Nurses and patient care technicians are on the front lines in the multiple short-term and long-term dialysis units that are caring for patients who may have COVID-19. Dialysis patients and staff have been hit hard by this virus, with more than 6000 patients and more than 700 staff members receiving positive test results as of April 21, 2020. More than 790 dialysis patients have died as a result of COVID-19.
Seattle was the initial locus of the virus, and the first death in the United States was that of a dialysis patient. New York City then became the “leader” in this horrible “contest,” with the most cases identified.
Nurse leaders in Seattle and New York City were asked to respond to questions about their experience, challenges, and advice for others. Liz McNamara, MN, RN, is vice president of patient care services and chief nursing officer for Northwest Kidney Centers in Seattle; Diane Morris, MS, MR, CNN, is director of nursing and clinical services for the Rogosin Institute in New York City.
We understand that the first patient death in the United States occurred in a patient at one of your dialysis centers. Had the patient been in a dialysis center during the period when he would have been contagious? How did your staff become aware of the patient having COVID-19?
McNamara: The first patient who died had last undergone dialysis in the outpatient facility 7 days before he died; so yes, we did provide care within the 14-day window. He was only symptomatic the last day he received dialysis with us, but he did report that he had been feeling unwell for 2 or 3 days prior. He died on a Friday night, and the clinic was closed on Saturday. We crafted an all-staff message that was texted out to ask all recipients to check their e-mail and to let all Northwest Kidney Center (NKC) staff know that the reported death was an NKC patient. We (leadership) went to the unit early Sunday morning and talked with the affected staff directly. The leadership also spoke with each patient individually that Sunday. I felt it imperative that patients hear from us directly rather than hear the news in the media.
How have your staff reacted to the need to care for patients with COVID-19?
McNamara: It has really ebbed and flowed. Many staff are quite frightened, because there is not much in the media about the mild cases and patients who do well. This type of disease was pretty new to outpatient dialysis. Both our chief medical officer and I have daily phone calls for the staff and physicians. We give updates from the county and the local hospitals, and then we field questions. This was very powerful in the early days. I have done calls with each unit and also with our acute care services division.
Morris: The staff have been very anxious for their own safety and the safety of their families. The concerns regarding limited personal protective equipment (PPE) add to their worries. We asked for volunteers from the staff to care for the known COVID-19–positive patients, and in each of our units, staff members volunteered.
How have you isolated COVID-19–positive patients? Are they in the same dialysis facility as COVID-19–negative patients, on different shifts, or in a different facility?
McNamara: We have 19 clinics, and all but three of them have a private room. We are not cohorting COVID-19–positive patients in one unit but have stood up the ability to perform dialysis to patients in modified contact/droplet precautions in each clinic. We plan to continue to provide patients care in their home units where they know the staff and are most comfortable.
Morris: The majority of the Rogosin Institute dialysis units have an open fourth shift on Tuesdays, Thursdays, and Saturdays. We have elected to keep the patients under investigation (PUIs) and COVID-19–positive patients in their respective dialysis units and segregate them on the fourth shift. We are keeping a distance of 6 feet between machines and patients, and the groups (i.e., COVID-19–positive patients and PUIs) are separated from each other. We are also planning on the possibility of cohorting patients from various facilities into a selected location by borough should there be a surge of COVID-19–positive patients needing dialysis.
What would cause you to transfer a COVID-19–positive patient to the hospital?
McNamara: The only reason we would send either a COVID-19–positive patient or a PUI to the hospital is if they are clinically ill enough to go.
Morris: We have asked patients to call before coming to dialysis if they have fever, cough, or respiratory distress. If the distress is severe, we instruct them to call 911 from home, and go to the hospital. If the patients do not have respiratory distress, we tell them to come to dialysis. These patients are met at the door, and a surgical mask is placed on them. Their temperature and symptoms are assessed. A patient who is a PUI will be diverted to a shift caring for PUIs, or if the symptoms warrant it (fever, cough, or respiratory distress), the patient is sent to the hospital.
Do you dedicate staff to the care of only COVID-19–positive patients?
McNamara: No; with the use of proper PPE there is no reason to do that.
Morris: We are seeing COVID-19–positive patients returning from the hospital before their test results are negative. We have dedicated staff to care for these patients.
What strategies have you put in place to deal with the psychosocial needs of both patients and staff?
