May 22, 2020
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To mitigate risks for COVID-19 in dialysis programs, cohorting may be best practice

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No one wants to continuously worry about the possibility of a crisis. However, they do happen, and as the report investigating the WHO’s response to the 2009 H1N1 pandemic concluded,1 “The world is ill prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.” That was more than 10 years ago.

In that report, Claire Standley, PhD, MSc, assistant professor of research at the department of international health at Georgetown University, said "...the simple answer is no one was specifically prepared for this outbreak." 2

Standley's research focuses on the analysis of health systems strengthening and international capacity building for public health, with an emphasis on prevention and control of infectious diseases in both humans and animals, as well as public health emergency preparedness and response. She understood the value of being prepared for the next outbreak.

Several years later, in a 2015 Technology, Entertainment, Design talk, Microsoft founder Bill Gates said the world was “not ready for the next epidemic.” Gates has been warning of a pandemic for years, as have notable infectious disease and flu experts Michael Osterholm and Robert G. Webster.

On March 11, 2020, the WHO declared the coronavirus a pandemic and we now are faced with a health threat as previously predicted, the magnitude not seen since the Spanish flu caused by the H1N1 virus in 1918.3

In response, CMS has issued a sweeping array of new rules and waivers of federal requirements (ie, facility licensure, ESRD Quality Incentive Program metric reporting, telehealth utilization in place of monthly in-person dialysis visits and special purpose renal dialysis facilities or SPRDFs) to ensure that local hospitals, health systems and dialysis providers have the capacity to absorb and effectively manage potential surges of patients with COVID-19.

Martin Schreiber

In addition, the CDC and the American Society of Nephrology, through the Nephrologists Transforming Dialysis Safety workgroup, continues to provide additional guidance to dialysis facilities to help control and prevent the spread of the virus that causes COVID-19. Cohorting patients on dialysis who are confirmed or suspected to be COVID-19 positive — described in detail later in this article — is part of this updated guidance.

While kidney patients are being encouraged to stay home and avoid crowds as much as possible during the outbreak, those treated with in-center hemodialysis must continue their scheduled dialysis clinic treatments, which are prescribed three to four times a week. The challenge for dialysis is designing a plan to maintain dialysis treatment control of uremia and fluid, while keeping both patients and health care professionals safe without compromising the quality of delivered dialysis.

As recommended by the CDC, if a hemodialysis facility is dialyzing more than one patient with suspected or confirmed COVID-19, consideration should be given to cohorting these patients and the nurse caring for them together in designated area of the unit and or on designated shift(s), ie, consider the last shift of the day.

In addition to cohorting patients, this practice provides opportunities for cohorting care teams (nurses, patient care technicians and others) and allows for a dedicated team approach to focus care and minimize exposure for patients infected with a single infectious agent in a specific geography.

To mitigate risks for COVID-19, DaVita is cohorting patients into the following three tier groups:

  • asymptomatic patients (PUI-A) who are not showing symptoms, but have had prolonged, close contact with confirmed or suspected person(s) with COVID-19;
  • patients under investigation who are symptomatic (PUI-S); and
  • patients confirmed to be COVID-19 positive (CP).

Three primary options are explored in each geography to better assess which cohorting site of care is operationally feasible.4 Based on dialysis facility density in specific geographies, expected numbers of CP patients being treated, and alternative options for segmenting infection populations, cohorting may or may not be possible for specific providers. However, if possible, the following operational options should be considered:

1.   Dedicate an entire clinic to treating CP patients: expected/experienced high volume of CP cases and where PUI-S and CPs can be relocated among facilities, de-novo clinic or partner with alternate providers to create a dedicated CP clinic;

2.   Establish a dedicated CP day (likely Tuesday-Thursday-Saturday) within a clinic that is treating regular patients (RPs) on other days (Monday-Wednesday-Friday). Accommodate CPs on the earliest possible shift (eg, TTS-1); and

3.   Temporarily transfer patients to existing cohorted clinic or day that was created under these rules.

Additional considerations include sending another provider who has setting #1 or setting #2 available, treat on dedicated last shift of the day (likely TTS-2 or TTS-3), with RPs on prior shifts on the same day while ensuring there is appropriate separation between RPs departing and CPs arriving.

Any cohorting strategy also needs to accommodate varied visit types and an understanding of where the visits will take place within the facility, including new patient training, lab draws, home patient urgent visits for an infection (catheter exits site, peritonitis), catheter complications (flow dysfunction, hole in catheter, drain pain, etc.), increase weight with edema and shortness of breath, initial home visit medication administration, routine patient maintenance and after-hours support.

Consider using a SPRDF or working with another local service provider for urgent TTS visits (or similar urgent visits during a specific timeframe that in-center is dialyzing COVID-positive or PUI patients) and include patients who travel temporarily to another home program (<90 minutes one way).

Our understanding of when and how to effectively cohort dialysis patients is evolving. Going forward, the kidney community must be prepared for what we will face in the future. Looking beyond today, understanding preparedness requirements, recreating innovative care delivery designs for high-risk patient populations (cohorting and virtual health) and planning for future health emergencies is critical. We will continue to learn how best to keep vulnerable populations such as those with end-stage kidney disease and health care workers safe, knowing future pandemics will occur. I am confident we will be ready. –by Martin Schreiber, MD

References:

1. https://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/. Accessed April 27, 2020.

2.   https://ijnet.org/en/story/key-quotes-are-our-health-systems-prepared-covid-19-qa-dr-claire-standley. Accessed April 27, 2020.

3.    Madhav N, et al. Pandemics: Risks, Impacts, and Mitigation. Chapter 17. In: Jamison DT, et al., editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd edition. 2017;doi:10.1596/978-1-4648-0527-1/pt5.ch17.

4. https://pressreleases.davita.com/2020-04-13-DaVita-Inc-Provides-Commentary-on-the-COVID-19-Pandemic. Accessed April 13, 2020.

Martin Schreiber, MD, is the chief medical officer for home modalities for DaVita Kidney Care. He can be reached at martin.schreiber@davita.com.

Disclosure: Schreiber reports no relevant financial disclosures.