Mount Sinai Hospital reports its procedures for patients who require dialysis during COVID-19 pandemic
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In an article published in Kidney Medicine, nephrologists from Mount Sinai Hospital in East Harlem, New York, outline how they are ensuring that patients who require dialysis receive safe and effective care during the COVID-19 pandemic.
According to Osama El Shamy, MD, and colleagues, New York City has the densest population of any municipality with a population of more than 100,000 in the United States. Therefore, the COVID-19 pandemic has presented health care professionals in the region with “extraordinary challenges,” including limited resources, such as hospital beds, personal protective equipment [PPE] and staff.
“As nephrologists,” the authors wrote, “we see our primary goals as twofold: 1) keeping our existing patients safe both at home and in their dialysis units, and 2) meeting the needs of patients who do require hospitalization, both COVID related and unrelated.”
To care for patients who undergo dialysis at home or who have been admitted to the hospital, El Shamy and colleagues have implemented a variety of strategies.
For patients on home dialysis, the hospital has focused on providing telemedicine services, obtaining iPads and using platforms such as FaceTime, WhatsApp and Zoom. During telehealth appointments, dialysis staff contact patients on the day and time of their clinic appointments. Patients take their temperature, pulse and blood pressure and speak with a dietician and social worker. Monthly medications are delivered to patients’ homes by a contracted company that also picks up urine and dialysate samples if necessary.
Furthermore, Mount Sinai has contracted with a laboratory company to provide home visits, with results available within 24 hours.
When it is necessary for patients to be seen in-person, primarily due to peritoneal dialysis (PD) catheter complications or suspected peritonitis, clinical staff call patients first to ensure no symptoms of COVID-19 are present. According to the authors, the hospital has successfully managed more than 80% of its patients remotely.
Procedures have also been implemented for patients who require in-patient dialysis, which the authors state has increased during the pandemic as patients admitted with COVID-19 often develop AKI and require urgent dialysis, while others on maintenance dialysis have missed regularly scheduled appointments. With a shortage of nephrology nurses, Mount Sinai has created an acute PD program with the “major goal of maximizing our ability to provide dialysis resources for this surge.”
The authors suggest that acute PD “reduces the number of central venous catheters being placed and therefore the number of central line associated blood stream infections and also provid[es] patients with a viable long-term solution for their dialysis needs if they continue to require it in the outpatient setting.”
The authors wrote that the acute PD program targets patients with CKD stages 4 to 5 who were transitioned to hemodialysis during their current admission and who are expected to have a prolonged hospital stay, as well as patients with unresolved AKI who have not yet initiated kidney replacement therapy and who are considered appropriate candidates for PD time of discharge.
The acute PD program consists of the following protocols:
- Patients’ suitability for PD is first assessed by the nephrologist; if deemed suitable, the nephrologist communicates with the surgeon/interventional radiologist for catheter placement;
- PD catheter insertion is followed by initiation within 48 to 72 hours;
- PD is performed overnight or throughout the day;
- Following each treatment, data related to initial drain, ultrafiltration, average dwell time, number of cycles and average drain time are collected and documented; the nephrologist reviews the data via electronic medical record and makes prescription changes as needed.
“A major advantage of PD in this crisis was our ability to train non-nursing staff in the PD procedure, which is not technically challenging but requires strict sterile technique,” the authors contended. “This differs from the technical requirements needed to provide [hemodialysis] HD and is particularly important should we encounter staff shortages of existing dialysis nurses and technicians.”
The authors wrote that these planning steps have helped prepare the hospital for the surge of patients who require dialysis during a pandemic which is “rapidly evolving.”
They concluded: “Circumstances will continue to change in the coming weeks, and we will pursue finding creative ways to combat and deal with them. The success of our proposed changes remains to be seen, but it is a work in progress that will hopefully meet the demands that we are anticipating.” – by Melissa J. Webb
Disclosures: El Shamy reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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