Clinical practice guidelines for the provision of renal service in Hong Kong: Accreditation of Renal Unit

Guideline statement #1: Design and spacing should cater for different needs of a renal unit

1.1 Government building and fire safety regulations should be met. (R)

1.2 Different areas should be provided for patient education, provision of HD and PD services. (D)

1.3 For renal units that provide HD for patients with chronic hepatitis B and hepatitis C infection, designated areas and HD machines should be provided for such patients. (R)

1.4 For renal units that provide HD for patients with potential infectious diseases, designated areas should be available to isolate these patients. (R) If there are patients with same strain of multi-resistant microorganisms, they should be cohorted. (D)

1.5 For centres with home HD service, designated area should be offered for training of home HD. (D)

1.6 Within the PD area, separate rooms are recommended for PD training and care for complications related to PD. (D)

1.7 Contingency guidelines should be in place for suspension of water, electricity supply and fire hazard. (R)

1.8 There should be areas dedicated to storage, clinic area, clean and dirty utility, toilets and staff offices. (D)

Guideline statement #2: There should be qualified staff in renal dialysis unit

2.1 The centre should have qualified nephrologist(s)* and renal nurses. (R)

(Key: *Qualified nephrologist: Name listed in the Medical Council of Hong Kong Nephrology Specialist Registration.)

2.2 Medical doctor should be available for consultation when required. (R)

2.3 Nurse-in-charge should be a registered nurse (general) at the Nursing Council of Hong Kong and has completed a post-registration renal nursing programme. (R)

2.4 Qualified renal nurses should be available during each shift to closely monitor HD procedures. (R)

2.5 Nursing staff is trained either through on-the-job training or a formal structured programme. (R)

2.6 All medical and nursing staff at the renal unit are familiar with resuscitation guidelines and trained to perform cardiopulmonary resuscitation (CPR). (R)

2.7 HD and PD prescriptions should be reviewed by nephrologists regularly. (R)

2.8 For centres with home HD service, qualified renal nurses should be available for training of home HD. There should also be provision of support service, for example telephone consultation, 24-h a day, 7 days a week. (R)

2.9 Qualified renal nurses should be available for training of continuous ambulatory PD (CAPD) and automated PD (APD). (R)

2.10 Channels should be in place for referrals/consultations to other medical specialists, for example surgeons, microbiologists, as well as paramedical personnel, for example dieticians, social workers, physiotherapists. (D)

Guideline statement #3: Water treatment system in the HD unit should be properly installed and maintained

3.1 Installation of a dual water treatment system is preferred. (D)

3.2 The water treatment system should be continuously monitored during patient treatment to ensure proper functioning. Alarms, either audible or visual, should be fitted within the dialysis treatment area to alert renal unit staff in case performance of the water treatment system drops below specific parameters. (D)

3.3 The operation of the water treatment system for each treatment day should be properly logged and filed. (R)

3.4 Procedure guidelines for disinfection of reverse osmosis machine and loop as recommended by the manufacturer are in place. (R)

3.5 No HD procedure should be performed during disinfection of the water treatment system and the loop. (R)

3.6 The water treatment system components should be regularly maintained (at least once per month) so that bacterial and chemical contaminant levels in the product water do not exceed the standards for haemodialysis water quality. (R)

3.7 Microbiological testing of the product water from the water treatment system and the loop should be done regularly (at least once per month) to ensure standard is maintained. (R)

3.8 Regular testing (at least once per month) of treated water for endotoxin is needed. (R)

3.9 Results of microbiological, endotoxin and chemical testing of treated water should be recorded and reviewed. Corrective action, if indicated, should be recorded. (R)

Guideline statement #4: HD machines should be properly maintained and regularly examined

4.1 Adequate number of unoccupied HD machine should be available on-site as backup. (R)

4.2 Procedure guidelines on preparation of HD machine for HD are in place. The guidelines should be easily accessible. (R)

4.3 Routine disinfection of both active and backup dialysis machines is performed according to defined protocol. For machines using chemical disinfectant, testing for and documentation of absence of residual disinfectants is required. (R)

4.4 Samples of dialysate from HD machines are cultured regularly (at least once per month). (R)

4.5 To ensure quality of dialysis fluid, regular testing for microbiological quality should be performed and documented regularly (at least once per month). (R)

4.6 To ensure quality of dialysis fluid, regular testing (at least once per month) for endotoxin should be performed and documented. (R)

4.7 Testing of inorganic contaminant is desirable. (D)

4.8 Regular testing of dialysate for electrolytes (at least once per month) is desirable to ensure proper function of HD machines. (D)

4.9 Repair, maintenance and microbiological testing results of the HD machines should be properly recorded. Corrective actions, if required, should also be recorded. (R)

Guideline statement #5: Reuse of haemodialysers and related devices should follow proper procedures

Currently, some centres are practicing single-use haemodialysers, while others reuse harmodialysers. This guideline is aimed at centres that are reusing haemodialysers.

