
Commentary

There continues to be a substantial variation between units in regard to initial and
prevalent dialysis modality.

The number of prevalent haemodialysis patients rose and the number on peritoneal
dialysis fell during 2005.

Forty percent of haemodialysis patients (457) receive less than 4.5 hours dialysis per
treatment session.

Thirty-two patients on thrice weekly dialysis are receiving less than 4 hours dialysis for
each treatment session.

Units should review the duration of dialysis treatment provided in light of data associating
haemodialysis for <4.5 hours/session with poorer outcomes than for longer treatments.

Although there is an increasing interest in the clinical benefits of increased frequency
dialysis, only seventy haemodialysis patients are having more than 3 dialyses per week.

Eight of ten units now achieve the standard for optimal vascular access (arteriovenous
(AV) fistula + graft) for prevalent patients but only one unit for all incident patients and
none meet the more stringent standard for non-late presenting patients.

There has been a small fall in the number of prevalent haemodialysis patients using a
vascular catheter for dialysis but only one renal unit has <10% of their patients using this
form of vascular access.

In both 2004 and 2005 57 patients received haemodialysis for up to 90 days before
starting on peritoneal dialysis. Almost all of these patients had a dialysis catheter, rather
than an AV fistula. Units may wish to review their policies regarding the placement of AV
fistulae in all patients during work up for dialysis treatment.
33

The continuing high rates of central venous catheter use are of concern because of the
evidence that survival is inferior with this form of access when compared with an AV
fistula.

The influence that any changes that renal units have been able to make in the organisation
and provision of surgical and radiological services for vascular access since the last audit
report are not apparent.

One year survival of first peritoneal dialysis catheters is excellent with all units achieving
the standard.

Peritonitis rates vary considerably. Two smaller units have achieved a rate of > 18
months/episode. Peritonitis rates for Maori and Pacific people are greater than for other
ethnic groups.

Dialysis patients with the anaemia of chronic renal failure and a haemoglobin
concentration < 100g/L are entitled to receive subsidised epoietin. The target haemoglobin
concentration for patients without overt cardiovascular disease is 110 – 130 g/L. The
proportion of dialysis patients with a haemoglobin concentration < 110g/L was
surprisingly high at 39% (719 patients).

Near complete data on provision of vascular access was available from three units, all of
which achieved the standards.

Four units provided data on dialysis catheter related blood stream infections and all had
rates < 4/1000 catheter days.

