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Dialysis in a Crisis with ASN · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the podcast series.
• 0:10
  SPEAKER_01: We are all in this together.
• 0:12
  SPEAKER_01: COVID-19 Allies in Infection Prevention, part of Society of Healthcare Epidemiology of America, Shay's Rapid Response Program.
• 0:22
  SPEAKER_01: I'm Dr.
• 0:23
  SPEAKER_01: Wali Javed, Director of Infection Prevention and Control at Mount Sinai Downtown.
• 0:28
  SPEAKER_01: And I'll be serving as your Shay moderator and speaker for today's podcast.
• 0:32
  SPEAKER_01: I'm also happy to welcome Dr.
• 0:35
  SPEAKER_01: Alan Tiger, Clinical Professor of Medicine at Jay's University of Madison, and co-chair COVID-19 response team for the American Society of Nephrology, the ASN, as well as Shannon Novasad, a medical officer, the Center of Disease Control and Prevention, and the team lead of dialysis safety team in the division of healthcare quality promotion.
• 0:59
  SPEAKER_01: Thank you both for joining and leading this new podcast series.
• 1:04
  SPEAKER_01: Discussions on the podcast does not reflect Shay's ASN's or CDC's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenge together.
• 1:18
  SPEAKER_01: Today's episodes will focus on collaborations between healthcare ebramology and neprology and how as a team we can work together to address the most important questions surrounding COVID-19 outbreak.
• 1:33
  SPEAKER_01: So let's get started with our first question.
• 1:36
  SPEAKER_01: What are you or your organizations doing to address COVID-19 in outpatient settings?
• 1:43
  SPEAKER_02: Well, hi, this is Alan Kleiger, and I appreciate your asking me to participate.
• 1:48
  SPEAKER_02: There are roughly half a million patients in the United States who require dialysis for kidney failure.
• 1:54
  SPEAKER_02: The vast majority come to outpatient hemodialysis units three times a week for treatment, usually lasting about four hours each time.
• 2:02
  SPEAKER_02: These patients are vulnerable to infection for two reasons.
• 2:06
  SPEAKER_02: They cannot shelter at home, but must come to a facility with other patients and staff three times a week, so they are more prone to become infected.
• 2:15
  SPEAKER_02: If infected, they're more prone to complications, not only because of their kidney disease, but also their high prevalence of diabetes, hypertension, heart disease, the risk factors for poor outcome for patients with COVID-19.
• 2:30
  SPEAKER_02: The American Society of Nephrology has worked with the many dialysis companies around the country and with the CDC to promote screening, identification of PUIs and infected patients and separation for dialysis, appropriate PPE and station disinfection.
• 2:48
  SPEAKER_02: We've sponsored weekly webinars, publications, and other meetings to inform and support staff and patients.
• 2:57
  SPEAKER_00: Thanks so much for allowing us to share our perspective today as well.
• 3:01
  SPEAKER_00: This is Shannon from CDC.
• 3:03
  SPEAKER_00: Similar to what Alan was saying, we really embarked on guiding facilities during COVID-19 to really help ensure that all patients could continue to receive dialysis safely.
• 3:17
  SPEAKER_00: One of our big, I guess, overarching or guiding thoughts in all this was really to make sure that, you know, no patients were missing this life-saving therapy due to the inabilities of facilities to be able to enact infection control guidance to protect them during dialysis.
• 3:33
  SPEAKER_00: So that's kind of how we went into this.
• 3:36
  SPEAKER_00: And really with ASN's help, we've really been able to get a lot of this infection control guidance into the hands of the dialysis providers.
• 3:45
  SPEAKER_00: So really the frontline staff who are seeing these patients every day and thinking about how to take care of them safely.
• 3:52
  SPEAKER_00: So we really started this all with kind of developing what we call some kind of guiding principles in our infection control guidance, again, to really help dialysis facilities kind of think through how they're going to be able to do this in the safest way possible.
• 4:06
  SPEAKER_00: And so it really focuses on screening patients before or as soon as they arrive at a dialysis facility for any symptoms suspicious for COVID, thinking through how they can separate patients and safely dialyze them away from others, whether that's separated within a facility or even separate shifts or facilities dedicated to COVID, and other things such as PPE for staff, good environmental cleaning and disinfection.
