Standards › Standard 26 › Policies
Policy · DIA-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 26.4
At a glance
- A dialyser is reused only if it is marked for reuse by the manufacturer.
- Reprocessing follows the validated procedure, and each cycle is recorded (DIA-REG-001).
- A dialyser is used only on the patient it came from.
- A dialyser that cannot be traced to its patient is not used.
- Stop and get help straight away if: a dialyser is reused on a patient other than the one it came from.
1. Purpose
To make sure dialysers are reused only where permitted, reprocessed safely and traced to their patient (26.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Dialysers are reused only in some services and only when they are marked for reuse. A reused dialyser that is not properly cleaned or traced can transmit infection or fail.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dialysis unit lead | Owns the reuse and reprocessing rule | Clinician or manager |
| Reprocessing staff | Reprocess and record each cycle | Staff |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Check the mark.
- Check the dialyser is marked for reuse before reprocessing.
Key point: Checked.
Step 2. Reprocess.
- Reprocess to the validated procedure, and record each cycle on DIA-REG-001.
Key point: Reprocessed.
Step 3. Trace.
- Keep the dialyser with its patient and cycle count, and use it only on that patient.
Key point: Traced.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Reused dialysers traced to the same patient and within the cycle limit | 100% | Monthly | Dialysis unit lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| DIA-REG-001 | Dialyser traceability and reprocessing register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 23500:2019 (fluids for haemodialysis) and the KDIGO Clinical Practice Guideline for Hemodialysis Adequacy (2015 update). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Dialysis & Renal Replacement Therapy (AMB-12)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)