For dialysis providers, COVID-19 offers lessons in preparedness
Dialysis companies in the United States have weathered natural disasters during the last 2 decades – tornados, hurricanes and earthquakes. Massive flooding from Hurricane Katrina 15 years ago in New Orleans and Hurricane Harvey in 2017 in Houston, where staff members had to be ferried down flooded streets by boat to stranded dialysis clinics, were handled by organized disaster teams. Protocols were in place to ensure patients received dialysis early and were sent to other clinics unaffected by the flooding.
However, there were no weather maps to warn dialysis providers how to prepare for the COVID-19 pandemic.
“I received a phone call on Friday night, the evening of Feb. 28 from the Evergreen Health Hospital saying that the first reported person in the country had died from coronavirus,” Suzanne Watnick, MD, chief medical officer of Northwest Kidney Centers, said during a webinar hosted by the American Society of Nephrology’s Nephrologists Transforming Dialysis Safety (NTDS). “It was one of our dialysis patients.”
Two days later, the CDC reported a second death from COVID-19, which was the harbinger of an outbreak at a skilled nursing facility. The patient also dialyzed at the Northwest Kidney Centers.
“We then sat down with the CDC and started preparing protocols to protect our patients and staff,” Watnick said.
Destiny of a pandemic
Since those first cases, the pandemic has spread to all 50 states, with more than 126,000 deaths linked to the virus. Among the largest concerns are patients admitted to hospitals and diagnosed with AKI after being placed on a ventilator. Hospitals shifted attention to finding dialysis equipment, and the FDA allowed Fresenius Medical Care North America’s (FMCNA) renal therapies group to ship dialysate solutions for use in continuous renal replacement therapy in the United States, beginning with hospitals in the New York metropolitan area. The FDA granted emergency use authorization to these solutions, as well as to Fresenius’ Multifiltrate PRO System for use in acute care settings during the COVID-19 pandemic.
The number of patients with COVID-19 also contracting AKI has been as high as 15% in some hospitals.
“A significant number of patients going into the hospital to be treated for COVID-19 are coming out as kidney patients,” Kevin Longino, CEO of the National Kidney Foundation, said in a recent statement. “We believe this may be a looming health care crisis that will put a greater strain on hospitals, dialysis clinics and patients, for whom chronic kidney disease will be a lasting remnant of the coronavirus crisis – even after a vaccine is hopefully found.”
Risk for dialysis staff
At Northwest Kidney Centers, Watnick and Liz McNamara, MN, RN, vice president of patient care services and chief nursing officer, have been educating staff and manage the virus at 19 clinics since the pandemic began. Protocols changed almost week to week as the CDC and NTDS consulted on how to slow the pandemic.
The situation was also tough on staff workers, who worried about bringing the virus back to their families.
“Like many health care workers, our teammates have kids at home because schools are closed,” Axel Lapica, a group vice president for DaVita Kidney Care, told Nephrology News & Issues. Lapica, who oversees field operations for the dialysis provider’s Midwest region, including the Chicago metro area and the state of Michigan, which was hard hit by the virus, said, “They are dealing with unprecedented disruption in the world, and yet they continue to step up and provide life-sustaining care for our patients.”
DaVita, which treats more than 200,000 patients, began talking to its vendors in January about the potential for greater need for personal protective equipment (PPE) and dialysis equipment.
“We haven’t experienced supply chain disruption to date; however, we’ve shared the same concerns as the broader medical community about availability of masks and have taken proactive steps to ensure that all our patients and caregivers have access to a mask,” Lapica said.
Lapica said DaVita also began anticipating staffing shortages as the virus spread to clinics around the United States “given the increased need for caregivers to support shifts and centers dedicated to COVID-19 patients, as well as the impact of this virus on our teammates’ communities,” Lapica said. “We reached out to alumni teammates who we know provide great care and have specialized education and experience with DaVita’s infection protocols.”
Within a few days, more than 1,400 DaVita alumni came back to help with patient care, Lapica said.
“We also had teammates from across the country volunteer to work in the hardest-hit communities,” he said.