5.1 Procedure guidelines for dialyser reprocessing are in place and followed. (R)

5.2 The reprocessed dialyser should be tested for presence of disinfectant before rinsing. Repeat testing for absence of disinfectant should be performed after rinsing. All results should be documented. (R)

5.3 Each dialyser is clearly labelled and identified to be re-used by the same patient. (R)

5.4 Reuse of dialyser is not recommended for patients with infections, for example chronic hepatitis B and hepatitis C. (R)

Guideline statement #6: Other equipment in the HD area should be properly maintained

6.2 All equipment, including backup equipment, should be operated within manufacturers’ specifications. Equipment should be examined regularly. Maintenance should be performed by qualified staff or contract personnel. (R)

6.3 HD unit staff should be trained to identify equipment malfunction, and to report to appropriate staff for immediate repair. (R)

6.4 All records regarding maintenance and repair should be kept on file. (R)

Guideline statement #7: Standards of equipment, solutions and training for PD should comply with international standards

7.1 Fluid for PD should comply with current international quality standards. (R)

7.2 Written protocols for common standard procedures concerning care of PD patients should be in place, reviewed regularly and followed. (R)

7.3 Written procedures and guidelines for training of CAPD and APD and management of complications should be in place, reviewed regularly and followed. (R)

7.4 All APD machines should comply with international standards for electrical and mechanical safety. (R)

Guideline statement #8: Sanitary conditions, hygienic practices and infection control should be maintained with the dialysis unit

8.1 All staff, including doctors, nurses, technical staff and dialysis assistants, should be trained to practise universal precautions. (R)

8.2 All staff should attend infection control refresher training course at least once every 24 months. (R)

8.3 Universal precaution should be practised for all activities involving patient care. (R)

8.4 Hand-washing sinks and alcohol-based hand rub should be readily accessible within patient area to allow hand cleansing before and after each patient care activity. (R)

8.5 Equipment, personal protective equipment and consumables, for example Sharps containers, gloves (both sterile and non-sterile ones), aprons, face masks and goggles should be readily available. (R)

8.6 All staff within the renal unit should have education on management of blood spillage on equipment and the floor. Education material should be readily accessible. (R)

8.7 The environmental surfaces of the renal unit and exterior surfaces of medical equipment should be cleaned and disinfected regularly (at least daily) using 1:99 sodium hypochlorite unless the surface is not compatible with this type of chemical treatment. (R)

8.8 For spillage of blood and other potentially infectious substances, the visible matter should first be cleaned with disposable absorbent material. The spillage area should be cleaned using 1:4 sodium hypochlorite, and left for 10 min. The area should then be rinsed with water. (R)

8.9 There should be a surveillance programme to monitor, review and evaluate the serological status of patients for blood borne viruses. (R)

Guideline statement #9: Other quality assurance activities for patient care should be ensured

9.1 Patients should have regular blood-taking (preferably at least once every 2–3 months) for checking haematology and biochemistry to ensure patients’ well-being and to guide modification of dialysis prescription and medications. (R)

9.2 Contingency plans and procedures should be available in case of equipment failure, power cuts or fire to ensure patient's safety and health. (R)

9.3 Drills for CPR and emergency conditions should be performed regularly to ensure staff is well trained in the latest guidelines. (R)

Guideline statement #10: Hong Kong Renal Registry should be updated regularly

This guideline is only for centres that are using the Hong Kong Renal Registry. This includes all renal units within Hospital Authority (HA) and some private hospitals. For patients being followed up by HA, and having HD in private centres, it is the responsibility of staff of HA to ensure the Renal Registry is updated.

10.1 Patients’ data should be entered and updated in Renal Registry. (R)

10.2 Mandatory data should preferably be updated within 2 weeks of the event. (R)

10.3 Regular update of data, at least once a year, is recommended. (D)