The data related to provision of vascular and peritoneal access for incident patients
suggest that units should review the effectiveness of their pre-dialysis programmes and in
particular the co-ordination of vascular access assessment and provision.
34
References
1. Marshall MR, Byrne BG, Kerr PG and McDonald SP. Associations of hemodialysis
dose and session length with mortality risk in Australian and New Zealand patients.
Kidney Int 2006; 69: 1229–1236
2. Leonardi B, McDonald S for the Haemodialysis Working Group of ANZDATA
Registry (Agar J, Kerr PG, Marshall MR). The Relationship between Practice
Patterns and the Survival of Australasian Haemodialysis Patients. Presented at the
Australia and New Zealand Society of Nephrology Annual Scientific Meeting, 2003.
http://www.anzdata.org.au/
3. Piraino B, Bailie GR, Bernardini J et al. ISPD Ad Hoc Advisory Committee on
Peritoneal Dialysis Related Infections. ISPD Guidelines/Recommendations. Peritoneal
dialysis-related infections recommendations: 2005 update. Peritoneal Dialysis
International 2005; 25: 107–131
http://www.ispd.org/treatment_guidelines.html
35
Appendix A: Circulation list
The National Renal Advisory Board
Standards and Audit Subcommittee
Heads of New Zealand Renal Units
Chief Executive Officers of DHBs with Renal Units
New Zealand Peritoneal Dialysis Registry
Australia and New Zealand Dialysis Registry
New Zealand Ministry of Health (Director General)
Australian and New Zealand Society of Nephrology
Renal Society of Australasia, New Zealand Branch
New Zealand Kidney Foundation
Board of Nephrology Practice New Zealand
Patient support groups/societies
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Appendix B: New Zealand Dialysis Standards 2006
These standards and guides are appended to the Tier 2 Renal
Service Specifications
http://www2.moh.govt.nz/QuickPlace/nsfl/PageLibraryCC256B4A00721041.nsf/e5674c2e19
b044adcc256b4a0072264f/979f8da3bd94401ecc256ec80080bf40/?OpenDocument
Access to Dialysis Treatment
Recommendations
1. All centres providing dialysis treatments must do so under the direct supervision of a
vocationally registered and credentialled nephrologist.
2. All centres must provide access to both haemodialysis (HD) and peritoneal dialysis (PD).
3. All centres to provide access to both independent (home/self care) and dependent (incentre/caregiver assisted) HD.
4. All centres must offer either directly, or indirectly, a conservative care program for those
who decline an offer of dialysis.
5. All centres must ensure that patients have access to transplantation services.
6. All centres must offer at least a 3 times a week HD schedule for those with minimal
residual renal clearance.
7. HD treatment duration, frequency and modality should be determined according to
clinical need. These modalities may include, but are not necessarily limited to, daily or
nocturnal schedules, and high flux dialysis.
8. HD services must be provided to patients by appropriately qualified medical, nursing,
technical, and clerical personnel.
9. Clinical dialysis staff and technicians should be certified or credentialled by an
appropriate professional body.
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Audit standards1
1. Dialysis modality for incident and prevalent patients (ANZDATA)
2. No HD patients dialysing for less than four hours per session or less than three times
weekly and Kt/V less than 1.2 or urea reduction rate (URR) <65%. (ANZDATA)
Vascular Access for Haemodialysis (HD)
Recommendations
1. Renal units must have access to appropriate vascular surgical services.
2. An arteriovenous fistula (AVF) is the vascular access of choice.
3. Preference should be given to formation of an AVF before placement of an arteriovenous
graft (AVG) or permanent central venous catheter (CVC) (preferred order of provision).
4. New (incident) HD patients should have a functioning AVF or AVG at commencement of
dialysis.
5. Patients should be referred for vascular access formation when the estimated glomerular
filtration rate (eGFR MDRD) 2 is <25mls/min or within 6 months of anticipated need for
dialysis.
6. If it is anticipated that a CVC will be required for HD for more than 3 weeks a tunnelled
cuffed catheter is preferable to a non-tunnelled line.
7. Placement of CVCs should ideally be with ultrasound or fluoroscopy guidance.
Audit standards
1. At least 70% of prevalent HD patients dialysing via AVF. (ANZDATA).
1
Source of data in brackets e.g. ANZDATA
2 MDRD equation. GFR (ml/min/1.73m2)= 0.021 x serum creatinine-1.154 (µmol/L) x
age-0.203 (x 0.742 if female)
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2. Less than 10% of HD patients dialysing using a central venous catheter (CVC) as their
permanent access. (ANZDATA)
3. More than 50% of incident HD patients commencing dialysis with a functioning AVF or
AVG. (ANZDATA)
4. More than 80% of non-late referrals3 commencing HD with a functioning arteriovenous
fistula or graft. (ANZDATA)
5. Less than 20% of patients on vascular surgery waiting list greater than 2 months from date
of referral. (Renal Units)
6. Estimated glomerular filtration rate (eGFR) by modified MDRD equation at time of
referral for first vascular access formation. (Renal Units)
7. Incidence of <4 episodes of CVC blood stream infection per 1000 catheter days. (Renal
Units)
Defined by the following:
a) Use of central CVC for HD,
b) blood stream infection (BSI) is considered to be associated with a central line if the
line was in use during the 48-hour period before development of the BSI. If the time
interval between onset of infection and device use is >48 hours, there should be
compelling evidence that the infection is related to the central line.4
3
