How dialysis staff survived the stress, heartache of COVID-19
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The COVID-19 pandemic has changed our lives and the practice of medicine.
It has exposed the fragility of our health system, highlighting our lack of space, equipment and staff, as well as our ability to provide mental health care support to our patients and frontline workers during a public health emergency.
The EDs, inpatient medicine services – with a focus on patients hospitalized with COVID-19 – and the ICUs were the most affected with the overwhelming number of patients and the severity of disease.
Telehealth came to the forefront, and replaced many of the traditional clinic visits, allowing health systems to continue to provide care in the comfort of patients’ homes and helping to implement social distancing.
In the midst of all these changes, dialysis staff and patients continued their routine, showing up to a health care setting several times a week, fearing for their lives yet putting on a brave face behind masks.
There was a coordinated effort from health systems, as well as dialysis organizations, to help mitigate the risk of transmission of disease including universal masking, minimizing the use of waiting rooms, providing personal protection equipment (PPE) and dedicated units for suspected or confirmed COVID-19 patients.
Despite those safeguards, dialysis staff felt vulnerable because of their ongoing exposure to patients, increased work related to COVID-19 cohorts, a high prevalence of disease in the patients they cared for as well as mortality associated with COVID-19.
I discussed the implications of the pandemic and related topics with a team of nephrology professionals in the University of Alabama at Birmingham’s (UAB) division of nephrology. Vinay Narasimha Krishna, MD, is an assistant professor in nephrology at the UAB. Angela Berry, RN, led the dialysis team at the DaVita COVID cohort unit, in collaboration with the UAB team. Jane Davis, DNP, CRNP, co-managed the COVID-19 cohort dialysis unit, and Masood Ahmed, MD, is a second-year nephrology fellow at the UAB.
Gaurav Jain, MD, FASN: How has the pandemic affected the dialysis unit staff and nephrologists?
Vinay Narasimha Krishna, MD: The pandemic has had a major impact on our cohort unit staff – physically, socially and emotionally. Many staff members volunteered shifts in the COVID-19 cohort unit, in addition to their usual responsibilities on other days. During the first few months, lack of clear guidelines and shortage of PPE had a significant impact on them as they feared contracting the illness while at work.
Patient transportation logistics, limited treatment chairs to adhere with social distancing guidelines and additional disinfection/personal protective measure precautions has meant longer days for the staff. These staff members often isolated themselves from immediate family and have lost patients they have known for years to COVID-19, all leading to increased emotional stress.
On a personal level, balancing a raging pandemic census between inpatient responsibilities and the additional outpatient dialysis surge was particularly challenging. During the pandemic, our dialysis unit started accepting patients from other practices to our COVID-19 cohort unit. The provision of transient care to a “new” patient with a transmissible illness while maintaining rigorous admission, treatment and discharge protocols increased work hours spent on patient care.
One of the unique challenges was building a physician-patient relationship, while using telehealth, with both the patient and physician wearing a mask. Last, but not the least, one of the most challenging parts of the pandemic was arranging vaccinations for our cohort dialysis staff. The dialysis staff, even in COVID-19 cohort units, were not a part of the initial vaccine roll out algorithm, leading to delays in their vaccination. It took a mammoth effort, in coordination with the leadership of our health system, to arrange vaccinations for our staff.
Jain: What is your perception of patient understanding about COVID-19 ?
Krishna: Many of our patients demonstrated a good understanding of the disease, masking diligently and following social distancing guidelines.
The dialysis staff played a big role in advocating mask use, promoting social distancing practices and explaining risks and vulnerabilities in the dialysis population to the patient. Just like the general population, we have had patients who do not understand the seriousness of contracting the virus and overlook social distancing/isolation guidelines; the changing guidelines from the national organizations on masking, duration of isolation and best practices did create a lot of confusion amongst the general population.
For example, the constantly evolving duration of isolation once a patient was infected had created a lot of confusion among patients, further causing discomfort in being at an unfamiliar dialysis unit and their eagerness to go back to their home dialysis unit. In my mind, continued dialogue with patients, especially by the dialysis unit staff, whom they trust the most, is likely our best strategy to continue to educate them, and keep them safe.
Jain: How has your interaction been with patients and staff regarding vaccinations?
Krishna: The concept of vaccinations has fortunately been relatively well embraced by the dialysis patients, possibly because they are used to getting annual vaccines at the dialysis unit. Many patients who understand the risks associated with their comorbidities have been vaccinated. There is a genuine concern among others, especially African American patients, regarding safety of the vaccine, with the relatively short duration of research, and concerns about the past history of vaccinations and research studies.
This is similar among the dialysis staff members, though I have engaged in dialogue with many of them to encourage vaccination; the fact that some team members and myself received the vaccine when available was comforting to many of them and served as encouragement.
Jain: What are some of the issues among patients and staff in regard to trust and relationships? What have been some of the challenges on the treatment floor?
Jane Davis, DNP, CRNP: With the possible exception of oncology, there is no other area where the patients and the staff have as close a relationship as in nephrology. Often, the nephrologists and advanced practitioners have known the patient prior to dialysis initiation. Once patients start dialysis, they are in the same unit with the same nurses and patient care technicians three times a week, often making themselves comfortable in this new “home” unit.
