While social distancing will help stem the spread of COVID-19, the practice is near impossible for thousands of vulnerable people who risk becoming severely ill without their regular treatment.
Patients with kidney failure are one of these vulnerable groups. Instead of keeping away from others, these patients, who tend to be older with several other chronic conditions, must visit a dialysis center to stay alive. They sit in clinics next to 10 to 30 other immunocompromised patients for four hours, three times a week. They have no choice. While other people may be able to put off scheduled doctor's appointments to avoid infection, dialysis can't be postponed.
"They are very fragile population and they are required to congregate," said Dr. Daniel Weiner, a nephrologist at Tufts Medical Center. "There is no way that they can socially isolate. There's no way that they can quarantine effectively if they are going to continue to receive their dialysis."
Because of this, dialysis providers face the grave challenge of keeping their patients safe while in the clinic and in transit to and from their appointments. Clinics have committed to continue dialyzing patients who contract COVID-19, so as not to overwhelm hospitals that will need as many beds as possible as the pandemic worsens. Providers are also trying to assuage fear and anxiety over the virus that could cause patients to skip dialysis sessions, which would only make them more vulnerable to illness.
Roughly 750,000 people had end-stage kidney disease in 2017 and most of them were on dialysis, according to the U.S. Centers for Disease Control and Prevention. Dialysis removes waste and fluid from the blood when the kidneys are no longer working.
Seattle-based Northwest Kidney Centers has ramped up prevention and infection control procedures. It is screening patients for COVID-19 symptoms, such as fever, cough and shortness of breath, as soon as they walk in the door, said Dr. Elizabeth McNamara, chief nursing officer of the not-for-profit provider, which worked with a CDC team for the first two weeks of March. One of Northwest Kidney Centers' patients was among the first reported U.S. deaths from COVID-19.
Patients with symptoms are given masks and clinicians use extra personal protective equipment to care for them, she said. Northwest Kidney has committed to continuing to dialyze those diagnosed with or showing signs of COVID-19 in its 19 outpatient clinics, sending them to the hospital only when there's a clinical need. Educating patients about its strategy has helped relieve anxiety.
"We don't want to put our patients at risk and we don't want to overwhelm an already overwhelmed system any more," said Dr. Suzanne Watnick, Northwest Kidney Centers' chief medical officer. "We can protect patients probably better than if they got sent to the emergency room environment by appropriately using infection prevention and control."
DaVita Kidney Care and Fresenius Medical Care, which combined operate the majority of U.S. dialysis clinics, likewise say they are doing what they can to keep dialysis patients healthy and out of the hospital.
In addition to screening and masking patients, Dr. Robert Kossmann, Fresenius chief medical officer, said Fresenius dialysis centers have limited visitors, run tabletop pandemic exercises, and bulked up on supplies back in January. The company expanded telehealth in response to CMS waivers to allow patients to communicate with their nephrologists and other care teams from home.
Fresenius and DaVita both have started providing dialysis to cohorts of patients with COVID-19 symptoms during separate shifts at the clinic or in entirely separate "isolation clinics" to keep them from infecting other patients.
"Our hope is to treat those patients in the outpatient setting, if we can, to leave hospital beds open for the system," Dr. Jeffrey Giullian, chief medical officer of DaVita, said in an email.
DaVita has daily calls to work through details, such as how patient information will flow from the patient's usual dialysis center to the new one while in isolation. The strategy also necessitates bringing in more staff. DaVita reached out to former employees, and within 48 hours, 380 nurses and 900 patient care technicians agreed to come back to work on a per diem basis.
Some sources pointed out that designating certain centers for COVID-19-infected patients could promote a stigma around the disease and make it harder to staff those clinics. Coordinating transportation to a new clinic may also prove difficult.
To further relieve the burden on other providers, DaVita and Fresenius say they hope to soon perform their own COVID-19 lab tests so patients don't have to go elsewhere, but the availability of diagnostic tests is an issue, as it is for other types of providers. DaVita has piloted the nasal swab test and is actively talking with biotechnology companies that may allow it to provide a different type of testing once those technologies come on the market, Giullian said.
