Proactively address seasonal influenza cases in the acute dialysis hospital setting

Issue: December 2018

ByJeffrey Giullian, MD, MBA, FASN

Unplanned hospital admissions — including those tied to dialysis — have historically fluctuated with each season. On average, dialysis census and treatment volume can increase from 18% to 20% — up to 50% from summer to winter months.¹

The 2018 winter season — November 2017 through April 2018 — showed a particularly drastic spike in hospital admits across the United States, with some hospitals experiencing a more than 15% year-over-year increase in February (see Figure).^2,3 Influenza rates both influence and track with hospitalization rates for patients on dialysis during winter months — and this past winter, influenza cases hit record-high numbers. In addition, winter months also can account for more cases of general sepsis, cardiac and pulmonary issues and organ failure, including acute kidney injury.⁴ With unexpectedly high patient loads, DaVita Hospital Services teams, who partner with hospitals across the United States to provide inpatient dialysis and apheresis, were tasked with finding innovative ways to ensure prevalent patients continued to receive the dialysis and quality care they needed in the hospital setting during the winter months.

Record number of cases

The high number of influenza cases this past year may have largely stemmed from the proliferation of a variety of virus strains and insufficient vaccine efficacy for protection from H3N2: a more-virulent virus strain that increased in prevalence during the 2017 to 2018 flu season. Many influenza vaccines have been developed to effectively protect against strains of the H1N1 virus, but the current vaccine offered a mere 10% to 24% protection from H3N2 this past year.^5,6 This low efficacy may have been due in part to 1) using an outdated model that leverages eggs as incubators, 2) experiencing difficulty with matching antigens perfectly and 3) forcing mutations in the virus as part of the development process, which can result in a vaccine that does not accurately target the specific virus strain.

During this past flu season, the DaVita Hospital Services teams were often propelled into a critical census status as they navigated the higher-than-normal cases of acute hospitalizations related to influenza. The volume of patients needing inpatient dialysis began spiking a month earlier (January) than anticipated and, almost instantly, by a higher number than in previous years. Adding to the challenges, the multiple virus strains mandated patient segregation and one-on-one treatments to avoid cross-contamination.

Olen Lehman, DaVita’s regional hospital services administrator (HSA) for 11 Kansas hospitals, saw a large influx of ICU patients who went into organ failure, went on continuous renal therapy (CRT) for at least 5 to 7 days or went on hemodialysis just to regain kidney function. His hospital medical director, Michael Grant, with 30 years in hospital leadership, found the influenza strains to be more toxic to the kidneys than he has seen.

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Catherine Ajero, a DaVita HSA in southern California, noted that the UCLA hospital, as a tertiary care hospital for critically ill patients who cannot receive treatment elsewhere, was hit especially hard. Her team prepared for the difficult season by ensuring full staffing months in advance, conducting the 3-month training and orientation before the season hit. They also followed a triage protocol, which were reviewed by their medical directors to prioritize patients based on their acuity. During the winter months (November through April), their 37 nurses performed approximately 1,700 treatments monthly, which was up from approximately 1,200 in the summer months (May through October).

With the unforeseeable magnitude of the spike, the teams scrambled at times to cover all bases, but ultimately were able to consistently provide quality care to their patients on dialysis. Lehman and Ajero credit their successful inpatient dialysis season to the following:

Building agility: DaVita acute nurses are cross-credentialed across multiple hospitals ahead of the season. With this preparation, nurses can be dispatched to whatever hospitals need them most that day. While the online training and onsite orientation require a considerable time investment, the education and acquired skills are vital to learning the differing protocols, cultures and resources at each hospital. Building this into a nurse staffing and training model can allow for agility in responding to the most challenging spikes.

Applying well-developed triage protocols consistently: Appropriate triage can make a critical difference between properly managing a high patient load and making a serious mistake. Nephrologists need to assess each patient to determine which patients to prioritize in receiving dialysis treatments on a red census day.

Increasing influenza-related communications: Not only do agile nurses stretch to learn the communication approach and other protocols of each hospital, but DaVita also connects with hospital leadership and nephrologists about how many incoming patients they estimate will need dialysis based on patient-by-patient evaluation. We keep in close contact with our outpatient facilities, so we know which patients on chronic dialysis have begun to experience influenza symptoms. These steps may seem obvious but in a complex hospital system, if steady communication is not habitual, it may disintegrate when pressures mount.

Lowering administrative communications: During flu season, non-urgent trainings and administrative meetings may need to move to other months of the year. It can help if, before the January upswing, dialysis nurses and other members of the acute team give others a heads-up that their availability may soon decrease as they invest longer hours on the floor.

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Encouraging off-season vacations and training: Particularly in non-union environments, administrators can encourage vacation scheduling during the summer months, helping minimize per-diem nursing and shortages when the patient load increases during the winter. Providing annual trainings during the summer can also free time for direct patient care in the winter.

