Specialised Services Policy:

Routine Access of Relatives / Carers at

Haemodialysis Units in Wales

Document Author: Manager, Welsh Renal Clinical Network

Executive Lead: Director of Finance
Approved by: TBC
Issue Date:
Review Date:
Document No:

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 1 of 9
Document History

Revision History
Version Revision Summary of Changes Updated
No. date to version
no.:
0.1 Draft for consultation

Date of next revision

Consultation
Name Date of Version
Issue Number

Approvals
Name Date of Version
Issue No.
WRCN Board TBC

Policy Statement

Background Haemodialysis units are busy complex clinical

environments. It is essential that aspects such
as infection control, health and safety and
dignity and privacy are central to their
operation.

Summary of The routine presence of relatives and carers at

Access Criteria haemodialysis units is not supported

Responsibilities The WRCN will be responsible for reviewing this

policy and its implementation across Wales

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 2 of 9
Table of Contents

1. Aim ................................................................................... 4

1.1 Introduction ............................................................... 4

2. Scope ............................................................................... 4

2.1 Haemodialysis Units in Wales ..................................... 4

3. Key issues ........................................................................ 4

3.1 Background ................................................................ 4

3.2 Factors for consideration ......................................... 5
3.2.1 Space .................................................................. 5
3.2.2 Infection Control ................................................ 5
3.2.3 Privacy and Dignity ............................................ 6
3.2.4 Time requirements ............................................. 6
4. National Policy Statement ............................................... 6

4.1 National Policy ........................................................... 7

4.2 Responding to individual circumstances .................... 7
4.3 Requirements of agreed visitors ................................ 7
4.4 Process for requesting access .................................... 8
4.4.1 Request not approved ........................................ 8
4.4.2 Request approved............................................... 8
5. Putting Things Right: Raising a Concern ........................... 8

6. Equality Impact and Assessment ...................................... 9

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 3 of 9
1. Aim

1.1 Introduction

This document has been developed as the policy for renal services
to use when considering the routine presence of a relative / carer at
a haemodialysis unit.
The purpose of this document is to
 Clearly set out the context of routine visitors and implications
regarding visitors
 Clarify the national position with regard to the routine access
for relatives / carers to a haemodialysis unit
 Provide guidance to renal services on implementing this policy

2. Scope
1. Purpose

2.1 Haemodialysis Units in Wales

Generally speaking, non-essential visitors are discouraged from

attending haemodialysis units on the grounds of infection control,
health and safety and ensuring privacy and dignity of the renal
patient community.
This policy is to provide guidance on the acceptance of routine
attendance of spouses, relatives and carers alongside haemodialysis
patients. This includes patients attending for a holiday session.
It does not specifically include:
 Ministerial / Ad hoc VIP attendances
 Service inspections by commissioners or other parties with
inspectorate functions e.g. Community Health Council

3. Key issues

3.1 Background

Unit Haemodialysis is the main dialysis modality used for patients

with End Stage Renal Disease. Typically this is undertaken during
three 4 hour sessions a week.
Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 4 of 9
There are 17 dialysis units in Wales ranging from Main units through
to smaller satellite units. The average age of dialysis patients in
Wales is now 69, they are predominantly male, and they have a
broad mix of frailty, other medical illnesses and needs, and self care
capability.
Patients are, however, typically increasingly frail. The nature of
their renal disease means that they have weaker immune systems
and that they are vulnerable to infection.
In order to undertake dialysis, patients require ‘vascular access’ to
the blood either in the form of permanent fistula / graft (which
require needle insertion) or temporary central line (which are
directly sited within large blood vessels). There are risks related to
the use of all vascular access, including bleeding and site infection.

Most units have a small number of cubicles to provide added dignity

and privacy for circumstances such as palliative care or where
greater complexity of nursing is required.
A haemodialysis unit is an extremely busy clinical environment with
very sick and dependent patients. The presence of ‘non-essential’
individuals within these areas needs to be carefully considered in
this context.

3.2 Factors for consideration

3.2.1 Space
A number of new and replacement units have been built to
newer Health Building Notes specifications that provide more
space for each dialysis station. This was to ensure appropriate
access to the patient for clinical care and emergencies, and
does not take into account bedside visitors.
There are a smaller number of units where space available is
less than the Health Building Note recommendations, and this
places even greater restriction / limitations.

3.2.2 Infection Control

Dialysis patients have compromised immune systems as a

result of their kidney disease. The nature of dialysis means
that the unit uses a large volume of sharps, swabs and
dressings. There is a consequent risk of exposure to blood and
other bodily fluids. Whilst staff are at greatest risk, universal
precautions such as vaccination against blood borne viruses,
Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 5 of 9
 and the wearing of gloves, aprons and visors all help to
minimise such risk. Unprotected visitors would be placed at
greater risk.
Connect and disconnect periods are particularly risky because
of the potential contact with blood.
Blood borne viral infections are of particular concern and all
individuals in frequent contact / presence of dialysis treatments
should ensure they have been vaccinated appropriately.