CEO’s tough start
At Northwest Kidney Centers, Rebecca Fox, MPH, started her new job as CEO when COVID-19 was firmly entrenched.
“I had to get up to speed rapidly on a situation where there is no playbook for how to respond,” Fox said. “I have learned through many years of leadership to listen and observe first, ask probing questions and then rapidly assess this information to develop a course of action.”
Fox joined Watnick and McNamara in setting up the right guidelines and procedures to help keep patients and staff safe. “The recommended guidelines were quickly evolving and information was not always consistent between federal agencies,” she told Nephrology News & Issues. “We had intense, ongoing consultations with our clinical leadership and other experts to ensure our practices were as safe as possible and to have confidence that we were always ‘following the science.’”
Fresenius Medical Care also recognized the need for consistent communication with both staff and patients. “Our care teams adjusted quickly to many new procedures and policies designed to keep our patients, employees and physicians safe,” Kathleen Belmonte, MS, RN, FNP-BC, MBA, who leads nursing and clinical services for FMCNA’s kidney care division, told Nephrology News & Issues. That included new infection control and testing procedures to embracing telehealth, she said.
“Our company knew these front-line employees and nurses were essential to maintaining dialysis for our patients both in center and at home,” Belmonte said. “That’s why we offered our care teams weekly childcare stipends and also increased pay during the peak of this crisis.”
Fresenius employees working in areas with significant community spread “were instrumental in establishing isolation centers for patients with a suspected or confirmed positive case,” Belmonte said. “We’re confident our ability to provide these patients with their required therapy in a separate environment significantly reduced the risk of spread to our other patients and employees.”
Belmonte said Fresenius faced challenges in replacing staff who contracted the virus.
“While we experienced some staffing challenges in the hardest-hit areas, such as New York and Chicago, we had nearly 1,400 employees step up and volunteer from across the country to go to these hotspot areas and help out,” Belmonte said. “These volunteers filled the additional demand required from creating isolation centers, assisting in screening and testing patients in a safe environment, as well as providing dialysis in hospitals that faced a spike in acute kidney injury caused by COVID-19.”
Fresenius joined DaVita, U.S. Renal Care and other providers in identifying areas around the country around the country to set up isolation clinics where the pandemic hit the hardest and created the need for treating patients diagnosed with the virus.
Like DaVita, Fresenius planned ahead on stockpiling personal protective equipment.
“We actually never faced a shortage of masks or other PPE in our centers,” Belmonte said. “Back in March, we started requiring that both patients and care teams wear masks at all times in our centers and prioritized the use of N95 masks inside our isolation centers and separated shifts. We believe this early policy decision, which went above CDC guidelines at the time, made a big difference in preventing the spread of the virus, especially as we waited for testing to become more readily available.”
With reports in late June of new outbreaks in Arizona, California, Florida and Texas, Watnick wrote in an editorial recently that strategies are needed from the kidney community to be better prepared for pandemics in the future.
“COVID-19 has exposed critical weaknesses in our health care system, notably including our dependence on in-center hemodialysis for nearly half a million U.S. residents,” Watnick wrote in a recent editorial. “This dependence not only increases the likelihood that hemodialysis patients will be infected with COVID-19 but also increases the risk to society, given the health care workers and transportation infrastructure needed to provide in-center hemodialysis.”
Fox said there is concern moving forward about another potential wave of cases and the complicating impact that the flu season could have.
“We now have embraced a new-normal that includes enhanced cleaning protocols and increased use of PPE. We are hopeful this will diminish cases of the flu as well. We feel prepared but realize we are in uncertain times,” Fox said. – by Mark E. Neumann
- Kathleen Belmonte, MS, RN, FNP-BC, MBA, can be reached at firstname.lastname@example.org.
- Rebecca Fox, MPH, can be reached at email@example.com.
- Axel Lapica, can be reached at firstname.lastname@example.org.
- Elizabeth McNamara, MN, RN, can be reached at email@example.com.
- Suzanne Watnick, MD, can be reached at firstname.lastname@example.org.