• 4:35
  SPEAKER_00: So we really attempted to kind of touch on all of these topics and our guidance, but I think the biggest thing has really been getting that information out to others.
• 4:44
  SPEAKER_00: And again, that's where working with partners such as ASN has been really valuable.
• 4:50
  SPEAKER_01: Thanks so much, Ellen and Shannon.
• 4:52
  SPEAKER_01: From health systems perspective, we have seen the same things that you have discussed already, including the impact COVID-19 has on patients who are undergoing dialysis.
• 5:03
  SPEAKER_01: As Ellen said, there's half a million patients who undergo dialysis three times a week.
• 5:08
  SPEAKER_01: There's a lot of exposures from infection control perspective and how to minimize and optimize care for those, and keeping COVID-positive patients away from COVID negative has been the biggest challenge.
• 5:20
  SPEAKER_01: I totally agree that the guidance from CDC as well as ASN has been really remarkable.
• 5:26
  SPEAKER_01: I think one of the things we'll touch upon a little later would be discussing COVID-19 as a cause of renal failure and increase in need of dialysis that has occurred during this pandemic.
• 5:39
  SPEAKER_01: I'll move on to the next question.
• 5:41
  SPEAKER_01: How about in inpatient settings?
• 5:43
  SPEAKER_01: What was your experience, Alan?
• 5:46
  SPEAKER_02: You know, in the inpatient setting, we knew as early as January from reports from China that among COVID-19 patients sick enough to be hospitalized, 40 to 50% had protonuria or hematuria, evidence for kidney damage.
• 6:01
  SPEAKER_02: A recent publication from China cites a 75% incidence of kidney disease among patients hospitalized with SARS-CoV-2 pneumonia.
• 6:12
  SPEAKER_02: In the United States, among patients sick enough to require ICU care, the incidence of acute kidney failure requiring dialysis or continuous renal replacement therapies or CRRT, the incidence is somewhere between 27 and 65%.
• 6:29
  SPEAKER_02: This very high incidence of acute kidney injury and kidney failure is far higher than anything we've seen before with other infectious outbreaks.
• 6:38
  SPEAKER_02: So the inpatient setting has proven particularly challenging.
• 6:42
  SPEAKER_01: What are your thoughts, Shannon?
• 6:44
  SPEAKER_00: Yeah, so I think the guidance that I mentioned earlier really focuses more on dialysis in the outpatient setting.
• 6:50
  SPEAKER_00: But we have been attempting to think through some of these issues in the inpatient setting as well.
• 6:55
  SPEAKER_00: And I think those fall into a couple of buckets.
• 6:58
  SPEAKER_00: As Alan was saying, multiple partners, including CDC, others in the federal government, HHS, CMS, Aspir, and others, as well as everyone out on the front lines taking care of patients, has quickly come to realize that the burden of acute kidney injury in the inpatient setting can be quite high.
• 7:18
  SPEAKER_00: And it's definitely starting or already has taxed resources in a number of areas.
• 7:23
  SPEAKER_00: So I think at CDC, we're really working to better understand the epidemiology of kidney disease as it relates to COVID and specifically the burden of acute kidney injury in the inpatient setting.
• 7:35
  SPEAKER_00: And as part of this, like how often CRT is being used.
• 7:39
  SPEAKER_00: And this information, again, is really critical for us and for other partners, again, at multiple levels, to better understand supply shortages in the coming months and how we can allocate supplies and resources to those who need it.
• 7:52
  SPEAKER_00: And then I guess kind of the other bucket is thinking just about infection control in the acute care setting.
• 7:58
  SPEAKER_00: So again, as I mentioned, you know, our guidance mostly focused on the outpatient setting, but we did start to get a lot of questions about providing dialysis in the inpatient setting and realized there were some questions that we needed to think through.
• 8:11
  SPEAKER_00: And that included protecting dialysis staff while they were providing dialysis, making sure that they were wearing appropriate PPE when dialysis was being done when a dialysis unit in an inpatient setting or even kind of in a single patient's room.
• 8:25
  SPEAKER_00: So we talked to a lot of those issues with partners and then also thought through with some others just about kind of placement of patients with COVID while they're getting dialysis in the acute care setting.