3.2.3 Privacy and Dignity

The layout of dialysis units for functionality can reduce the

opportunity for privacy and dignity. This means that bed side
conversations, which may be difficult and sensitive, can be
easily overheard by anyone in the area.
Some units are linked to acute hospitals and provide treatment
for inpatients that are transferred across for their dialysis.
These patients can be particularly unwell / confused and
anxious.
For some, unit haemodialysis is provided as part of palliative
and end of life care. This is often provided within a cubicle or
side room within the unit, but this is not always possible.

3.2.4 Time requirements

Unit haemodialysis is an outpatient service i.e. the patients are

transient, passing through the unit for a specific treatment
before returning to the normal residence or another hospital
ward three times a week.
Typically treatment consists of four hours dialysis plus the time
taken to travel to and from the unit. It is not uncommon for
the total time away from home to be 6-8 hours per treatment.

4. National Policy Statement

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 6 of 9
4.1 National Policy

On the basis of the above factors, the WRCN clinical

community has agreed that the routine presence of relatives
and carers is not appropriate.

4.2 Responding to individual circumstances

There may be individual circumstances where the presence of a

relative / carer is required or appropriate and these should be
considered on case by case basis. Attendance should only agreed in
advance by Senior staff in the unit concerned, and the relative /
carer should be vaccinated appropriately and provided with an
agreed set of boundaries e.g. time limits; not being present during
connect / disconnect times.

Such circumstances could include:

 Where the relative / carer communicates on behalf of the
patient e.g. where a patient has communication difficulties or
language barrier
 To provide psychological support as agreed at the renal MDT
to ensure compliance with treatment
 Where the patient is on the end of life pathway and dialysis is
being provided to manage symptoms.

4.3 Requirements of agreed visitors

Given the issues relating to infection control, any individuals with

agreed visiting arrangements who have symptoms of an active
infection e.g. cough, sneezing or recent gastrointestinal upset must
not attend the unit.

It is reasonable for the clinic manager to refuse access in such

circumstances in order to prevent the potential spread of infection.

There may also be a requirement to be vaccinated as part of the

infection control measures at the unit. This will be advised by the
renal team.

Individuals must recognise the communal nature of dialysis units

and respect requests by clinical staff to wait outside the clinical area

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 7 of 9
during periods such as connect / disconnect, clinical visits to
adjacent patients and during emergencies.

4.4 Process for requesting access

The patient and the relative should make a formal request to the
Consultant responsible for their care in writing setting out why the
request is being made. This will be considered by the Consultant
and the relevant Dialysis Unit manager and considered against this
policy.

4.4.1 Request not approved

 Where the decision is to decline the request, the reason(s)

should be clearly stated.
 Appeals should be directed to the Directorate Manager for the
renal service.

Where the decision to decline routine access is supported following

appeal, relatives will be expected to comply with this decision.
Visitors who attempt to attend without permission will be declined
entry. Repeated attempts will be escalated to the Health Board who
will handle this as per their policies for security and acceptable
behaviour.

4.4.2 Request approved

 Where the decision is to accept the request, limitations (if

applicable) should be clearly set out and shared with the
patient and family member in writing. This will become an
agreement between the family and the renal service regarding
routine access.

Given the busy nature of dialysis units the number of routine

visitors will be limited to one individual unless there are exceptional
circumstances and these will be considered on a case by case basis.

5. Putting Things Right: Raising a Concern

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 8 of 9
Whilst every effort has been made to ensure that decisions made
under this policy are robust and appropriate for the patient group, it
is acknowledged that there may be occasions when the patient,
visitor or their representative are not happy with decisions made.
They should be guided by the clinician, or the member of NHS staff
with whom the concern is raised, to the appropriate arrangements
for management of their concern.

6. Equality Impact and Assessment

The Equality Impact Assessment (EQIA) process has been

developed to help promote fair and equal treatment in the delivery
of health services. It aims to enable Welsh Health Specialised
Services Committee to identify and eliminate detrimental treatment
caused by the adverse impact of health service policies upon groups
and individuals for reasons of race, gender re-assignment,
disability, sex, sexual orientation, age, religion and belief, marriage
and civil partnership, pregnancy and maternity and language
(welsh).
This policy has been subjected to an Equality Impact Assessment.
The Assessment has shown that there will be no impact.
For patients, access to unit haemodialysis is decided between the
nephrology Multi-Disciplinary Team and the patient (and their family
/ carers) and is based on the opportunity to benefit clinically,
socially and emotionally from the treatment.
All patients are counselled when due to start dialysis and factors
such as their identify, how they wish to be addressed etc are dealt
with. There is to be no change to this part of the pathway and as
such, no bearing on gender, religious beliefs, etc.
The decision to allow (or not) routine visitors will be determined on
an individuals’ circumstance and will reflect the decision of the MDT
in applying this policy. It will take into account aspects such as
disability, communication and treatment compliance for the patient,
as well as the wider issues of infection control, health and safety
and privacy and dignity for all at the dialysis unit.

Version: 0.1
Specialised Services Policy: Patient / Carers access to Haemodialysis Units
Page 9 of 9