How to Manage Residents Who Receive Dialysis When COVID-19 Is at the Door

By Caralyn Davis, Staff Writer - May 27, 2020

The Centers for Medicare and Medicaid Services (CMS) has tried to make it easier for dialysis providers to offer home dialysis to long-term care residents to reduce the risks of COVID-19 transmission. Note: For more information, see Quality, Safety, and Oversight (QSO) memo QSO-20-19-ESRD – REVISED, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Dialysis Facilities, as well as the Expanding Availability of Renal Dialysis Services to ESRD Patients section of COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.


However, home dialysis often isn’t a realistic option, says Mary Gruel, RN, CDN, education coordinator at Tri State Dialysis in Dubuque, IA, and program coordinator for the April 2020 Spring Clinical Meetings’ nursing track at the National Kidney Foundation. “During the pandemic is not the time to change modalities to home therapy,” she advises. “Most dialysis facilities don’t have the training and staffing capacity to make that transition for multiple residents or the extra machines that would be needed to provide that service in the facility.”


Consequently, many nursing homes will need to continue to send residents out for dialysis treatments for the duration of the pandemic. However, taking the following steps can help mitigate the risks:


Assess whether you should cohort dialysis residents

On April 30, the Centers for Disease Control and Prevention (CDC) released Responding to Coronavirus (COVID-19) in Nursing Homes to help nursing homes make cohorting decisions about residents with confirmed or suspected COVID-19, as well as new admissions/readmissions. This is supplementary guidance to the Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes.


The Infection Control Assessment and Promotion Program (ICAP) at Nebraska Medicine in Omaha, NE, suggests a more aggressive approach, according to ICAP panel members at the May 8 webinar, Long-Term Care: Strategies to Care for Vulnerable Populations. Note: This webinar is part of the free NETEC COVID-19 Webinar Series from the National Emerging Special Pathogens Training and Education Center (NETEC).


Providers considering this approach should weigh both the advantages and disadvantages of moving residents together by risk level, adds Jill Morgan, RN, BSN, a nurse at Emory University in Atlanta and a NETEC subject matter expert.


When a suspected or confirmed COVID-19 case is in a facility, providers should plan “to identify red, yellow, and green zones where the residents can be cohorted based on their symptoms and exposure risks to COVID-19,” says ICAP in the Cohorting Plan for LTCF. “Facilities are also recommended to establish a transitional zone (gray zone) for asymptomatic patients who are being transferred from other healthcare facilit[ies].”


Here are ICAP’s basic zones and where dialysis residents may fit in:


  • Red is the isolation zone. This zone should include a dark red zone for confirmed COVID-19 residents and a separate light red zone for symptomatic residents with suspected COVID-19.

  • Yellow is the quarantine zone. This zone is for asymptomatic residents who have had an exposure risk. For example, yellow zone inclusion may be merited for “all asymptomatic residents of a single unit/hallway/neighborhood where a few residents are symptomatic (suspected of COVID-19 infection), and one has already tested positive for COVID-19,” says ICAP.

  • Green is the COVID-free zone. This zone is for residents who are asymptomatic and are not considered to be exposed. If COVID-19 is widespread in a facility, there may be points in time when there is no green zone, notes ICAP.

  • Gray is the transitional zone. This zone is for residents who are asymptomatic, have no known COVID-19 exposure, and are being transferred into the nursing home from an outside facility. Gray zone residents could include new admissions, residents returning from the acute-care hospital, and residents who come in and out of the facility, including residents who receive outpatient dialysis. Providers should have gray zone units even when there are no suspected/confirmed COVID-19 cases in the building, and residents should be kept in the gray zone to monitor for symptoms for 14 days since the last entry into the facility, meaning outpatient dialysis residents would remain in the gray zone indefinitely.


While it’s preferable to establish “geographically distinct” areas within each nursing home to serve as each zone, cohorting by exposure risk for dialysis residents could be as simple as moving two dialysis residents (i.e., residents with similar risk levels) together into the same semiprivate room, notes Morgan.


Staffing considerations include the following:


  • Most nursing homes won’t have the capacity to dedicate staff to each zone, so to protect residents in green and gray zones, the next-best alternative is to “avoid assigning those staff who are working in the red or yellow zones to the green or gray zones to the extent possible,” says ICAP.

  • If staff have to work in multiple zones, their work schedules should be planned so that they do all their work in one zone and then move to the next zone rather than moving back and forth between zones repeatedly. In addition, staff shouldn’t practice extended use or reuse of personal protective equipment (PPE) when moving to a new zone to avoid zone-to-zone transmission, says ICAP.

  • Staff in gray zones should use the same level of PPE that they use for confirmed or suspected COVID-19 cases. “If PPE supply is inadequate, nursing homes can consider limiting COVID-level precautions to only high-contact resident care activities or aerosol-generating procedures within the transition zone,” says ICAP.


