In response to the Coronavirus Disease 2019 (COVID-19), the Centers for Medicare & Medicaid Services (CMS) supplemented its guidance to dialysis facilities on March 10, 2020, to provide guidance regarding infection control to minimize the transmission of COVID-19. The CMS memorandum developed frequently asked questions for dialysis facilities with respect to the transmission of COVID-19. The Centers for Disease Control and Prevention (CDC) also issued interim additional guidance for outpatient dialysis facilities, updated as of March 10, 2020, to supplement its general recommendations with respect to COVID-19. This article highlights several of the key recommendations from CMS and CDC for dialysis facilities since dialysis services remain necessary for patients who are suspected or confirmed to be infected with COVID-19.
Early Recognition and Isolation of Individuals With Respiratory Infection
- Facilities are encouraged to screen patients, staff and visitors and contact home dialysis patients for the following:
- Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath or sore throat.
- Contact in the last 14 days with someone with a confirmed diagnosis of COVID-19, or someone who is under investigation for COVID-19 or ill with a respiratory infection.
- Travel within the last 14 days to countries with sustained community transmission.
- Residence in a community where community-based spread of COVID-19 is occurring.
- Health care personnel should be reminded to not report to work when they are ill, and facilities should implement sick leave policies that allow ill personnel to stay home. If any staff member begins to exhibit signs and symptoms of a respiratory infection at work, they should immediately stop working, put on a face mask and self-isolate. The ill staff member must notify the facility administrator and provide information regarding the persons, equipment and locations with whom or which they have had contact.
- Signs should be posted at clinic entrances with instructions for patients with fever or symptoms of respiratory infection to alert staff so appropriate precautions can be implemented.
- Facilities should identify patients with signs and symptoms of respiratory infection before they enter the treatment area. Patients should be instructed to call ahead to report fever or respiratory symptoms so the facility can be prepared for their arrival or triage them to a more appropriate setting (e.g., an acute care hospital). Patients with symptoms of a respiratory infection should put on a facemask at check-in and keep it on until they leave the facility.
- Facilities should provide patients and health care personnel with instructions about hand hygiene, respiratory hygiene, and cough etiquette. Facilities should have supplies positioned close to dialysis chairs and nursing stations to ensure adherence to hand and respiratory hygiene, and cough etiquette. These include tissues and no-touch receptacles for disposal of tissues and hand hygiene supplies (e.g., alcohol-based hand sanitizer).
Treating Ill Patients
- Facilities should have ill patients in the waiting room seated at least 6 feet from other patients. Patients with respiratory symptoms should be brought back to an appropriate treatment area as soon as possible in order to minimize time in waiting areas. Medically stable patients without other care needs can have the option to wait in a personal vehicle or outside and be contacted by phone when ready to be seen.
- Facilities should maintain at least 6 feet of separation between masked, symptomatic patients and other patients during dialysis treatment. It is recommended that symptomatic patients be dialyzed in a separate room (if available) with the door closed (which can be the hepatitis B isolation room if the patient is either hepatitis B surface antigen positive or there are no such patients requiring treatment). If a separate room is not available, the masked patient should be treated at a corner or end-of-row station, away from the main flow of traffic.
- If a facility is dialyzing more than one patient with suspected or confirmed COVID-19, consideration should be given to cohorting those patients and the health care personnel caring for them in the same unit and/or on the same shift (e.g., the last shift of the day). In addition, the health department should be notified about the patient, and facilities should follow the CDC guidance regarding infection control for COVID-19 patients.
Personal Protective Equipment and Cleaning Guidelines
- Health care personnel caring for patients with undiagnosed respiratory infections should follow the Standard, Contact and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis) as each of those Precautions has been further defined by the CDC. This includes the use of: (1) gloves, (2) facemask, (3) eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face) and (4) isolation gown. It is advised that if there are shortages of gowns, they should be prioritized for initiating and terminating dialysis treatment, manipulating access needles or catheters, helping the patient into and out of the station, and cleaning and disinfection of patient care equipment and the dialysis station.
- Facilities should continue to follow routine infection control requirements related to cleaning and disinfecting, using EPA-approved products with viral pathogen claims against COVID-19, if possible. Facilities should provide additional work supplies to avoid sharing (e.g., pens, pads) and disinfect workplace areas (e.g., nurse’s stations, phones, etc.)
Transferring Patients to Alternative Sites
- Dialysis facilities should consider transferring patients to another treatment site if the facility cannot fully implement the recommended precautions. Transport personnel and the receiving facility should be notified in advance of the patient’s health care needs, and the patient should wear a facemask and remain separated from other patients while awaiting transfer.
Special Considerations for Home Dialysis
- Dialysis facilities should continue to provide monthly monitoring of home dialysis patients onsite at the facility. While it is important to limit exposure for home dialysis patients, it is also important that these patients do not miss their onsite appointments in which it can be confirmed that all procedures are being followed in order to ensure a safe environment for the home dialysis patients.
As the number of cases around the world grows, Faegre Drinker’s Coronavirus Resource Center is available to help you understand and assess the legal, regulatory and commercial implications of COVID-19.