CDC Recommendations for Dialysis Centers Grappling with COVID-19

Infection control strategies

The Centers for Disease Control and Prevention’s (CDC) COVID-19 website for dialysis providers now includes more detailed information about screening for COVID-19 and triage of patients upon arrival at dialysis centers, said Shannon Novosad, MD, MPH, medical officer with the Dialysis Safety Team in the Division of Healthcare Quality Promotion at the CDC. She noted that the recommendations haven’t changed, but that many centers had questions about them or difficulties following them.

“If the screening and triage is not happening as effectively as it could be, it really kind of sets you up for not being able to implement all of the other recommendations in terms of patient and healthcare [staff] protection,” Novosad said.

She emphasized the need for a multilayered approach, with patients who have symptoms calling before arrival to ensure the center is prepared. Some centers are helping to remind patients to call ahead through robocalls or texts a few hours before their scheduled dialysis, Novosad said. Screening and triage should also take place on patient arrival at the door or outside as weather permits. Patients with symptoms should don a mask at arrival.

Given current supply chain difficulties, Novosad recommended that if dialysis centers change disinfectants, they must ensure that the new product’s label indicates it is effective against bloodborne pathogens. “We don't want to cause any other inadvertent infections or increase the risk for bloodborne pathogens with the use of these new disinfectants,” she said.

The CDC, working with ASN, has created a dialysis facility checklist to help walk leaders through what they may already have in place or additional steps they need to take during the COVID-19 pandemic.

“In communities that have not had a lot of cases yet, this tool could be valuable for thinking through how they are preparing,” she said.

Another challenge dialysis centers are grappling with is determining when personnel can return to work or when transmission precautions can be removed after a suspected or confirmed case of COVID-19 in a patient. The CDC has recommendations for centers using a test- or no-test–based strategy.

“In a lot of areas, testing capacity is still not what it should be, and it’s really difficult to get sometimes the required number of tests to be able to make some of these decisions,” Novosad said. “Even in places where there is more widespread testing available, I think getting dialysis patients to wherever this testing is happening could be very difficult to actually implement in real time.”

When tests are available, two negative tests 24 hours apart are recommended before a staff member returns, she said. If no testing is available, employees may return at least 3 days after recovery, defined as the absence of fever without medications, and at least 7 days after the first symptoms appeared. Facilities may want to consider adding more days prior to return for personnel who work with immunocompromised patients.

“If it has been less than 14 days since illness onset, the healthcare providers should consider wearing a face mask at all times within the healthcare facility,” Novosad said.

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Dialysis centers should also carefully develop strategies for preserving their personal protective equipment (PPE) and tweak them based on their needs. If PPE-preserving strategies are implemented, she emphasized that front line staff should be informed why they are in place and how to most safely follow procedures. She also noted that numerous potential PPE sources are becoming available and urged centers to contact their state public health department for help.

“We all know that PPE shortages are posing a tremendous challenge to our healthcare system,” she said. “PPE optimization strategies are really only meant to be options for providing ongoing patient care when supplies are stressed or running low, or in some instances even absent.”

Transportation precautions

Safe transportation for dialysis patients during the pandemic is another concern. Only about one-quarter of patients arrive for dialysis via private cars, 7.9% take public transportation or taxis, and 66.8% use a van or ambulance service, according to 2013 data from the US Renal Data Service. Medicare only covers transportation in emergencies. Medicaid does cover transportation.

“It’s important that we recognize the patients who have barriers to get to dialysis as otherwise they will end up in the emergency room,” said Anitha Vijayan, MD. “This is absolutely not what we want at this time for sure.” Vijayan is professor of medicine at Washington University in St. Louis and director of the Acute Dialysis Unit at Barnes-Jewish Hospital.

New York state has provided guidance for its public transport agencies on proper cleaning and disinfection for public transportation, and some dialysis transportation companies have been proactive, she said. For example, LogistiCare has instructed drivers on CDC guidance for cleaning and disinfection, and the company eliminated the need for signatures to verify trips in order to reduce the need to touch devices or pens. They are also transporting confirmed or presumed cases one at a time via ambulance and providing solo van rides for patients at high risk of harm from COVID-19.

If a patient arrives with symptoms after transport or is diagnosed with COVID-19, it is important for the dialysis center to notify the public health department, their transportation company, or the patient’s nursing facility immediately, Vijayan noted. This ensures that contact tracing, cleaning, and necessary quarantine precautions are taken for drivers or other patients who may have been exposed.

“It’s important that both the medical directors and the nurse managers familiarize themselves on how the patients are being transported to the dialysis facility,” Vijayan said. “It’s important that we communicate with them ahead of time to understand what mitigation and containment strategies [transportation companies] already put in place.”