On March 10, 2020, the Centers for Medicare & Medicaid Services (CMS) issued the Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Dialysis Facilities. This guidance addresses practices that dialysis facilities are expected to follow to limit transmission of COVID-19 in dialysis facility settings, including screening patients, visitors and staff, as well as isolating patients with suspected or confirmed COVID-19 and transferring patients to alternative providers when necessary.
Dialysis patients have a unique vulnerability to COVID-19, as evidenced by the fact that the first two patients in the United States who died from COVID-19 were in-center dialysis patients in the Seattle area. Accordingly, dialysis facilities should carefully review and update their policies and procedures to align with the guidance and ensure, to the greatest extent possible, that they have an ample stock of personal protective equipment (PPE).
Key points from the CMS guidance include:
1. Screening patients, staff, visitors and home dialysis patients for COVID-19 infections. Dialysis facilities should screen patients, staff, visitors and home dialysis patients for COVID-19 symptoms based on the following criteria: (i) signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath or sore throat; (ii) contact with someone with or under investigation for COVID-19; (iii) travel within the last 14 days to or from countries with sustained community transmission of COVID-19; or (iv) residence in a community where community-based spread of COVID-19 is occurring. As information regarding COVID-19 symptoms is evolving, dialysis facilities should refer not only to this guidance, but also to current CDC guidelines regarding symptoms of COVID-19. Dialysis facilities should have patients call ahead to report fever or respiratory symptoms and post signage at the facility entrance instructing patients to notify staff if they have a fever or respiratory infection symptoms so appropriate precautions may be exercised and the facility can triage patients to an appropriate setting, if necessary. Patients who present with signs and symptoms of respiratory infections should be identified prior to entering the dialysis treatment area and should be required to wear a face mask at check-in and until they leave the facility.
2. Restrictions on visitation. Dialysis facilities should defer visitation for visitors who present with signs and symptoms of a transmissible infection until they are no longer potentially infectious. Since the issuance of the guidance, many facilities have adopted a policy prohibiting visitors, except as essential to the rendition of patient care.
3. Hand and respiratory hygiene. Dialysis facilities are expected to provide patients and staff with instructions (in appropriate languages) regarding hand hygiene, respiratory hygiene and cough etiquette, and to provide related supplies, i.e., tissues, hand sanitizer and no-touch disposal receptacles.
4. Monitoring staff for COVID-19 symptoms. Staff who have signs and symptoms of a respiratory infection should not report to work. If symptoms arise at work, staff members should immediately stop working; use a face mask; self-quarantine at home; inform the dialysis facility administrator of patients, staff and equipment that they came into contact with; and contact and follow the local health department recommendations for testing and treatment options. Dialysis facilities should also follow CDC interim guidance for exposures that might warrant restricting asymptomatic healthcare personnel from reporting to work.
5. Waiting areas for symptomatic patients. Dialysis facilities should arrange for a space in waiting areas to segregate ill patients from other patients by at least six feet and provide masks to symptomatic patients. Dialysis facilities should also encourage medically stable patients with no other care needs to wait in their cars or outside the facility until the staff is ready for them.
6. Treatment of patients with COVID-19 symptoms. If possible, dialysis treatment of symptomatic patients should be provided in a separate room with the door closed. Otherwise, facilities should maintain at least six feet of separation between masked, symptomatic patients and other patients and stations during dialysis treatment. Symptomatic patients should be treated at a corner or end-of-row station that is away from the main flow of traffic. Hepatitis B isolation rooms may be utilized for symptomatic patients if (i) no hepatitis B surface antigen positive patients require treatment at the facility, or (ii) if the suspected or confirmed COVID-19 patient is hepatitis B surface antigen positive. Facilities should continue to follow infection control requirements, including hand hygiene, PPE, isolation and routine cleaning and disinfection procedures. Dialysis facilities are also encouraged to cohort multiple patients with confirmed or suspected COVID-19 infections and the dialysis staff caring for them together in a unit and/or during the same shift (preferably the last shift).
7. Infection control requirements. Dialysis facilities should continue to follow Medicare program requirements for infection control and ensure that environmental surfaces, medical devices and equipment are appropriately cleaned and disinfected. This includes: (i) using PPE, including isolation gowns, gloves, face masks and eye protection; (ii) implementing isolation and routine cleaning and disinfection procedures appropriate for use against COVID-19, including using products with EPA-approved emerging viral pathogen claims; (iii) providing additional work supplies to staff to avoid sharing (e.g., pens, pads); and (iv) implementing routine disinfection protocols for workplace areas, such as nurse’s stations, phones and internal radios.
8. Transferring patients to alternative sites. A dialysis facility should consider transferring a patient to another treatment site if the facility cannot fully implement the recommended precautions or if the patient requires a level of care that the facility is unable to provide. Transportation personnel and the receiving facility should be notified in advance of the patient’s healthcare needs, and the patient should wear a face mask and remain separated from other patients while awaiting transfer. If stable, patients can be asked to wait in their cars or to return home.
9. Home-dialysis patient monitoring. Dialysis facilities should continue monthly monitoring of home dialysis patients on-site at the facility. The guidance indicates that dialysis patients should maintain their appointments to ensure that appropriate dialysis procedures will be followed. Of course, regardless of the CMS guidance, decisions regarding care delivery remain the province of the patient’s treating nephrologist and the facility’s medical director.
10. Supply Shortages. Due to the scarcity of some supplies in certain areas of the country, CMS has directed state and federal surveyors not to cite facilities for not having certain supplies — including PPE, such as gowns, N95 respirators, surgical masks and alcohol-based hand rubs — where the shortage is outside of the control of the facility. However, CMS expects facilities to take actions to mitigate any supply shortages and take all appropriate steps to obtain supplies as soon as possible. Dialysis facilities should contact local and state public health agencies to notify them of any PPE shortages, follow national guidelines for optimizing their current supply, and identify the next best option for patient care.
As the COVID-19 situation continues to evolve, CMS has encouraged all dialysis facilities and other healthcare providers to monitor the CDC’s website for up-to-date information and resources and to contact local health departments when needed. Please contact the authors of this alert for additional guidance on how other COVID-19 considerations may impact healthcare providers. McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues.