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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Background

These recommendations should be used with the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. This information is provided to clarify COVID-19 infection prevention and control (IPC) recommendations that are specific to outpatient hemodialysis facilities. This information complements, but does not replace, the general IPC recommendations for COVID-19.

This guidance is based on the currently available information about COVID-19. This approach will be refined and updated as more information becomes available and as response needs change in the United States. It is important to stay informed about COVID-19 to prevent introduction and minimize spread of COVID-19 in your dialysis facility. Consult with public health authorities to understand if community transmission of COVID-19 is occurring in your community.

Recommendations

A part of routine infection control, outpatient dialysis facilities should have established policies and practices to reduce the spread of contagious respiratory pathogens. This includes:

Early recognition and isolation of individuals with respiratory infection:

  • Facilities should implement sick leave policies that are non-punitive, flexible and consistent with public health policies that allow ill healthcare personnel (HCP) to stay home. HCP should be reminded to not report to work when they are ill.
  • Facilities should identify patients with signs and symptoms of respiratory infection (e.g., fever, cough) before they enter the treatment area.
    • Instruct patients to call ahead to report fever or respiratory symptoms so the facility can be prepared for their arrival or triage them to a more appropriate setting (e.g., an acute care hospital).
    • Patients should inform staff of fever or respiratory symptoms immediately upon arrival at the facility (e.g., when they check in at the registration desk).
    • Patients with symptoms of a respiratory infection should put on a facemask at check-in and keep it on until they leave the facility.
  • Facilities should provide patients and HCP with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette.
    • Instructions should include how to use facemasks, how to use tissues to cover nose and mouth when coughing or sneezing, how to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
    • Post signs at clinic entrances with instructions for patients with fever or symptoms of respiratory infection to alert staff so appropriate precautions can be implemented.
  • Facilities should have supplies positioned close to dialysis chairs and nursing stations to ensure adherence to hand and respiratory hygiene, and cough etiquette. These include tissues and no-touch receptacles for disposal of tissues and hand hygiene supplies (e.g., alcohol-based hand sanitizer).
  • Patient placement: Facilities should have space in waiting areas for ill patients to sit separated from other patients by at least 6 feet. Medically stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be seen.
    • Patients with respiratory symptoms should be brought back to an appropriate treatment area as soon as possible in order to minimize time in waiting areas.
    • Facilities should maintain at least 6 feet of separation between masked, symptomatic patients and other patients during dialysis treatment. Ideally, symptomatic patients would be dialyzed in a separate room (if available) with the door closed.
      • Hepatitis B isolation rooms should only be used for dialysis patients with symptoms of respiratory infection if: 1) the patient is hepatitis B surface antigen positive or 2) the facility has no patients on the census with hepatitis B infection who would require treatment in the isolation room.
      • If a separate room is not available, the masked patient should be treated at a corner or end-of-row station, away from the main flow of traffic (if available). The patient should be separated by at least 6 feet from the nearest patient (in all directions).
        • If the patient is unable to tolerate a mask, then they should be separated by at least 6 feet from the nearest patient station (in all directions).
  • Personal protective equipment: In general, HCP caring for patients with undiagnosed respiratory infections should follow Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis). This includes the use of:
    • Gloves
    • Facemask
    • Eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face). Personal glasses and contact lenses are NOT considered adequate eye protection.
    • Isolation gown
      • The isolation gown should be worn over or instead of the cover gown (i.e., laboratory coat, gown, or apron with incorporate sleeves) that is normally worn by hemodialysis personnel. If there are shortages of gowns, they should be prioritized for initiating and terminating dialysis treatment, manipulating access needles or catheters, helping the patient into and out of the station, and cleaning and disinfection of patient care equipment and the dialysis station.
      • When gowns are removed, place the gown in a dedicated container for waste or linen before leaving the dialysis station. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.

When COVID-19 is suspected or confirmed in a patient receiving hemodialysis at the facility, the following additional measures apply:

If a hemodialysis facility is dialyzing more than one patient with suspected or confirmed COVID-19, consideration should be given to cohorting these patients and the HCP caring for them together in the section of the unit and/or on the same shift (e.g., consider the last shift of the day). If the etiology of respiratory symptoms is known, patients with different etiologies should not be cohorted (for example, patients with confirmed influenza and COVID-19 should not be cohorted).

 



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