Dialysis Centers Adapt to Evolving COVID-19 Outbreak

Maintaining patient care, reducing transmission are priorities

Bridget M. Kuehn
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Dialysis centers across the country are taking extraordinary measures to ensure the safety of patients and staff during the Coronavirus Disease-2019 (COVID-19) pandemic. The team at Seattle’s Northwest Kidney Centers found itself on the leading edge of that effort when they learned that one of their dialysis patients was the first US fatality.

“Our guiding principles were first and foremost to ensure that patients are coming to dialysis,” said Suzanne Watnick, MD, Chief Medical Officer, Northwest Kidney Centers.

Watnick and Elizabeth McNamara, Vice-President of Patient Care Services and Chief Nursing Officer, shared their experiences during a webcast hosted by ASN’s Nephrologists Transforming Dialysis Safety (NTDS) initiative. They were joined in the call by leaders from NTDS and Shannon Novosad, MD, MPH, a medical officer with the Dialysis Safety Team in the Centers for Disease Control and Prevention’s (CDC) Division of Health Care Quality Promotion. ASN has also teamed up with the CDC to create a COVID-19 Response Team that meets weekly. The team published its first set of recommendations in the Clinical Journal of the American Society of Nephrology and expects to issue frequent updates. It is all part of an ongoing effort by leaders in nephrology to help keep clinicians abreast of the latest information in the rapidly evolving pandemic.

“It’s a challenge being on the forefront of an evolving pandemic,” McNamara said. “That’s what I told the staff: ‘What we said yesterday might change today. What we said two hours ago might change, and it’s not because we have wrong information. It’s because we’re finding out new information, so we have to stay facile. We have to able to adapt.”

Evolving US response

Given how much the COVID-19 outbreak has evolved since it was declared a pandemic by the World Health Organization on March 9, 2020, Novosad said it is critical for dialysis centers to plan ahead for what may come next.

Watnick said they immediately began coordinating their efforts with the CDC and local public health authorities to facilitate their response and crafted a letter to patients notifying them of the patient death and the precautions they would be taking.

“We wanted to be transparent and felt they had the right to know,” McNamara said. Staff were trained in droplet precautions and protocols to follow for patients with suspected or confirmed cases, patients were screened for potential symptoms, and strict protocols for regular disinfection of all surfaces were enacted.

Alan Kliger, MD, chair of NTDS, noted that older patients, particularly those older than 80 years, and those with chronic conditions like heart disease, lung disease, and diabetes appear to have the greatest risk of dying. Although data are limited, he noted that patients with kidney disease are expected to be at higher risk.

“Kidney care patients typically have multiple chronic conditions, which make them a vulnerable population in general, and it’s no different in this situation,” said Jeff Giullian, chief medical officer for DaVita, in an e-mail interview. “The safety of patients is our top priority, which is why we’ve been actively educating both patients and clinicians on the importance of maintaining discipline with infection control practices and the CDC’s established best practices for helping prevent exposure to this and other diseases.”

Communication with patients is critical, Kovosad emphasized. This should include basic information about COVID-19 through posters, letters, or staff talking points. Patients should know what symptoms to look for such as fever, cough, sore throat, and muscle aches. They should also be educated about the precautions being taken to protect them and how they can help, for example, by using cough etiquette or proper handwashing.

“It helps patients take an active role in staying healthy and it also helps a number of procedures that clinics will be implementing, such as screening,” she said.

Communication with staff and transparency about procedures and policies is also vital, Kovosad said. Staff need to be kept up to date on how to keep themselves and patients safe. They must be trained in the use of protective equipment and have easy access to it and receptacles for disposal. She also said dialysis centers should ensure sick leave policies are “non-punitive and flexible” and that staff know what they are.

“It’s important that healthcare personnel understand they can be a source of infection both to other patients and fellow staff members and they shouldn’t report to work when ill,” she said. If they develop symptoms at work, they should immediately don a mask, inform their supervisor, and leave the treatment area. During times of community transmission or when infected patients are in the facility, they may also want to check their temperature regularly.

Multidisciplinary cooperation and planning are also key. Giullian said DaVita established domestic and international task forces in January, made up of people who specialize in emergency management, infection control, and supply chain management and communications. They’ve also been working closely with the CDC, ASN, Kidney Community Rapid Response, and other providers, he said.

“What many people don’t know is how connected and supportive providers in the kidney care community are of one another in times of need,” he said. “Establishing and engaging proactively and consistently with these organizations helps all of us better support our patients.”