Late referrals defined as referral to a nephrologist less than 3 months before 1st
treatment. It is acknowledged that it is difficult to achieve late referral rates less than 30%
4
Centers for Disease Control and Prevention. Guidelines for the Prevention of
Intravascular Catheter-Related Infections. MMWR 2002;51(No.RR-10):28.
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Peritoneal Dialysis (PD)
Recommendations
1. Automated Peritoneal Dialysis (APD) should be available as an alternative to Continuous
Ambulatory Peritoneal Dialysis (CAPD) for patients with inadequate solute clearances or
ultrafiltration failure (high transporter membrane type) on CAPD or for significant
psychosocial reasons.
2. New PD patients should have a PD catheter placed 2-4 weeks prior to their requiring
dialysis.
3. Renal units must have access to appropriate Surgical and/or Radiological services for PD
catheter implantation.
4. Icodextrin peritoneal dialysate should be available for use when clinically indicated.
5. Units must have policies and procedures to minimise the rate of peritonitis on
APD/CAPD.
Audit standards
1. Percentage of total PD patients on APD. (ANZDATA)
2. Less than 20% of incident patients requiring interim HD via a temporary CVC before
starting PD. (ANZDATA)
3. Peritonitis rate of > 18 patient months/episode.
4. More than 80% of catheters functioning at 1 year. (NZPD Registry)
5. Percentage of total PD patients using Icodextrin. (Renal Units)
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Dialysis facilities standards5
(These standards apply primarily to hospital and satellite HD centres. It should be noted that
for training facilities involving home based therapies, an environment equivalent to a
domestic situation would be acceptable.)
Lighting
1. 500 lux shadowless light positioned to cater for individuals or focussed activity such as
cannulation (NZ Building code).
2. Less than 100 Lux for general purpose unit lighting (NZ Building code).
3. Wherever possible ceiling and wall light fittings should be recessed so that they are flush
with the surrounding surface to prevent dust collection and minimise cleaning needs
(Design considerations for Infection Control 9.6)
4. Emergency lighting of 3 lux for at least 10 minutes duration must be available to enable
evacuation of building. This can be separate lighting or part of existing lighting but
attached to battery back up (NZ Building code).
5. Battery torches should be kept on the premises (NZ Building code).
6. Systems to deal with power failure should be available.
Controlled environment
1. Either open windows or mechanical ventilation to be used (NZ building code). The ability
to adjust environment locally can be advantageous and should enable staff to function and
carry out their duties.
2. The air change rate should be capable of removal of odours.
5
Design consideration for Infection Control: the Technical Advisory Centre for Health
Facilities, New South Wales Hospital Planning Advisory Centre, Australia, April 1989
Guidelines for Satellite Dialysis Units, Victoria, Australia, May 1999
Hospital and Healthcare facilities: guidelines for design and construction, The American
Institute of Architects Academy of Architecture for Health, 2001
New Zealand Building Code
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3. Mechanical ventilation air intake should be filtered.
Oxygen and suctioning
1. Availability, type and location will depend on number of patients, and location of unit
(Victorian satellite guidelines).
Security
1. Requires individual assessment for both staff and patient safety particularly if the area is
used in the evening or is isolated (Victorian satellite guidelines).
Vinyl floors
1. A hard-wearing surface that is durable, has a floor waste hole and 15 – 30 cm coving.
Telephones
1. Telephones should be linked to other areas and /or Emergency Services.
2. Public phone access for patients is desirable but subject to local policy (Victorian satellite
guidelines).
Dialysis and emergency service access
1. Disabled and ambulance access to the unit is necessary.
Toilets
1. A designated toilet and hand basin for staff and separate wheelchair accessible facilities
for patients should be adjacent to or within the treatment area. The number of toilets to be
provided per person is indicated in the NZ Building code.
Emergency spills
1. A shower and eye bath for staff or patients affected by blood or chemical spills subject to
OSH guidelines.
Clean and dirty utility
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1. A clean workroom should be provided and used for preparing patient care items. This
should contain a work counter, a hand washing station and storage facilities for clean and
sterile supplies. If the room is only used for storage and holding as part of a system for
distribution of clean and sterile materials, the work counter and hand washing station may
be omitted.
2. A dirty utility room should be provided that contains a sluice with face guard, appropriate
pan sanitiser or pan disposal facilities, hand washing station, work counter, storage
cabinets and storage of contaminated waste bins. Sharps containers and dirty linen skips
can also be kept there (Hospital & Health Care facilities 7.14.B11) (Victorian satellite
guidelines).
3. Wheelie bins or separate containers for contaminated and general waste as required
(Victorian satellite guidelines).
4. The dirty utility and clean utility should have no direct connection (Hospital & Health
Care facilities 7.14.B10).
Ancillary facilities
1. A waiting room ideally with toilet and hand washing facilities and seating with cleanable
surfaces for waiting periods be provided or accessible to the dialysis unit (Hospital &