Limit tub room use

Residents in gray zones, including dialysis residents, should have baths in their rooms, suggests ICAP. However, if a dialysis resident needs to be bathed in a tub room/bath house (e.g., to get a whirlpool bath), nursing homes can take steps to reduce the risks associated with that, say ICAP staff. These steps include the following:


  • Have the dialysis resident wear a mask throughout. The resident should wear a mask during transport in the hallway and also during the bath. “We would want to ensure that the mask doesn’t come off while the person is being bathed,” they stress.

  • Bathe the dialysis resident last on the bathing shift. Airflow is often a problem in tub rooms, note ICAP staff. “You would probably want to have that resident be last of the day so that airflow in the bathhouse could turn over sufficiently before baths are begun again the next day.”

  • Disinfect the tub room. After the dialysis resident is bathed, environmental services staff should clean all surfaces in the bath house with a disinfectant that is approved by the Environmental Protection Agency (EPA).


Note: ICAP and the Nebraska Department of Health and Human Services hold a weekly webinar for post-acute and long-term care providers in the state. These suggestions are from the April 30 webinar.


Consider increasing surveillance frequency

Nursing homes that have no suspected COVID-19 residents should “actively screen all residents daily for fever and symptoms of COVID-19” and consider increasing the screening of asymptomatic residents to every shift when there are presumed or confirmed cases, according to the CDC’s Key Strategies to Prepare for COVID-19 in Long-term Care Facilities. However, providers also may want to consider adopting varying levels of surveillance for some residents, such as dialysis residents, says Morgan. “Is symptom and vital sign monitoring done at the same frequency on all your residents, or are there some people you will put on more frequent vital sign and symptom monitoring because of their higher risk profile?” she asks.


Develop/review transportation protocols

Providers should establish protocols to reduce contamination risks when residents are transported to dialysis and other outside appointments, says Morgan. Questions she recommends asking to formulate these protocols include the following:

  •  Are residents being asked to wear PPE when they leave the facility?

o   Can they wear face masks?

o   Should they have gloves on?

o   Should they wear a gown or other covering when they get to dialysis or when they leave dialysis?

  • Are residents being offered easy access to hand hygiene when they enter and leave the facility?

  • How close are the residents who are being transported (1) to each other, and (2) to the transporter/driver?

  • What infection prevention measures should be taken in regard to the staff who send and receive residents?


In addition, if the transport vehicle is being provided by the dialysis center, nursing homes should ask who else will be in the van, suggests Gruel. “For example, before the pandemic, a dialysis provider’s transportation bus may have picked up two or three residents from different nursing homes on the same trip. Now it should be one patient at a time unless two residents are coming in from the same facility. In addition, it’s a good idea to look at whether the drivers are masking as well.”


Report all potential COVID-19 symptoms since the last dialysis visit

Nursing home staff should check a dialysis resident’s temperature and assess for COVID-19 symptoms before the resident leaves the facility, says Gruel. “If the resident has a temperature or any common or uncommon symptoms of COVID-19—or has had any of those issues since their last visit to the dialysis center—you should have a process in place to call the dialysis provider before you send them. For example, if the resident went to the dialysis center on Tuesday, had a temperature on Wednesday, and does not have a temperature on Thursday, you should notify your dialysis provider of that temperature that occurred on Wednesday before you send the resident out for their Thursday dialysis appointment.”


This notification is important because it alerts dialysis providers to implement controls, says Gruel. “For example, your dialysis provider may want to send a resident who is exhibiting symptoms to a respiratory clinic for COVID-19 testing and then dialyze that resident in the isolation room used for COVID-19 patients until the results come back.”


Be vigilant about masking dialysis residents

Residents who have trouble breathing or who cannot remove their masks themselves shouldn’t wear one, advises ICAP staff. Note: ICAP personnel made this recommendation at an April 23 webinar. However, all other residents, including dialysis residents, should wear at least a cloth mask whenever possible, they suggest.


For dialysis residents, this includes whenever they leave their room, as well as when they leave the facility, suggests Gruel. “You also want them to wear a mask any time they interact with staff, even if they are in their own room, to avoid asymptomatic transmission.”


Stick closely to the care plans

“All dialysis patients are immune-compromised, they have increased morbidity, and most have diabetes and hypertension,” notes Gruel. “You want to keep blood sugars in good control, have good fluid control, and have strict diet control as well. Medication compliance is always important but especially during this pandemic.” Note: The ESRD Network at the Health Services Advisory Group (HSAG) offers two resources: The slide set Dietary Guidelines for End Stage Renal Disease (ESRD) Residents provides information and resources about nutritional needs, fluid management, and medication management for long-term care dialysis residents. Long-Term Care Facility Information for Dialysis Residents: Tips and Best Practices for End Stage Renal Disease (ESRD)-Specific Patient Care is a 14-page tip sheet that helps nursing homes review the special needs of dialysis residents, including nutrition recommendations, psychosocial recommendations, and recommendations for nursing staff.


Talk to your dialysis provider

Nursing homes should make sure everyone “is keyed into the idea of safety,” says Morgan. “What can you ask of the dialysis center? What kind of screening are they doing for themselves, for their staff, and their other patients?” Note: The CDC offers Screening Dialysis Patients for COVID-19 and Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities.



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