• 8:37
  SPEAKER_00: So thinking about it again from a variety of viewpoints.
• 8:41
  SPEAKER_01: Yes, I think that actually goes along with our upcoming questions as well, but very similar to what you have said and what Alan has said already, the COVID-19 illness itself had remarkable effect on kidney function and overall required a lot more resources than any other illness that we have seen in the past.
• 9:01
  SPEAKER_01: And that kind of has its own impact.
• 9:04
  SPEAKER_01: As Alan has said, that we already knew about the kidney injury part of this illness, so we were preparing.
• 9:10
  SPEAKER_01: But how to schedule a lot more patients and how to prepare for those things is a challenge in itself.
• 9:18
  SPEAKER_01: I'll get into what unexpected challenges we had, and then I'll ask you guys as well to tell us your experiences.
• 9:25
  SPEAKER_01: But unexpected challenges for us really were the sheer number of cases, uh, especially in the New York City area that we saw, and then the amount of dialysis that was required.
• 9:37
  SPEAKER_01: That did require us to function our dialysis unit quite differently as it was before.
• 9:43
  SPEAKER_01: Do dialysis in rooms versus doing in a dialysis unit itself, using precautions obviously for patients who have COVID.
• 9:53
  SPEAKER_01: But then what do you do in between those patients, wiping down the surfaces and the machines, and how do you reprocess it quickly enough to get things ready?
• 10:03
  SPEAKER_01: All those things were basically quite unexpected, quite challenging.
• 10:07
  SPEAKER_01: But I think preparation, understanding, and information from ASN as well as Shay and TDC had been very, very helpful.
• 10:15
  SPEAKER_01: What have been your experiences, Alan, in this regard?
• 10:19
  SPEAKER_02: Yeah, well, Walid, similar to what you just described, the unexpected frequency of kidney failure and the frequency of multisystem disease in the ICUs was a real surprise.
• 10:30
  SPEAKER_02: As you said, in New York's experience at Epicenter, this required a doubling of ICU beds and a four to five-fold increase in dialysis or CRRT equipment supplies and personnel.
• 10:44
  SPEAKER_02: At the peak of their pandemic in New York, the rate that hospitals burned through supplies such as dialysis fluid for CRRT and dialysis filters and cartridges threatened shortages, limiting the capacity to deliver these life-saving therapies.
• 11:01
  SPEAKER_02: ICU nurses with CRRT experience were severely strained.
• 11:06
  SPEAKER_02: Nurses from around the country flew to New York in order to help out.
• 11:10
  SPEAKER_02: Hospitals were creative in adopting to the challenge using more intermittent dialysis therapies, sustained low-efficiency dialysis or sled acute peritoneal dialysis.
• 11:22
  SPEAKER_02: And they negotiated with supply companies for more fluids.
• 11:25
  SPEAKER_02: Finally, patients surviving the infection, but with persistent acute kidney injury strain the system for outpatient dialysis.
• 11:35
  SPEAKER_00: Yeah, I think echoing what Alan had said, I think a big challenge that was maybe expected, but also a little surprising, again, I think, was the burden of acute kidney injury and definitely the strains that it had on the supply chains and staffing and ability to provide care both for COVID patients and non-COVID patients.
• 11:56
  SPEAKER_00: So again, I think the biggest response to that has really been the work across multiple groups to really pull together knowledge from kind of various sources, you know, to really tackle something like this.
• 12:08
  SPEAKER_00: We have to understand the numbers, we have to understand the epidemiology, we have to understand the supplies needed and the staffing needed, and all of that really can't come from just one person or one group.
• 12:18
  SPEAKER_00: So pulling people from across multiple channels together is the best way for this.
• 12:24
  SPEAKER_00: And again, I think what we're trying to do moving forward to hopefully mitigate some of this happening in other areas as the country, as we all kind of move through different stages of COVID in different cities and different states.
• 12:36
  SPEAKER_00: And then I guess the other, I don't know if that it was necessarily an unexpected challenge, but I do think that one of the challenges we have with infection control and outpatient dialysis, and also similar for inpatient, is that every outpatient dialysis facility is different.
• 12:53
  SPEAKER_00: And while we have guidance on how to screen patients and how to triage patients and how to separate patients, we can't really dictate it be done in one way everywhere because every dialysis facility is a little bit different in terms of where they can place screeners.
