19 April 2020
Renal dialysis in normal times and normal conditions can be done in a hospital, in an outpatient dialysis center, or at home. But clearly the COVID19 conditions are anything but normal. Officials thinking about this virus pandemic as it was developing clearly thought this was about respiratory illness. Other human organs were considered only at risk because of the supplemental drain that would be caused. As the pandemic took hold in Italy there was indications other human organs, and particularly the kidneys, may also be under attack in the most severe patient conditions. We are now seeing patients needing dialysis within the hospital at a 3 or 4 fold increase.(1) Kidney failure has been largely treated as an outpatient clinical chronic condition where the vast majority of patients are treated within outpatient clinics. Recently home health situations are allowed expansion of home dialysis but very special education and home treatment arrangements are required. While renal dialysis has remained the treatment protocol for the large majority of all dialysis patients, hemodialysis and peritoneal dialysis accounted for virtually all of the remaining percentage of the total patient population. Hospital dialysis has heretofore been a supplemental care within hospitals with the bulk of the services being delivered in an outpatient setting. Decisions are now relegated to caregivers trying the assess which patients have the potential to survive without dialysis as kidney function is impacted.
Dialysis at the Outpatient Treatment Clinics (OTCs) is usually by appointment with several time slots throughout the day; some centers running 2 or 3 shifts. Most patients visit 3 times per week and the treatment lasts for 2 to 4 hours. The regulations governing the treatment facilities vary slightly from State to State and each State regulates the licensure of the facilities through their Department of Health (or similar entity). Most States allow an open treatment floor with full observation by the medical staff. A few States require a full Inflection Isolation Room with a single patient station, but most States only require just a seclusion room with one station. Direct and continuous observation by the staff is required and considered essential. The Isolation Rooms are constructed to protect staff and other patients from the infection(s) that may be transmitted from the patient being isolated. Thus, if you have more than one patient requiring isolation the current facilities are falling far short of the mark. These treatment floors have no way of isolating the staff sufficiently, so the personal protective gear worn is the first and last line of defense from the virus for these providers.
“About one percent of dialysis patients are now dialyzing at home” said Christopher R. Blagg, MD, professor emeritus of medicine at the University of Washington.(2) The actual projected rate is suspected to level out at under 3% of all patients. Obviously, isolation is only relevant to the conditions in the home setting and visiting staff most certainly take universal precautions when they have the proper supplies at hand. Again, personal protective gear becomes of utmost importance to them.
For those minority of patients in the hospital setting we have a very different condition. Hemodialysis is considered a supplemental service condition to other comorbidities. It is not intended as a frontline patient service. Hospital designers and professional staff rarely have the intensive experience and background to actually have a unit that runs independently as a department in and of itself. This is proving to be a very significant issue for pandemic care. Staff is in critical shortage at the regular clinics and the situation of having a largely outpatient function suddenly become a critical part of intensive care is something that has been clearly overlooked. Where do we get qualified staff and where can we set-up the artificial kidney function? Where are the supplies critical to delivering this care?
Typically, the OTCs are designed in a way that the building itself becomes and extension and part of the hemodialysis treatment, supplying critical fluids to the artificial kidney machines that remove the toxins from the blood of the patients being treated. As one can imagine these machines require sanitation and cleaning after each shift in the non-pandemic settings. The situation is magnified in the pandemic setting. Like the hospitals, which are experiencing critical shortages of staff, kidney machines, fluids, protective gear, and other supplies,(1) the OTCs are having issues where whole shifts or even treatment centers are having to be converted to patient treatment for those exposed to COVID19. Exposed patients may require even further adjustment to operations. The intensity and exposure of the staff is a considerable concern. There are not enough supplies and staff to cover all the conditions that are surfacing. In hospitals Doctors are having to assess what patient will have immediate hemodialysis care and which one has to wait. Sometimes the wait does not work out well.
Meanwhile staff in the OTCs continue to get stretched thinner and co-workers fall sick and supplies of all types continue to dwindle, with the probable exception of the processed fluids delivered by the building systems.
Today we have a problem. We certainly should have and probably will see extended discussions about the issues encountered. We need systemic thinking about the problems revealed. The human body is a system of interrelated organs each vital to the life and condition of the human being. It is going to take forethought and leadership to move this forward, it is not as easy as we once thought. We need to be ready for the challenge when current conditions improve, and the pandemic subsides.
(1) Sunday New York Times 19 April 2020 – Cover Page Story
(2) Taken from on line article – KIDNEY NEWS ON-LINE - https://www.kidneynews.org/kidney-news/cover-story/home-hemodialysis-industry-poised-for-growth