4 May 2020
- Dr. Jashira Naidoo
Covid-19 Changes in Healthcare
AS COVID-19 changes how we look at everything in medicine, one population stands out: patients on dialysis. Of all the patients who engage with the health system, patients on dialysis may have the most frequent and the most intimate contact with the medical system.
Additionally, these patients can't abide by the standard instructions to avoid infection, i.e. they are unable to just shelter in a place for a week or two while the epidemic burns itself out. Because of this, we need a special fund of knowledge to ensure that these patients remain as safe as possible.
What follows is a summary and discussion of some of the major issues and challenges facing dialysis patients during the COVID-19 pandemic. We are trying to collate the facts - and these are not recommendations because the evidence is either too sparse or rapidly evolving.
There are also logistical challenges or local institutional policies or constraints that one should bear in mind while reading what follows.
The risk of COVID-19 in patients receiving chronic dialysis
One would think that given the increased risk of the disease in older people, as well as those with hypertension and other comorbid conditions, that the risk would be higher in people on chronic dialysis. We have sparse data in this population so the usual precautions apply.
An important aspect for patients on hemodialysis (HD) is that they cannot avoid travelling, so safe and secure transportation needs to be addressed. Depending on the spread in HD units, they may also need dialysis in designated centres. This is a good time to be on home dialysis, whether it be peritoneal or home HD.
How do we (physicians, nurses, techs, clerks etc.) get up to speed on COVID-19?
All staff should receive training in clinical knowledge about COVID-19, prevention guidelines, and local institutional/ hospital protocols.
This training should preferably include (could be done online): How to use different types of masks, how to cover the nose and mouth when coughing, how to dispose of contaminated items in waste receptacles and how to perform hand hygiene. Latest care recommendations and epidemic information should be updated and delivered to all medical staff.
Responsibilities of staff working at a dialysis centre
One of the major concerns in maintaining a safe dialysis environment is preventing the dialysis centre from being a source of infection. All staff need to ensure that they are not infected to prevent them from harming their patients.
All staff need to self-monitor for symptoms of COVID-19 (e.g. fever or new onset cough, fatigue, nausea, diarrhea, anosmia) and notify the medical director or team leader if they develop any symptoms suggestive of COVID-19. The staff should notify the medical director or team leader if their family members develop symptoms suggestive of COVID-19 infection. Sick members of the team should stay at home and should not be in contact with patients or other team members. The duration of self isolation may vary from centre to centre, and whether or not COVID-19 was tested and negative.
What dialysis patients should do outside the unit
Though we do not have data to point to, it is intuitive that dialysis patients are part of a susceptible group and need to take extra precautions. Stay at home while they are not receiving dialysis. Try as much as possible to use individual transport to the dialysis centre and avoid public transportation if possible (see more below on transportation). Avoid contact with other people, including their children and grandchildren. Be aware that young people serve as a vector of the disease, often without symptoms or only minimal symptoms. Dong (Pediatrics 2020). Family members living with patients on dialysis must understand the precautions to prevent within-family transmission. These include body temperature measurement (at least once a day), personal hygiene, handwashing and prompt reporting of symptoms suggestive of COVID-19.
Hygienic measures to consider adopting in our centres
Our colleagues from Italy shared a series of recommendations, including general hygienic measures. Cozzolino (CKJ 2020) Put alcohol dispensers in patient rooms, waiting rooms etc, and advise patients to use them. Recommend the patients to wash their hands and fistula before starting dialysis. Nursing and medical staff should wear surgical masks and protective glasses while they are in the dialysis room, wash their hands with soap and water and use alcohol solutions systematically. If you share dialysis nursing staff between adult and paediatric units, consider permanent separation of staff to minimise the risk of cross infection.