McNamara: This is really an evolving issue. We have created patient letters and walked through how to have the conversation with a patient with our staff. For our staff we have provided our usual employee assistance program resources, along with some supplies that may be hard for them to get, like toilet paper, cleaning products, and a weekly treat delivery. This is an area we are continuing to work on.
Morris: We have seen a lot of anxiety among staff because they are fearful they will catch COVID-19 or infect their families. We have a psychologist on staff who has put together a program of Zoom support calls for the staff to ask questions and express their fears. We also have a yoga therapist who works with our patients and provides a daily meditation for the staff through Zoom. As part of the Rogosin employee benefit package, the staff also have access to counseling and telemedicine. Our unit managers have also been active in supporting the staff, especially when they have child care or transportation issues. Additionally, our nurse managers and administrators are conducting daily huddles with the staff to answer any questions or concerns they may have. The social workers and the psychologist have provided support for the patients. The patients have not expressed the degree of anxiety about the virus that I expected. I suspect they see the dialysis unit as a safe place where they receive care by well-trained staff, so they feel well cared for during treatment.
If you are experiencing a shortage of PPE, what is in short supply, and what measures are you taking?
McNamara: Surgical masks are of concern. We are wearing them longer than we normally would. We have been working to actively source more masks, and several of our dialysis partners have been helping us. We are having hand sanitizer made. We are accepting hand-sewn masks from the community but are using those for our patients and saving the medical-grade masks for our staff. We have also created NKC bandanas for our patients to use, which can be used in place of or in addition to the hand-sewn masks. We also offer these to our transport drivers as a thank-you.
Morris: We have experienced difficulty in obtaining surgical masks, N95 masks, shoe covers, impermeable gowns, thermometer probe covers, and disposable thermometers. We were able to obtain nondisposable face shields for all the staff members, and we have distributed face masks to wear under the shields as an added layer of protection. We have asked staff to conserve the face masks. We continue to take the temperatures of staff, patients, and their companions daily on entry to the dialysis unit building.
What are the biggest challenges you are facing during this pandemic?
McNamara: The biggest challenge right now is supplies. We started actively conserving supplies early on, but surgical masks and disposable gowns are at the top of my concern list. Hand sanitizer as well. We are working with a compounding pharmacy to actually make our own! The other challenge has been all the different sources of information. At the end of February, the World Health Organization came out and very clearly stated that COVID-19 was spread primarily by droplets and was not airborne like tuberculosis. Canada followed suit, as did our local healthcare systems here in Seattle. We have followed that guidance, knowing the potential of airborne organisms, with highly aerosolized generating procedures. It is matching the PPE to the exposure risk. The CDC has not officially stated the route of transmission, so there is a lot of confusion, and with all the different media reports, that has been tough. I will say that our local county public health department and the CDC team that worked on site with us for the first 2 weeks of March have been amazingly supportive.
Morris: The conservation of PPE and managing staff anxiety have been the biggest challenges.
Do you feel you have all the resources you need to care for your patients?
McNamara: I think all of us wish we could have additional staff when they may be needed. The only other resource I worry about is the supplies.
Morris: We do have the resources we need, but we have been very careful to conserve them because we have experienced great difficulty in finding sources from whom we can purchase PPE.
If necessary, has the local or federal government provided you with the resources you need to provide safe care to your patients and a safe work environment for your staff?
McNamara: The King County public health department has been a great source of information, and I am still in contact with our CDC colleagues who came on site early in the pandemic.
Morris: We participate in a weekly webinar from the New York state department of health on COVID-19 updates. The state department of health staff have also been available by phone to answer our questions. Unfortunately, no outpatient testing is available to us. We have applied to the New York City office of emergency management for surgical masks and hope to receive a shipment soon.
Are you facing any staffing concerns with staff having to be quarantined? If so, how are you dealing with those staffing shortages?
McNamara: The guidelines around quarantine changed during about our second week. We actively screen all of our healthcare workers for symptoms every day when they come in to work. This is a symptom screen (cough, shortness of breath, sore throat) and temperature that is documented daily. Staff who are asymptomatic can work. If they experience symptoms they must go home.
Morris: We have faced staff shortages but have managed to staff the dialysis unit normally. We have discussed contingency plans in the event the staff shortages worsen, and we may consider shortening the dialysis day to be able to cover with a single shift of staff.
Have you experienced an increase in patient absences resulting from fear of contracting COVID-19? If so, what measures have been taken to combat those fears?
McNamara: We have not seen an uptick. We are really giving our patients messages about what they can do for staff, and the number-one thing is to come to dialysis. We want them to feel safe with us.