• 13:09
  SPEAKER_00: They may have a parking lot, they may be inside of another building, how much room they have inside to separate by six feet, so how they're able to do that, their ability to add on different shifts.
• 13:19
  SPEAKER_00: So I think, again, maybe not unexpected, but a challenge we've had to work through is just how to kind of help facilities adapt our guidance to kind of each of these different situations.
• 13:30
  SPEAKER_01: Thank you.
• 13:31
  SPEAKER_01: Another question that we had discussed before was what practice changes have you made to reduce exposure and what has driven those changes?
• 13:40
  SPEAKER_01: Alan, any thoughts?
• 13:42
  SPEAKER_02: Yeah, well, you know, if you were to come to our outpatient dialysis units now, they look really different in practice than they did before this pandemic.
• 13:52
  SPEAKER_02: We're asking people to call in in advance before they come into their shifts to report any potential symptoms or contacts.
• 14:00
  SPEAKER_02: Screening happens before people walk into the unit with temperature screening and questions, contacting COVID patients in advance to be on different shifts.
• 14:10
  SPEAKER_02: So we've now created whole dialysis facilities in some of the larger cities that accommodate only COVID-positive patients, other shifts that have PUIs only, and in some of the smaller places separate shifts, and if that's impossible in very small dialysis facilities, sometimes separate areas within a dialysis facility with designated staff.
• 14:32
  SPEAKER_02: So overall it looks really different than it used to before this.
• 14:37
  SPEAKER_02: Current challenges are really important to talk about too.
• 14:41
  SPEAKER_02: How do we know when it's safe for infected patients or staff to return to the outpatient dialysis unit?
• 14:47
  SPEAKER_02: CDC has been really good at giving us guidance, but there's still uncertainty about PCR test availability and what the results really mean.
• 14:56
  SPEAKER_02: Around the country, patients have been identified that have PCR positivity for weeks or even longer than weeks.
• 15:04
  SPEAKER_02: And what's the evidence for their infectivity?
• 15:07
  SPEAKER_02: Those are questions that remain substantial challenges.
• 15:11
  SPEAKER_00: Yeah, and I think I guess similar to a practice change, but I guess I think of it more as kind of a recommendation or guidance change.
• 15:17
  SPEAKER_00: We've tried to, you know, in all of our communications with dialysis clinics and health departments and others, just thinking through all these issues, really emphasize that the guidance is based on what we know is happening at that point in time.
• 15:32
  SPEAKER_00: COVID is something we're all still learning about and thinking about.
• 15:35
  SPEAKER_00: And we really want to be able to adapt and change as needed to provide the safest care across healthcare settings and including in dialysis.
• 15:44
  SPEAKER_00: So we've had had to make changes in the guidance as we go.
• 15:47
  SPEAKER_00: And again, partners such as ASN have been great in helping us communicate these changes to staff and administrators and others, you know, basically as quickly as we're able to get the changes out, they're they're able to help us communicate that, which is really great.
• 16:01
  SPEAKER_00: A recent example again was kind of the recommendation on universal source control, a change that was really made across healthcare settings, but based on increasing evidence of asymptomatic infections.
• 16:13
  SPEAKER_00: So again, I think just changing as we learn more to be able to provide the safest care possible during the time of COVID.
• 16:20
  SPEAKER_00: And then anticipating these other changes as they come, just trying to work together to answer some of these questions that we know are still lingering, including, you know, when it's safe to discontinue transmission-based precautions, what persistent positive tests mean, and whether perhaps that means something different in a dialysis patient than it means in a patient who doesn't have kidney disease.
• 16:43
  SPEAKER_01: Thank you.
• 16:43
  SPEAKER_01: Those are really, really great important points.
• 16:46
  SPEAKER_01: A few things that we observed for inpatients in epicenter of the pandemic, one thing we saw was remarkable ability of healthcare professionals to come together.
• 16:57
  SPEAKER_01: We had our vascular access teams before, but then during this pandemic, our vascular surgeons actually made teams dedicated to putting dialysis catheters and then aggressively taking care of those lines to kind of stay ahead of the best practices in care of these lines.