Fresenius, meanwhile, is "in the process of securing tests and making arrangements with laboratories to get results as quickly as possible," Kossmann said.
Fiona McKinney, 59, who suffers from kidney failure and has been on dialysis for 12 years, said she feels safe at her Fresenius-owned dialysis clinic in Manhattan, New York. The clinic takes everyone's temperature at the front door and gives each patient a mask, which they must reuse to conserve supplies. In case of a travel lockdown, the clinic armed patients with letters explaining they need to come to dialysis. When one patient at her clinic showed symptoms a little over a week ago, staff put the patient in an isolation room and called the emergency department, she said.
But McKinney has had trouble finding extra masks and knows her dialysis clinic is worried about running out. She takes a Medicare-funded car service to dialysis and is concerned that other people getting in and out of the car may be affected by the virus. She has also heard from other dialysis patients who fear going to their sessions.
"I'm definitely concerned," McKinney said. "I do realize I'm more vulnerable being on dialysis with a low immune system, but I'm doing everything I can. I've seen other dialysis patients talking about making a will, but I'm not there yet."
Beyond the clinical characteristics that make dialysis patients more vulnerable to severe illness than others, many also face economic and social disadvantages that put them at risk.
LaVarne Burton, president and CEO of the not-for-profit American Kidney Fund, said many dialysis patients are not able to work. Those that do often work hourly jobs or are self-employed. Many don't drive and must take public transportation or car sharing services to their dialysis centers. They often have strict dietary needs.
Burton described one patient with kidney failure who gets most of his meals from a food bank in a small community. Since the coronavirus outbreak, contributions to the food bank have dried up. The American Kidney Fund activated a $300,000 emergency fund to help patients in those kinds of situations afford food, transportation and medications. It received enough applications for assistance to exhaust the fund on the first day it was opened and is continuing to raise money to assist more patients.
Dr. Weiner of Tufts Medical Center said ambulances could be used to help transport patients to the dialysis center, but doing so would require a regulatory change. That may be necessary, he said, if hospitals need to free up beds. Dialyzing patients at the hospital would use up resources unnecessarily. But hospitals can't discharge patients who have no way to get to dialysis.
"We need ambulances to be able to step up and take people from their homes to dialysis units because ambulance crews are trained in how to clean their vehicles after an exposure," he said. "Right now though, that's prohibited; it's not reimbursed for ambulances to pick up patients from their homes and bring them to chronic care. That would be something regulatory that would help with this whole issue."
Providing dialysis at the patient's home could also theoretically help prevent the spread COVID-19 while eliminating the need for transportation. Just 12% of dialysis patients receive home dialysis, though the numbers have been growing in recent years in response to support from the federal government. But before patients can be placed on home dialysis, they need weeks of training and a minor hospital procedure to place a catheter.
"I'm certain that every dialysis unit right now is trying to think how can they get patients (to dialyze) safely at home, those who could get it at home, but as the number of cases of COVID-19 increase and overwhelm our healthcare capacity at hospitals, it's going to be more and more difficult to get procedures done," said Dr. Holly Kramer, president of the National Kidney Foundation.
Jonathan Paull, chief compliance officer and general counsel at Dialyze Direct, provides staff-assisted dialysis in nursing facilities, said home dialysis is the solution for nursing home patients, however, and "allows for a full quarantine of the facility" during the pandemic. He argued that hospitals should be making sure to discharge dialysis patients to nursing facilities that are able to provide dialysis onsite. Nursing facilities without that capability should transfer dialysis patients to facilities with dialysis dens.
Some hospitals and nursing facilities understand that, he said, and Dialyze Direct's roster of 2,400 patients has been growing by the week.
But while most patients won't be able to switch to dialyzing at home overnight, experts expect the COVID-19 pandemic to act as a catalyst to future uptake.
"I think that people will be able to point to what's going on now when we emerge on the other side of this and go, hey, here's another great reason why we need to have more home dialysis, Weiner said. "If you have other pandemics like this, if you're on home dialysis it's a whole lot easier to reduce your exposure than it is with coming into an in-center hemodialysis unit."
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