The coronavirus pandemic will spur major changes in the dialysis world, particularly when providing services to patients residing in the epicenters of the pandemic: nursing homes. More than one-third of all U.S. COVID-19 deaths are nursing home residents. There are nearly half a million hemodialysis patients in the United States, and more than 15 percent of these patients spend time at a nursing home at some point during a calendar year. This reflects both the vulnerability of the elderly population to COVID-19 infection and the difficulty in containing infection in these sequestered communities with residents living closely together.
In the face of COVID-19, the nursing home dialysis population will become even greater, because COVID-19 infection in non-dialysis patients is associated with a high incidence of acute kidney injury. Too many of these patients do not survive their hospitalization. However, to the extent they do, those most seriously affected often require acute dialysis as well as post-acute care dialysis. The kidney damage seems to persist for a long time with no assurance of ever recovering kidney function. Thus, COVID-19 has significantly increased the demand for nursing home dialysis services.
Amid COVID-19, the dialysis industry has had to rapidly find ways to meet the increased demand. Not only have patients become more medically complex, but also there now are extensive infection control requirements necessary to mitigate viral spread and ensure protection for patients and staff. Now, staff is screened for COVID-19 signs or symptoms daily, and patients are screened before each dialysis session. Patients are masked and staff wears full protective equipment. Patients are assigned to treatment areas based on symptoms or COVID-19 positivity, and physical distancing rules are enforced.
A central component of the enhanced infection control strategy has been rapid expansion of on-site dialysis in the nursing home. A further enhancement of infection control strategy in on-site nursing home dialysis patients has been the conversion to more frequent hemodialysis therapy. Five times per week treatment in nursing home patients is reducing the relative risk of hospitalization by as much as 20 percent, compared to four or fewer treatments per week (ADC 2020). With the more frequent treatment modality, elderly patients in the SNF show even more significant reduction in hospitalization. This secondarily reduces potential emergency room and hospital-based COVID-19 exposure.
Moreover, concerning infection control, COVID-19 symptoms in nursing home hemodialysis residents have served as a sentinel for COVID-19 within the general nursing home population. The more frequent five-times-per-week hemodialysis model provides intense and relevant local surveillance compared to less frequent conventional off-site HD. An example of the power of COVID-19 symptom monitoring was illustrated by the difference of COVID-19 symptom penetrance in nursing home dialysis patients between New York and Florida. This is likely attributable to differences in community disease prevalence, skilled nursing facility (SNF) infection control capabilities, their relationships to referring hospitals and state health regulatory environment (ASN 2020). On March 25, 2020, New York mandated SNFs to accept COVID-19 hospital returns and forbade SNFs to demand proof of negative test before accepting the return of suspected patients. The results of New York policy on nursing home COVID-19 infections were unintentionally devastating. This newly developed strategy can inform an urgent pivot of infection containment efforts by the nursing home and larger regulatory agents. Lessons learned from successful containment strategies have already been implemented; the New York State Department of Health has greatly expedited approvals for dialysis dens and other treatments that serve the population and health systems well by ensuring unprecedented access to on-site dialysis and other services.
Broadly, the current COVID-19 pandemic already is transforming the dialysis world in several ways:
- Remote work, including telehealth-driven patient care and multidisciplinary communication already is improving care and information sharing.
- Staff, clinical leadership and management are working together creatively more than ever.
- From this creative energy has come flexible working schedules and a culture of trust with high concern for the safety of both patients and staff — each confident that we all care for each other.
- COVID-19 crystalized a greater focus from Centers for Medicare and Medicaid Services, regulators and SNF operators to rapidly expand adoption of this modality.
From this dark cloud, which will pass, we finally can see something of a silver lining portending a future that will be brighter than ever.
This piece has been updated.