Patients on dialysis like consistency and want to be in their “home” unit; even changing chairs or treatment times can cause consternation. All this is upended for the patients treating for a limited time in a COVID-19 positive unit, which may or may not be their “home unit.” The location, the interior and the staff are unfamiliar, while still dealing with the stress of an infectious disease like, COVID-19, that is potentially fatal.
The staff is garbed in PPE so patients cannot read facial expressions and often have a difficult time hearing someone talk through a mask and shield.
As a provider, I depend on the trust the patients have in me and the knowledge I have of them, which develops with continuity of care. There is not time in six or eight treatments for this to develop, which is often the case when treating patients in a COVID-19 cohort unit for dialysis. The staff also have similar challenges, often working in units which are not their “home” unit, with new team members, and patients who do not have an established relationship with them.
As the patients are in the unit for such a short time, each treatment is essentially a blank slate. Staff who have treated a patient for several times learn how they react (ie, Do they come in hypertensive and drop blood pressure abruptly mid-treatment? Do they cramp above a certain level of fluid removal?) These are often minor issues which assume major significance when the patient is already stressed. Providers are adjusting weight, time and dialysis prescriptions for the short term. Different providers and staff have varying approaches to medication administration and timing. We have to adjust our own patterns to those of the patients and as they can come from a number of different units and providers, this can be challenging. Last, but not the least, the patients often do not know all their medications and reconciliation is rarely possible, which can potentially affect care.
Jain: What were some of the major challenges in the COVID-19 cohort unit?
Angela Berry, RN: Many patients were using public transportation and because they were now considered positive, most transportation companies were not willing to transport them to dialysis. Even family members were reluctant to transport these patients, often leading to significant emotional turmoil for the patients and their families. The one transportation company that was willing to serve those with COVID-19 diagnosis was exceptionally busy, causing patients waiting for rides for hours before and after dialysis, and often not getting to the dialysis unit (or home) on time.
On the dialysis floor, our staff often felt the fear of the unknown. This was a new yet deadly disease and little was known about it. Each day, I would watch news channels and visit the CDC website to obtain information as it pertained to the disease. Television channels were flooded with reports of thousands of individuals dying daily and those who were becoming ill from this deadly pandemic.
In the cohort unit, we had up to 14 patients in the shift at one time, and some colleagues at other units contracted the virus despite best efforts at taking adequate precautions, all of which heightened our worries. The change in protocols, with time-based vs. testing-based discharge from the unit, as well as the lack of PPE during the initial phase was also challenging.
The pandemic taught me how to embrace change and adapt quickly. I needed to concentrate on caring for those who had a serious illness and help them achieve their health care goals, while keeping myself distracted from the thought of contracting the illness.
Jain: How has the pandemic changed nephrology fellowship training?
Masood Ahmed, MD: The pandemic has changed the workflow and education dramatically during the past year, with many lectures and conferences conducted in a virtual format and increasing use of telehealth in the care of patients. There has been a clear decrease in the exposure of trainees to preceptors, inherently as part of the social distancing guidelines, especially the social interactions like retreats and team meetings.
The pandemic has allowed us to get trained in telehealth, which was a welcome change, and prepares us well for the future where telehealth will likely play a major role in patient care.
Lastly, specifically in nephrology, our patient census was exceptionally high at the peak of the pandemic, related to high prevalence of COVID-19 in patients on dialysis, as well as the risk of AKI with COVID-19. While this led to an excellent exposure as a trainee, it also led us to think of innovative ways to redistribute the workload among the team to keep trainees engaged.
This was a challenging year for trainees finishing their residency or fellowship. Many practices were on a hiring freeze considering the decrease in outpatient volumes and the uncertainty associated with the pandemic. For those who those who advertised positions, in person visits were not being encouraged to prevent travel and exposure to the candidate.
While this was certainly ideal from the infection control perspective, it is challenging to consider a job opportunity without visiting the practice location. These factors have made some of the fellows consider alternative pathways, for a transient time, such as hospitalist jobs.
Jain: The changes in clinical practice, team dynamics and morale and training programs secondary to the pandemic are impressive, and hopefully will make us better as a nation. We now have a better infrastructure in place to deal with another public health emergency and will continue to build on it. The lack of PPE was embarrassing and will help us plan better for the future. Telehealth will likely become a routine part of our clinical practice, improving access and reducing the burden of travel on patients.
What did not change was the never-ending enthusiasm and sincerity of our dialysis staff, who work long, difficult hours, in outpatient dialysis units, building bonds with our medically complex patients on dialysis.
They are our unsung heroes.
- For more information:
- Gaurav Jain, MD, FASN, is an associate professor in the division of nephrology, the Anderson Family-Endowed Professor in Nephrology, director of ambulatory nephrology, medical quality and safety officer, and co-director of the Home Dialysis Program at University of Alabama at Birmingham Health Systems. He can be reached at gjain@uabmc.edu.
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