First COVID Deaths in the US Mobilized a Dialysis Network

Marcia Frellick

March 30, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

At 9:30 PM on Friday, February 28, Suzanne Watnick, MD, chief medical officer at Northwest Kidney Centers in Seattle, got a call she never expected.

The nephrologist who called asked if Watnick was sitting down, then told her the first known death from COVID-19 in the United States was a patient who had been dialyzed at one of the 19 centers in their network.

The first outpatient dialysis unit in the United States, which opened in 1962, was part of Northwest Kidney Centers. They never expected to add this dubious "first," Watnick said during her virtual presentation at the National Kidney Foundation 2020 Spring Clinical Meetings.

A three-pillared plan was quickly set in motion: continue to provide dialysis; ensure that the centers follow the science; and provide strong leadership through assurances, transparency, and communication.

The patient who died had last been at the center a week before, on February 21. At that time, only patients who had recently traveled to a country of concern or who had been in close contact with someone infected met the Centers for Disease Control and Prevention (CDC) requirements for testing.

"As soon as that had lifted, the patient, who was gravely ill in the ICU, got tested, but died later that day," Watnick reported.

From there, the center, in conjunction with the local public health department, developed a full list of anyone who had been near the patient on February 21, when the patient had a cough but no respiratory symptoms, so they could be informed about their possible exposure.

Staff members who had direct contact with the patient were placed on furlough for 14 days, a recommendation that has since changed.

Now, staff can return to work if there is no diagnosis. If they test positive for COVID-19, they can return to work 7 days after the first symptoms appear or 72 hours after symptoms mitigate, whichever is longer, but must wear a mask until symptoms resolve, according to CDC guidance.

Two nights after the first death, the news came that a second patient on dialysis had died from COVID-19.

Second Person Who Died Dialyzed in Same Facility

"This second patient dialyzed at the same facility but on a different shift and on different days," Watnick reported.

One of these patients lived in a nursing facility where there had been an outbreak of COVID-19, but the other seemingly acquired it through the community, she said.

Testing then began for anyone at any of the 19 facilities in the network who had symptoms, and guidelines were developed and procedures put in place to screen all patients and staff.

Now, anyone who arrives is screened for the "big four" — fever, new shortness of breath, new cough, and sore throat — and temperatures are taken as patients enter the clinic, rather than at the bedside, Watnick said.

"We also have new signage, and any patients with symptoms immediately wear a mask. If necessary, they sit in the waiting room at least 6 feet from others, but we try to get these folks in quite quickly," she added. "Those who screen positive are dialyzed in private rooms, if we have them. If not, we cohort them at the end of a row."

The clinical staff undergo the same screening. If staff members have any symptoms, they cease work immediately and put on a mask. If they have a diagnosis other than COVID-19, such as flu or strep throat, they can return to work when they haven't had a fever for 24 hours and their symptoms are markedly waning, she said.

Areas that weren't being disinfected routinely — rails on the scales, doorknobs on the bathroom, seats in the waiting room, and hand rests on wheelchairs — are now being disinfected. The centers have checklists and sanitize these at appropriate intervals.

"To date, even though we have had 12 patients who have been COVID-19-positive, we have had no staff taking care of them in the outpatient setting coming back with a positive test for COVID-19," Watnick said.

CDC Team Leader Updates Guidance for Centers

Part of the guidance for outpatient dialysis facilities is the imperative to reassure patients about safety, said Shannon Novosad, MD, acting team lead for the CDC Dialysis Safety Team, who also spoke during the virtual session.

"We know patients really have to come to their dialysis center; they cannot miss dialysis," she said.

But patients are likely to miss sessions if they don't feel safe, so explaining what the facility is doing to keep them safe is important, she pointed out.

Education should include instruction on hand hygiene, respiratory hygiene, and cough etiquette. And policy at a center should encourage workers who are sick to stay home and not make them feel that they are expected to report to work.

Some centers in COVID-19 hot spots are taking the temperatures of all staff as they arrive at work, Novosad said.

Screening won't be the same for all facilities, she acknowledged, but plans should be in place to screen patients before they enter the building. Patients should be encouraged to call ahead if they have symptoms so the staff has time to prepare. Some places are using robocalls or texts to remind patients to call ahead.

Patients who do come to the facility should be asked about symptoms as soon as they arrive. That will entail having staff stationed outside or just inside the doorway to ask about any symptoms and having masks available for symptomatic patients.

Facilities need to have a way to separate symptomatic patients from those without symptoms, even if that means asking patients to wait in their vehicles until it is time for their treatment.

And extra personal protective equipment will mean that trash cans have to be added around dialysis stations.

Disinfectants used should be approved for use against SARS-CoV-2, as outlined on List N of the Environmental Protection Agency, Novosad said.

Some patients will need a higher level of care and will need to be transferred either to another dialysis center or to acute care. In such cases, staff should call the receiving staff so they can prepare for the patient.

And if COVID-19 is suspected, the health department should be notified, she added.

National Kidney Foundation (NKF) 2020 Spring Clinical Meetings. Presented March 27, 2020.

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