Health Care facilities 7.14.C3).
2. An office area should be available for administrative services (Hospital & Health Care
facilities 7.14.C4). This should be separate from the treatment areas.
3. There should be a dedicated staff room for meal breaks separate from treatment areas.
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Other facilities
1. If a kitchen is provided for patients it should contain a sink, a work counter, a refrigerator,
storage cupboards and equipment for serving nourishment as required (Hospital & Health
Care facilities 7.14.B13).
2. An environmental services closet should be provided adjacent to and for the exclusive use
of the unit. The closet should contain a sink and storage space for housekeeping supplies
and equipment (Hospital & Health Care facilities 7.14.B14).
3. A storage space should be provided for wheelchairs out of direct line of traffic (Hospital
& Health Care facilities 7.14.B17).
4. A clean linen storage area should be provided. This may be within the clean workroom, a
separate closet, or an approved distribution system. It must be out of the path of normal
traffic and under staff control (Hospital & Health Care facilities 7.14.B18).
Specific Haemodialysis Facility Standards
Haemodialysis chairs
1. Purpose built HD chairs is desirable. Chairs for HD areas should be assessed on their
comfort for patients, ease of transfer and appropriateness & safety for staff in carrying out
the dialysis and emergency procedures.
2. Other considerations include suitability for surface cleaning, durability and mobility.
Dialysis Machines
1. Machines should be surface cleanable between patient treatments.
Dialyser Re-Use
1. Dialyser re-use not recommended for Hepatitis B,C, D or HIV infected patients
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Hand basins
1. Hand basins should be of sufficient size to allow patients to wash their arms without
touching the basin or taps.
2. The height of the basin from the floor should be 910mm.
3. There should be a ratio of at least one hand basin to every four patients (Victorian satellite
guidelines).
4. Soap dispensers should be smooth surfaced and easy to refill and clean.
Treatment areas
1. Treatment areas may be an open area and shall be separate from administrative and
waiting areas (Hospital & Health Care facilities 7.14.B1).
2. The facility should have an adequate layout with sufficient space, light and temperature
control to allow best practice infection control by staff.
3. The staff station should be located within the dialysis treatment area and designed to
provide visual observation of all patient stations (Hospital & Health Care facilities
7.14.B2).
4. The minimum working area for HD is 1 metre out from each point of the HD chair or 9
square metres per dialysis station.
5. An open unit should be designed to provide privacy for each patient (Hospital & Health
Care facilities 7.14.B5).
6. If a medication dispensing station is required then a work counter and a hand-washing
area should be included in this area. If required, provision should be made for controlled
drug storage, preparation and refrigeration of medications (Hospital & Health Care
facilities 7.14.B7).
7. An examination room of at least 9.29 square metres with hand-washing and writing
surface should be provided (Hospital & Health Care facilities 7.14.B9).
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Isolation Facilities
1. There should be at least one dialysis station in an isolation room in each Dialysis Unit
Specific Peritoneal Dialysis Facility Standards
Peritoneal Dialysis Training Room
1. There should be at least one room available for training patients in PD which provides
visual and auditory privacy.
2. Minimum size 3m x 3m.
3. Hand basin and bench accessible.
Peritoneal Dialysis Clinic room / Interview room
1. A private room available for clinic reviews and interviews.
2. Minimum size 3m x 3m.
3. This room may be combined with the training room dependent on patient numbers and
location of the unit.
Storage
1. There must be sufficient clean storage area available to hold dialysis supplies for expected
unit use over a 4 week period.
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Technical standards for dialysis
General
All work required to provide for the point of installation for dialysis equipment shall comply
with:
1. The Building Act and Building Controls, 1991 (modified in 2004)
2. The New Zealand Building Code, 1992
3. Any specific Local Body requirements
Electrical
The installation and use of dialysis equipment shall comply with:
1. AS/NZS 2500:1995, Amendment A, June 2003; Guide to the safe use of electricity in
patient care
2. AS/NZS 3003:1999; Electrical installations – Patient treatment areas of hospitals and
medical and dental practices
3. AS/NZS 3551:1996, Amendment A, June 2003; Technical management programs for
medical devices
4. AS/NZS 3200.2.16; Medical electrical equipment – Particular requirements for safety –
HD, haemodiafiltration and haemofiltration equipment
Dialysate
Haemodialysis solutions (dialysate) shall comply with:
ANSI/AAMI RD52:2004; Dialysate for Haemodialysis
However this, and other currently available standards, relates specifically to facility-based HD
and do not address home-based HD. Whilst the end quality of the dialysate should be the
same in either location the standard raises significant technical and logistical issues for home
HD installations, especially relating to testing frequency. It is therefore the responsibility of
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individual home HD services to develop a testing protocol which ensures maximum
compliance with the standard.
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