• 17:18
  SPEAKER_01: The impact and the need for all these dialysis didn't only stay within the dialysis unit or just nephrology, but impacted the hospital throughout with the resources that were needed, the lines that were needed, as well as people that were needed to take care of, to insert and to manage the lines.
• 17:38
  SPEAKER_01: Obviously, we couldn't get permanent dialysis solutions as quickly as possible.
• 17:42
  SPEAKER_01: But another thing we explored was peritoneal dialysis in several of these cases as well, and that was quite successful.
• 17:50
  SPEAKER_01: I think that has been the highlight of this pandemic that a lot of different groups came together to get through this pandemic.
• 17:58
  SPEAKER_01: And that takes me to my last question: what opportunities are there for individuals working in possible Epi and nephrology to work together to handle the pandemic and long-term?
• 18:10
  SPEAKER_00: I think some of these are probably points I brought up before, but I think some of the best opportunities are really working together to remain flexible and adapt and implement infection control guidance as it comes out.
• 18:23
  SPEAKER_00: Again, you know, several of these points we've already brought up, including being able to kind of adjust the way dialysis is provided in the acute care setting as the number of COVID patients with acute kidney injuries increased, and then kind of anticipating and planning for shortages of supply.
• 18:38
  SPEAKER_00: So, again, that's not something that just inframologists can do or just healthcare epidemiologists can do by themselves, or public health can just do by themselves.
• 18:46
  SPEAKER_00: I really think we all have to keep working together to really understand these issues and, you know, ensure that everyone has what they need long term for this.
• 18:56
  SPEAKER_00: And then I think the other thing, not just one really, but another thing that we can all work together is to think through ways to answer some of these questions that we know are still there.
• 19:08
  SPEAKER_00: And again, some of the ones that I know because we've been asked at CDC several times about these, and I'm asking them myself, is really thinking through how we can move patients with COVID back into the regular dialysis units.
• 19:24
  SPEAKER_00: As the pandemic goes on longer, and you know, over the next several weeks to months, more patients with COVID are going to be diagnosed and they're gonna have to be utilizing, you know, specific shifts or units that are dedicated to COVID, and we have to be able to know when it's safe to move these patients back into the regular dialysis facility.
• 19:43
  SPEAKER_00: Again, we do have current guidance for that that I know a lot of facilities are using, but some of the issues of people being persistently PCR positive, you know, are limiting the ability sometimes of those uh recommendations to be implemented.
• 19:58
  SPEAKER_00: So it's definitely a question we're looking to understand more.
• 20:01
  SPEAKER_00: So again, I think a partnerships with public health and nephrology and hospital epidemiology are really the way through to learn and answer some of these questions.
• 20:11
  SPEAKER_02: Yeah, well, uh, you know, if if there is a silver lining to all of this, it's shown how critically important it is that we do work together.
• 20:19
  SPEAKER_02: We've seen competing dialysis companies come together every week to share experiences, best practices, and questions.
• 20:28
  SPEAKER_02: CDC has been a critical partner in that effort.
• 20:32
  SPEAKER_02: It's been not only the source of best evidence, but we've really, by having Shannon kind of on those calls, that when we meet with the 40 or so dialysis companies around the country that come together, we get a chance to understand what the data are, but what the limitations of interpretation are, and how we can really get the best answers working together.
• 20:56
  SPEAKER_02: So if this is silver lining, it's been made so clear that epidemiologists working with clinicians, working with hospital ID folks is the only way that we're gonna get through all this.
• 21:08
  SPEAKER_01: Thank you very much to our speakers, Dr.
• 21:11
  SPEAKER_01: Alan Kleiger and Shannon Novosad, for joining us today and sharing your experiences.
• 21:18
  SPEAKER_01: And a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to the COVID-19 pandemic.
• 21:29
  SPEAKER_01: This podcast can be accessed on SHA Online Education Center Learning CE under the Rapid Response Program.
• 21:37
  SPEAKER_01: You will also find additional resources such as recorded webinars from healthcare facility outbreak preparedness and the SHA COVID-19 town halls, as well as additional podcasts, the COVID-19 updates, what we know now, which is released every Thursday.
• 21:56
  SPEAKER_01: That concludes this episode of Allies in Infection Prevention podcast series.
• 22:02
  SPEAKER_01: Thank you for tuning in.