Covid-19 HSE Clinical Guidance and Evidence

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Interim guidance for management of individuals on dialysis with suspected/confirmed COVID-19 infection (CD 19-005/16.03.20)

• Scope and Purpose

• Key principles for preventing the spread of COVID-19 in Dialysis Units

• General Preparedness

  • Before arrival to the Dialysis Unit

  • Transport

  • Patient Placement

  • Medical Assessment

  • Satellite Dialysis Units

  • If a dialysis patient has clinical features of COVID 19 and is still at home

  • Follow up of contacts where a dialysis patient is subsequently identified to have COVID-19 infection

  • Waste

  • Environmental Cleaning & Disinfection

  • Further information

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Scope and Purpose

This guidance document specifically relates to the management of patients on dialysis. They are not intended to cover every situation or event however the general principles contained within this document, coupled with national interim infection prevention and control guidance Interim Infection Prevention and Control Precautions for Possible or Confirmed 2019 novel Coronavirus (2019 nCoV), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Avian Influenza A in Healthcare Settings available on www.hpsc.ie can be used as a framework to guide local preparations.

Key principles for preventing the spread of COVID-19 in Dialysis Units

• Apply standard precautions when caring for all patients at all times and standard, contact and droplet precautions for those with respiratory symptoms

• Ensure pathways are in place for early identification and management of those with potential COVID-19 infection

• Keep up to date with information with guidance and information from www.hse.ie and www.hpsc.ie
   

General Preparedness

• All dialysis patients should be provided with information on the signs and symptoms of coronavirus infection and general measures including  respiratory cough etiquette, hand hygiene and social distancing available on www.hse.ie

• Units should post signs in the waiting area regarding symptoms and steps to minimise exposure. COVID -19 posters are available here

• Review patient pathways to the dialysis unit e.g.

  • Ensure that arrangements are in place for individuals who do not have access to private transport to attend for their dialysis if they have symptoms of respiratory infection

  • If a symptomatic individual attends the unit, arrangements should be in place for samples to be collected and tested for COVID-19 as swiftly as possible. Where possible referral to another site to facilitate this should be avoided to limit exposure and to optimise result turn around time.

• Review patient pathways within the dialysis unit

• Ensure a designated isolation area has been identified for dialysis

• Ensure that processes are in place for rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory tract infection

• Develop strategies to minimise patient to patient contact for example

  • stagger arrival times

  • expand waiting areas or bring patients directly to their dialysis station

• Provide access to alcohol hand rub and tissues

• Consider providing a surgical mask to patients to keep at home so that it can be used in the event they develop symptoms and need to attend the unit

• The routine use of surgical face masks by non-symptomatic patients attending the haemodialysis unit is NOT recommended

• Ensure that the most up to date risk assessment algorithms from www.hpsc.ie are readily accessible

• Ensure there are sufficient supplies of personal protective equipment and staff are familiar with safe donning and doffing procedures – refer to www.hpsc.ie for instructional videos

• Ensure that all staff are aware of plan and relevant contact information available

• Limit access of visitors and suppliers to the dialysis unit to the minimum
   

Before arrival to the Dialysis Unit

• Dialysis patients should be instructed to contact the dialysis unit if they have symptoms of respiratory tract infection or fever rather than presenting themselves for dialysis

• Dialysis patients who have been in close contact with someone who has suspected or confirmed COVID-19 infection should be instructed to advise the dialysis unit in advance of attending

• Patients should be advised to check their temperature before getting dialysis transport
   

Transport
Asymptomatic Individuals can travel as per usual means.

Asymptomatic Individuals who have been informed that they are close contacts of person with COVID-19 infection will be following public health advice for self-quarantine. They may drive themselves to the unit or be driven by someone who is willing to drive them ( Units should have arrangements in place in the event this is not possible) They should not use public transport or travel with another patient from the unit. The patients should be advised to

• Wash hands with soap and water before leaving their house

• In so far as is possible maintain 1m (3 feet) distance from other individuals e.g. sit in the back seat from the driver

Individuals who have symptoms of possible COVID-19:

Should telephone in advance of their appointment and if necessary may drive themselves to the unit if they feel well enough or be driven in private transport by someone who has already had exposure and is willing to drive them. If they have a surgical face mask this should be worn for transfer to the hospital.

Where this is not possible the unit should have alternative arrangements in place.
 

Patient Placement

Asymptomatic Individuals - should proceed with dialysis as per usual and standard precautions applied.Asymptomatic individuals who are a close contact of someone who has confirmed COVID-19 should be placed in a dialysis station with at least one metre physical separation from other patients*. Standard precautions should be applied.

*Note that although a distance of 1m is generally regarded as sufficient to minimise direct exposure to droplets the current public health case definition of a “close contact” for COVID-19 refers to a distance of 2m therefore it is preferable to increase the distance beyond 1m where this is practical

Symptomatic Individuals – with possible or confirmed COVID-19 infection should be placed in a single room, the door should remain closed where possible.   Negative pressure isolation is not necessary unless aerosol generating procedures are to be performed (see list of AGP on www.hpsc.ie). Appropriate isolation signage should be placed on the door.

Standard contact and droplet precautions should be applied.

In the event that the need arises, consideration can be given to cohorting patients with confirmed COVID-19 infection who require dialysis.
 

Medical Assessment

Clinical judgement in conjunction with knowledge of the emerging epidemiology of COVID- 19 in Ireland will be required to determine who should be tested however it is important that other causes of infection are not overlooked and the local protocols for laboratory testing (e.g. blood cultures) and empiric antibiotic prescribing in unwell patients should be adhered to.
 

Satellite Dialysis Units
If a dialysis patient has clinical features of COVID 19 and is still at home

The patient should be instructed to stay at home, and the parent renal unit should be informed so appropriate arrangements can be made.If a dialysis patient has clinical features for COVID-19 presents to a satellite dialysis unit the patient should be placed in a single room and the parent renal unit contacted. If there is no isolation facility the patient should be given a surgical mask, access to alcohol hand rub and tissue and placed in an area at least 1m away from other individuals. If there is no surgical mask available ask them to use a tissue to cover their mouth if they cough and to dispose of the tissue and decontaminate their hands with alcohol hand rub after.
 

Follow up of contacts where a dialysis patient is subsequently identified to have COVID-19 infection
Liaising with local infection prevention control teams or public health specialists is advised.
 

Waste
Dispose of all waste in the isolation room as Category B Waste – healthcare risk waste (otherwise referred to as clinical waste)
 

Environmental Cleaning & Disinfection

The dialysis machine cleaning protocol should be as per standard machine cleaning.

Clean and disinfect the environment, furniture & equipment after use with a neutral detergent and disinfectant (e.g. hypochlorite solution 1000ppm) or combined detergent disinfectant solution (at a dilution of 1000 parts per million available chlorine).

Environmental disposable wipes that meet these criteria may be used.

Pay special attention to thorough cleaning of frequently touched sites (door handles, bed rails hospital mobiles, TV remotes etc.) and horizontal surfaces.

For further details on environmental cleaning and disinfection refer to the national interim IPC guidance
 

Further information

• The Health Protection Surveillance Centre – updated daily with new information at 1pm

• Department of Foreign Affairs – updated travel information and advice