CMS prioritizes dialysis access procedures, offers regulatory relief for nephrologists amid COVID-19
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CMS has re-classified vascular access placement for patients on dialysis as an essential surgical procedure during the COVID-19 pandemic, according to recently updated guidance.
The agency is also offering regulatory relief on Medicare quality measures reporting and is expanding telehealth options for nephrologists caring for patients on in-center dialysis.
The changes were announced March 26 during a webinar hosted by the CDC and Nephrologists Transforming Dialysis Safety (NTDS), a coalition formed by the American Society of Nephrology. The webinar is the second in the last 3 weeks as Medicare regulators and dialysis staff continue to develop strategies on how to deal with more diagnosed cases of COVID-19. Organizers said the webinar attracted close to 2,000 attendees. A replay and slides of presentations during the webinar are available at the NTDS website, https://www.asn-online.org/ntds/
Comments from the kidney community about having difficulty scheduling vascular access surgeries for patients on hemodialysis and peritoneal dialysis prompted CMS to re-list the procedures as essential services, the agency said in a statement.
“We wish to clarify that these planned procedures are essential in that establishing vascular access is crucial to end-stage renal disease patients to receive their life-sustaining dialysis treatments,” according to the memorandum.
During the webinar, Jeffrey Silberzweig, MD, chief medical officer of the Rogosin Institute, detailed the regulatory waivers from CMS that include the following:
- data submission requirements for most quality reporting and pay-for-performance programs, such as the Quality Incentive Program, CrownWEB, and the Merit-based Incentive Payment System. “CMS recognizes that the data collected during the COVID-19 crisis may not reflect the services provided throughout the year,” Silberzweig said;
- licensed professionals can practice across state lines (unless state-specific laws prohibit the practice);
- telecommunications between patient and provider have been extended for most outpatient and office settings, and now includes virtual check-in, which is a brief (5 to 10 minute) encounter via telephone or remote evaluation; and
- telehealth care can be furnished to patients in any location.
Telehealth is currently not permitted to be conducted via telephone only, and nephrologists do need to have one, face-to-face visit with the patient each month, Silberzweig said.
During the webinar, Shannon Novosad, MD, MPH, a medical officer with the dialysis safety team in the division of health care quality promotion at the CDC, updated attendees on revised guidance for dialysis staff and patients. A new Outpatient Dialysis Facility Preparedness Assessment Tool is available from the CDC that offers a checklist of steps dialysis providers should take when managing patients with COVID-19.
Recommendations include the following:
- Dialysis staff should test patients for signs and symptoms of respiratory infection (eg, fever, cough) before they enter the clinic. The CDC is using a body temperature of 100° as a threshold for suspected symptoms, Novosad said. Patients with symptoms of a respiratory infection should put on a facemask at check-in and keep it on until they leave the facility;
- Routine cleaning and disinfection procedures for dialysis machines should be conducted after each treatment; Novosad did not have any recommendations on how soon a dialysis machine can return to service after being used to treat a patient with COVID-19. Disinfectants should have a bloodborne pathogen claim (eg, hepatitis B, HIV), she said. Any surface, supplies or equipment located within 6 feet of symptomatic patients should be disinfected or discarded.
Novosad said the CDC recommends that if there is more than one patient with suspected or confirmed COVID-19, patients and the dialysis staff caring for them should be placed together in a section of the unit and/or on the same shift (eg, consider the last shift of the day).
Responding to questions about when staff can return to the clinic after a COVID-19 diagnosis, Novosad said the CDC offers guidance for those who can be tested or in cases where tests are not available. The test-based strategy excludes a staff member from work until resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (eg, cough, shortness of breath), along with negative results of an FDA emergency use authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected at least 24 hours apart (total of two negative specimens).
If a COVID-19 test is not available, staff should be excluded from work until at least 3 days (72 hours) have passed since recovery, defined as resolution of fever without the use of fever-reducing medications, and improvement in respiratory symptoms (eg, cough, shortness of breath); and at least 7 days have passed since symptoms first appeared.
After returning to work, staff should wear a facemask at all times while in the health care facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer. Staff should also be restricted from contact with severely immunocompromised patients (eg, transplant, hematology-oncology) until 14 days after illness onset.
Novosad said dialysis facilities need to find ways to preserve personal protective equipment because of developing shortages. The use of eye and face protection gear (respirator or facemask) can be extended for repeated contacts with the same patient, Novosad said. Personnel must not touch their eye protection and respirator or facemask. Eye protection and the respirator or facemask should be removed, and hand hygiene performed if they become damaged or dirty and when leaving the unit, she said. – by Mark E. Neumann
References:
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis/screening.html
Disclosures: Silberzweig and Novosad report no relevant financial disclosures.