Thursday, October 14, 2010

Evidence Based Design: Hemodialysis Unit Case Study

Hemodialysis is a medical procedure where the blood is removed from the body and filtered of impurities prior to being returned to the body. Hemodialysis is most commonly used for patients with renal (kidney) failure. While on occasion it is used on a temporary basis for patients with acute renal failure, hemodialysis is frequently used as a long-term treatment for patients with end stage renal disease. Patients receive the treatment multiple times per week. It is required indefinitely unless the patient has a kidney transplant.

Healthcare design has long integrated the principles of evidenced base design. Clearly, many factors can be influenced by design in the healthcare environment. Design can influence the experiences of patients, visitors, clinicians, and staff. Processes, such as waiting times and turnaround times, can be greatly affected by design. Perhaps the most important outcomes that can potentially be improved are clinical variables. The intent of this case study was to evaluate the elements of design that can affect clinical outcomes in an ambulatory hemodialysis center.

The research for this study involved collective information from a variety of sources and then triangulating the data to arrive at conclusions for design solutions. The public health literature was reviewed for statistics regarding end stage renal disease and usage of hemodialysis in the United States. Patient support online chat resources and medical literature were reviewed to delineate issues regarding patient experience. In addition, the medical literature also provided information about important clinical outcomes for hemodialysis. Standard texts in healthcare design provided typical current issues for hemodialysis unit design. The design literature was consulted for information about design elements that can impact patient clinical outcomes.

  1. The incidence and prevalence of people requiring hemodialysis more than doubled between 1900 and 2004.  In 2004, there were 295,000 people requiring hemodialysis, with 88,500 of those being new cases that year.
  2.  In general, a person with end stage renal disease will require hemodialysis three times per week.  Each session can be from 3-5 hours duration.  Upon arrival, the patient will be weighed and have blood drawn.  This determines the current fluid and electrolyte balance, influencing the duration and parameters of the daily treatment.  The patient is then placed in a recliner chair and hooked up to the dialysis machine.  Access to the vascular system is either through a catheter or through an arterio-venous fistula implanted in the forearm.  If a fistula is used, the patient will have limited use of that arm during the treatment.  During the treatment, the nurse will monitor the patient’s vital signs and the settings on the machine.  On some occasions, the patient may meet with the physician, dietitian, or social worker during or after the treatment.  Following treatment, the patient is weighed again before leaving.
  3. Hemodialysis units can vary greatly in size based on the number of treatment stations.  Each patient treatment station requires a minimum of 80 square feet.  In addition, space will be required for reception, nursing station, preparation and storage of dialysis materials and medications, patient education/counseling, and laboratory.  Special areas of particular concern for a hemodialysis unit are patient privacy, infection control, and plumbing.
  4. Patients generally do not consider hemodialysis to be a good experience, especially initially.  They report feeling tired and sometimes ill during the treatment.  They also report a sense of social isolation and boredom.  Patient satisfaction has been found to have strong influence on levels of staff burnout.  Staff satisfaction was influenced by access to information, professional accomplishment, and patient satisfaction.
  5. A wide variety of clinical outcomes are regularly followed in hemodialysis units, including adequacy of filtration, serum albumin (protein) levels, fistula use, metabolic bone disease, hospitalization rates, blood pressure, and mortality rates.
  6. In a variety of hospital settings, design interventions have been shown to reduce stress and blood pressure.  These design elements include giving the patient sense of control, access to support, positive distractions (e.g. nature), and lack of negative distractions (e.g. television).  Exercise during hemodialysis has been shown to improve filtration, improve sense of quality of life, and reduce requirement for antihypertensive medication.

Hemodialysis units are a common component of the health care system. Given that patients who require hemodialysis will have too many hours at a unit multiple times per week, the opportunity for design to have a cumulative impact on various healthcare outcomes is great. A typical unit is not set up in a manner to allow the patient to have many choices about how to spend time or to be able to socialize. It is not unusual for a patient to spend the four hours of treatment watching television. Based on available evidence, I propose to design a unit addressing these issues. The design would include patient access to environmental controls for each treatment station. The treatment stations will be set up to allow the patient to have visitors during treatment. Patients should have more options during treatment. Areas of the unit will be set aside to allow patients to socialize and to exercise. Based on these interventions, I anticipate that patients at the unit would report a greater quality of life and require less antihypertensive medication. Patients who regularly exercised during the treatment would have improved filtration and ultimately require less time for each individual treatment. While not the direct subject of this case study, these interventions should have positive impact on patient and staff satisfaction as well.


Argentero, Piergiorgio, Bianca Dell'Olivo, and Maria Santa Ferretti. Staff Burnout and Patient Satisfaction With the Quality of Dialysis Care. American Journal of Kidney Diseases, 2008: 80-92.
Clinical Outcomes. (accessed online: October 2010).

Daul, A. E., R. F. Schafers, K. Daul, and T. Philipp. Exercise During Hemodialysis. Clinical Nephrology, 2004: accessed online.

Himmelfarb, Jonathan, Arnold Berns, Lynda Szczech, and Donald Wesson. Cost, Quality, and Value: The Changing Political Economy of Dialysis Care. Journal of the American Society of Nephrology, 2007: 2021-2027.

Kidney Patient Guide. (accessed online: October 2010).

Skaggs, Ronald L. Ancillary Departments. В Building Type Basics for Healthcare Facilities, editted by Stephen A. Kliment, 132-136. Hoboken: John Wiley & Sons, Inc., 2008.

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