One step that all facilities should take now is an inventory of their personal protective equipment and preparing to have supplies conveniently available, Kovosad said.

“If your facility is concerned about a potential or imminent shortage of [personal protective equipment], definitely contact your state or local health department,” she said. “They are in the best position to help you troubleshoot through temporary shortages.”

“We worked closely with our vendors and distributors to secure supplies of medications, dialysis disposables, and personal protective equipment,” Giullian said.

Facilities should also develop triage protocols, for example, having symptomatic patients call ahead. Symptomatic patients should wear masks while in the facility, be kept at least six feet from other patients, and be dialyzed at the end of a row or in a private room with the door closed, if available, Kovosad said. If a center has numerous symptomatic patients, they may wish to begin cohorting them and the staff who treat them, for example, dialyzing them on the last shift to allow for disinfection.

When a patient is diagnosed with COVID-19, the local public health department should be notified immediately, she said. These patients, or those with suspected cases, should be treated in a separate room, but negative air pressure is not currently recommended, she noted.

“We can provide dialysis to patients with COVID-19,” Watnick emphasized. “We have an obligation as a community to provide it so our patients are receiving the safest and most effective care.”

Watnick offered reassuring advice to other centers about the outbreak. She emphasized following the latest science and working in collaboration with the CDC and local public health authorities. She also emphasized the role centers can play in helping to reassure staff and patients. Watnick noted that their centers are in daily communication with staff, including having daily conference calls to field questions.

“There’s a lot of fear, a lot of anxiety, not only for our patients, but also for our staff and the community in general,” Watnick said. But she said centers can provide reassurance, be transparent, communicate well, and provide as much support as possible for patients, the dialysis staff, and the medical staff.

International perspectives

While some US dialysis centers are still bracing for the effects of COVID-19, their colleagues in other parts of the world are offering advice and early data about what to expect. In a recent overview of the data, Vivekanand Jha, MBBS, MD, DM, PhD, President of the International Society of Nephrology and Executive Director of the George Institute for Global Health in Newtown, Australia, highlighted the data so far on the potential kidney effects of COVID-19.

“The data is limited essentially to people who present to hospitals and are admitted afterward—individuals who have a more advanced COVID infection,” he cautioned.

Among people admitted to hospitals with the infection, more than half had some kidney involvement such as proteinuria and a smaller proportion also had a decline in the filtration function of the kidneys, Jha noted. In an unreviewed manuscript published on the preprint server medRxiv, Yiquiong Ma, of the department of nephrology at Renmin Hospital of Wuhan University in China, described the experience of one dialysis center in Wuhan where the virus originated. Between January 14, 2020, and February 17, 2020, 37 of the center’s 230 hemodialysis patients and 4 of its 33 staff were diagnosed with COVID-19. Seven patients died during that period, including 6 with COVID-19. The COVID-19–infected dialysis patients had a different immunologic profile than other patients infected with the virus. The dialysis patients had fewer lymphocytes and fewer inflammatory cytokines.

The Chinese Society of Nephrology and the Taiwan Society of Nephrology have leveraged their countries’ experience on the leading edge of the pandemic to develop guidelines for dialysis centers around the globe. A summary of the guidelines was included in Jha’s paper. Among the recommendations are screening patients at the door, separating staff during lunch breaks, appropriate protective gear for staff, protective gear for transport personnel, and cohorting patients and staff to avoid cross-contamination. Communication was also emphasized.

Most dialysis centers around the world are adapting on the fly. Jha said the unprecedented scale of the pandemic makes it a unique situation compared to the previous outbreaks of the related SARS and MERS viruses.

“Dialysis units are developing their own practices for containment,” Jha said. The key, he said, is to ensure uninterrupted access to dialysis including for those with COVID-19 infections. He also argued for judicious use of protective gear in the face of potential shortages, “just to make sure that we maintain a sense of balance as we deal with this condition.”

Kliger, the lead author of the COVID-19 Response Team’s recommendations, echoed the call for a steady response through the pandemic.

We are witnessing a response to a pandemic that we have never seen before,” Kliger wrote. “Such unprecedented steps create anxiety and uncertainty in us all.”

But he noted that most people with COVID-19 infections develop mild symptoms and survive without complications. Children seem to do well. Elderly and high-risk people must think carefully about how to protect themselves.

Our best strategy to stop viral transmission is frequent hand hygiene, social distancing, avoiding contact with infected people, and if we develop symptoms, self-quarantine, use cough/sneeze etiquette, wash surfaces with disinfecting spray or wipes and keep informed about best practices from the CDC and local health departments.

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