Maintaining safety with positivity: Influenza spikes can increase strain across the care team as they work extra hours to cover patients. To help maintain team morale, Lehman approaches serious situations, such as hand hygiene, with lightheartedness. For example, he encourages the team, whenever someone touches a machine without following proper hygiene protocol, to gently say the catchphrase “Sneezy!” instead of giving a more-negative reprimand. Lehman and Ajero lead by example, wearing nurse uniforms and joining the team as equals on busy days.

Figure. Percentage of visits for Influenza-like Illness. Reported by the U.S. Outpatient Influenza-like Illness Surveillance Network, Weekly National Summary, 2017 to 2018 and selected previous seasons.³ Source: CDC.

Building a strong leadership team: Success starts at the top, with a corporate commitment to addressing these challenges and regional managers working with all HSAs to maintain open lines of communication and ensure the care team is receiving the support it needs.

Approach 2019 proactively

There is a likelihood that acute hospital teams may experience a similar influenza spike in 2019.⁷ Cases of influenza have been steadily increasing during the past several years. In 2009, the swine flu infected 60.8 million Americans, hospitalized 274,304 and was responsible for 12,469 deaths.⁸ During the 2014 to 2015 flu season, influenza caused 710,000 hospitalizations and 56,000 deaths. Although the data are not fully in, as of mid-February, the 2017 to 2018 season’s epidemic was on track to exceed that record, particularly in number of deaths. This trend has significantly affected employers; this year, lost employer revenue related to influenza and decreased work productivity increased to $21 billion, which is $1 billion compared with last year.⁹

With consideration to this trend, DaVita is preparing for a potentially difficult upcoming season in the following ways:

Continue to promote vaccination: The CDC estimates 40,000 lives were saved between 2005 and 2014 by virtue of seasonal flu shots.10 As scientists continue to work on improving on a vaccine that targets the H3N2 virus, our task remains to educate patients that vaccines may prevent or shorten a flu illness.

Encourage age-dependent doses of the vaccine if they are available next year: A recent VA study on influenza found older patients have a less-dramatic immune response to a given vaccine dose, producing lower antibody levels than young people.¹¹

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Proactively evaluate patients for antiviral regimens: The CDC recommends physicians consider prescribing Tamiflu (oseltamivir phosphate, Genentech Inc.) or Relenza (zanamivir, GSK) for their most vulnerable and fragile patients about 6 weeks during the peak of the flu season. Alternatively, prescribing Tamiflu or Relenza for 5 days (at a lower dose for kidney patients) for newly symptomatic patients may cut the progression short and help prevent complications.

Work with the health care community: Encourage early visits with primary care physicians and help develop and communicate clear guidelines for physicians, patients and hospitals on when to go to the primary care physician, an urgent care clinic or the emergency department.

Universal Influenza vaccine

A universal vaccine that would protect against most known type A flu viruses recently passed the mouse model stage and is on to testing in ferrets, whose respiratory reactions bear important similarities to humans. Researchers explain that rather than focusing on the exterior surface proteins of a virus, this vaccine will target the interior stalk, which all flu viruses share, and which is less likely to mutate.

In the meantime, health care providers must work together — through advanced planning, communication and teamwork — to address the increasing prevalence of influenza cases across the world.

References:
DaVita Hospital Services billing data, 2016-2018.
DaVita Hospital Services billing data, 2016-2018.
CDC. 2017-2018 Influenza Season Week 29 ending July 21, 2018. www.cdc.gov/flu/weekly.
Iwagami M, et al. Nephrol Dial Transplant. 2018;doi:10.1093/ndt/gfy011.
Sullivan S, et al. Low interim influenza vaccine effectiveness, Australia, 1 May to 24 September. Eurosurveillance, Oct. 25, 2017. Accessed April 30, 2018.
www.eurosurveillance.org/content/10.2807/1560-7917.ES.2017.22.43.17-00707.
http://time.com/5068553/this-years-flu-virus-could-be-worse-than-usual
CDC. CDC 24/7: Saving Lives, Protecting People. Accessed April 30, 2018.
Update: Flu cost to employers $21B. Challenger Gray & Christmas Inc. Accessed April 30, 2018.
Foppa IM, et al. Vaccine. 2015;https://doi.org/10.1016/j.vaccine.2015.02.042.
Keitel, W, et al. Arch Intern Med. 2006;166(10):1121-7. Accessed April 30, 2018.

For more information:
Jeffrey Giullian is the chief medical officer for DaVita Hospital Services, DaVita Inc. in Denver. He is also a member of the Nephrology News & Issues Editorial Advisory Board. Disclosure: Giullian reports no relevant financial disclosures.