Preparing for the Surge Nephrologists Prepare for Fall COVID-19 Surge, Increased Dialysis Demand

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As the COVID-19 pandemic started sweeping across the United States this spring, hospitals began preparing for a surge in critically ill patients by increasing the numbers of intensive care unit (ICU) beds and trying to secure more ventilators. But they were “blindsided” by a huge increase in the need for renal replacement therapy among COVID-19 patients and the resulting shortages in dialysis nurses, equipment, and supplies, said Anitha Vijayan, MD, professor of medicine at Washington University in St. Louis.

“We were completely caught off guard by the proportion of patients with acute kidney injury who required dialysis,” said Sumit Mohan, MD, associate professor of epidemiology and medicine at Columbia University in New York City. Some New York hospitals documented rates of AKI higher than 30% (1).

As hospitals across the country brace for a potential second surge of critically ill COVID-19 patients, ASN and the Department of Health and Human Services are urging nephrologists to take a leading role in preparations. The two organizations hosted two 90-minute roundtable sessions to identify best practices for managing a dialysis surge. The insights gleaned during the sessions have been summarized in a the Scarce Resources Roundtable Report (2).

“The collaboration between ASN, CMS [Centers for Medicare & Medicaid Services], Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and ASPR [Office of the HHS Assistant Secretary for Preparedness and Response] demonstrates how successful public-private partnerships can be in helping hospitals identify the resources they need to care for these patients,” said Kristen Finne with the HHS COVID-19 Ambulatory Care and Dialysis Team, Health Care Resilience Working Group. “These roundtables were instrumental in identifying best practices and lessons learned from the early days of the pandemic that can be used today across the country and showed the importance of nephrologists collaborating within hospital response structures to ensure COVID-19 patients had access to the dialysis care they needed to improve patient outcomes.” Finne is also director of the HHS emPOWER Program and senior program analyst, HHS/ASPR/EMMO/Readiness.

Machines and disposables

As the number of ICU beds at Michigan Medicine increased from 100 to 250 to accommodate the surge of COVID-19 patients this spring, Michael Heung, MD, MS, professor of nephrology at the University of Michigan, and his colleagues scrambled to bring in more continuous renal replacement (CRRT) machines. They purchased a couple more CRRT machines and borrowed unused hemodialysis machines from outpatient centers. But acquiring the necessary renal replacement supplies became a challenge, as suppliers limited hospitals to purchasing 110% of their usual supplies, Heung said.

“Everybody was trying to get more supplies around the country,” Heung said. “We were having double the volume, so [110%] wasn’t good enough.”

At the epicenter of the pandemic in New York City, Mohan and colleagues were running twice as many CRRT machines and deployed a machine-sharing protocol to further double the capacity. To meet their excess demand for dialysate, the CMS, in collaboration with ASPR and the Strategic National Stockpile, helped them find some additional small suppliers, Mohan said. They also began using dialysis machines to make ultra-pure dialysate in-house and sought FDA guidance and public health department approval to use it if they ran out of commercially produced dialysate.

“We developed, tested, and deployed our production system, but we were fortunate that we never pulled the trigger on their direct use because we came right up to the precipice of running out of commercial dialysate] but never fell off the cliff,” he said.

Staffing

Most hospitals only have a small team of skilled dialysis nurses and other nurses can’t be easily trained so many teams were working overtime, said Faith Lynch, MSN, RN, who leads a 10-nurse team as clinical nurse manager at New York University Winthrop in Mineola, New York.

“We were working like 6 to 7 days a week, night and day, trying to dialyze patients,” said Lynch, who is also Acute Care Specialty Practice Network Leader at the Nephrology Nurses Association. To extend their capacity and cover for nurses who became ill, the team began cohorting patients in groups of four cared for by two nurses. Eventually, they were able to add traveling nurses to the team.

Many patients with severe COVID-19 experienced excessive blood clotting, which further exacerbated supply and skilled staffing shortages by causing frequent filter clogs and requiring anticoagulation protocols, noted Vijayan, who co-authored the Scarce Resources Roundtable Report.

Early planning is critical

The report recommends that hospitals create a scarce resources plan now and begin making preparations for potential shortages of skilled dialysis nurses, renal replacement machines, and renal replacement supplies.

“You need everyone involved,” Vijayan said. “You need critical care nursing, pharmacy, you need the nephrologists involved, everyone needs to come to the table to develop a protocol.”

Lynch also emphasized the need to involve nurse managers, administrators, and frontline nurses in both preparations and implementation.

“Nurses that are actually dialyzing the patients are the ones that are dealing with the reality,” she said.

Developing a staffing surge plan and cross-training nurses who can help train dialysis nurses in advance is also critical. The report recommends establishing a “buddy system” where nurses not familiar with CRRT can work with ICU nurses thereby increasing the number of dialysis machines that the trained ICU nurse can support. Staffing plans need to take into account possible quarantine following exposure, as well as reassigning those who are immunocompromised or at high risk from COVID-19, Mohan said.

The plans need to be flexible and able to adapt to changing circumstances. For example, a shortage of machines led Mohan and his colleagues to develop an alternating 24-hour protocol, which was associated with an increase in the use of supplies and increased nursing burden.

Training also needs to begin now to implement new protocols such as citrate anticoagulation, which Vijayan noted cannot be learned on the fly. “If you don’t institute the protocol properly it will lead to more patient safety events,” she said.

Starting planning as early as possible and including nephrologists, who are most familiar with the supply chain and knowledgeable ways to do dialysis creatively, from the beginning is key, Heung said.

“It’s critical,” he said. “Nephrologists absolutely need to be taking the lead.”

References

1. 

Hirsch JS et al Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020; 98:209–218. doi: 10.1016/j.kint.2020.05.006

2. 

ASN/HHS “Scarce Resources Roundtable Report” https://www.asn-online.org/includes/cms/covid-19/uploads/Scarce_Resources_Roundtable_Report_FINAL_09.08.2020(a).pdf

October-November 2020 (Vol. 12, Number 10 & 11)