Morris: Interestingly, we have not seen an increase in patient absences except for hospitalized patients. Again, I suspect patients see the dialysis unit as a safe place where they receive care by well-trained staff, so they feel safe and well cared for during treatment.
What about home patients?
McNamara: Our home patients have been faring well. The home program is now scheduling virtual visits with them, and we are doing some online education for choices classes so we can continue to help patients choose home or go home. The mask supply has affected our PD patients, so we are having them reuse their masks for multiple days. We have also created NKC bandanas that patients can wear to extend the life of their masks.
Morris: We are seeing home patients by videoconference or phone if the patients cannot manage Zoom. We have mailed their medications to them. The PD patients are using a community laboratory to have their blood drawn. We are completing training with those who had started. We have patients with PD catheters who are receiving flushes, but we have not yet determined a training schedule for them. We will continue to offer new patients modality options, but we will delay the start of training until this crisis is over.
Do you feel your emergency preparedness plan prepared you for this pandemic? Explain.
McNamara: Yes; we immediately stood up our emergency operations command center, and having worked together in that structure before really helped us. Although this is different from our last emergency related to heavy snowfall in 2019, many of the issues were the same: transportation, missed treatment follow-up, staff coverage. Within that structure, the leaders continue to meet daily and to provide a daily communication update that goes to all staff, including our physicians and nurse practitioners.
Morris: The emergency preparedness plan has been effective in guiding staff and patient communication. It provides the units with a framework in which to operate if we have staffing shortages. We’re considering adding the difficulty in obtaining PPE supplies in a pandemic scenario, along with cohorting affected patients and other pandemic scenarios, to our hazard vulnerability assessment tool.
Is there anything else you would like to share?
McNamara: This is an unprecedented time in healthcare, and being at the forefront of an evolving pandemic has been both challenging and rewarding. I see our nurses shine every day, using those skills and keeping our patients safe. I do think that much of what we have stood up will continue: the extra environmental cleaning, and the screening during our next flu season. Modified contact droplet precautions may indeed have a positive impact on our regular virus season.
Morris: I would like to thank Liz McNamara and the team at Northwest Kidney Centers for freely sharing their experience with COVID-19 early in this epidemic. Their information was invaluable in allowing the team at Rogosin to prepare our units for the epidemic in New York City.
We thank Liz McNamara and Diane Morris for sharing their experiences. Both Northwest Kidney Centers and the Rogosin Institute are independent small chains. The two largest dialysis providers, Davita and Fresenius Medical Care, have received waivers from the Centers for Medicare & Medicaid Services to allow them to establish designated isolation centers, which are paired centers where one will accept COVID-19–positive patients and the other will accept COVID-19–negative patients as a way to segregate these groups of patients. These centers are open to all providers who agree to participate. Also, daily calls are conducted by the Kidney Community Emergency Response Coalition. These calls offer the opportunity to ask for help with supplies, including PPE.
For direct care staff seeking more information and support, the American Nephrology Nurses Association (ANNA) has developed a COVID-19 webpage (https://www.annanurse.org/article/coronavirus) on the ANNA website to share innovative measures being taken to provide the safest and most efficient care to these patient populations. The webpage is updated several times daily with the latest evidence, policies, and advocacy opportunities. ANNA’s virtual community, known as Open Forum, is another way information and best practices are shared. ANNA is also sharing continuing education content at no cost to members and nonmembers to expand knowledge and science during this unprecedented time.
ANNA recognizes that nephrology nurses are providing care to patients under unconventional circumstances in an environment where there has been an increase in acute kidney injury cases related directly to COVID-19. Tamara Kear, ANNA’s chief executive officer, reports that ANNA has been working with other associations and healthcare organizations to provide resources to nurses and other healthcare providers caring for patients with kidney failure, those receiving dialysis, and those receiving continuous renal replacement therapy. ANNA is proud of all members who are providing direct and indirect patient care during this challenging time.
Screen everyone, staff and patients, each time they enter the unit—by phone if possible, or at the entrance.
Isolate COVID-19–positive patients as much as possible.
Reinforce education of staff on the importance of PPE, strict adherence to hand hygiene, and cleaning surfaces between patient treatments. Identify champions to troubleshoot areas where compliance seems to lag.
Hold leadership rounding in the unit; talking to staff lends credibility to promises of support.
Data are helpful—share your own numbers constantly with staff.