What are the general protocols for dialysis units when managing COVID-19 positive patients undergoing dialysis?

General Protocols for Dialysis Units Managing COVID-19 Positive Patients

Dialysis units must implement strict segregation protocols with dedicated isolation areas, universal PPE requirements, and enhanced screening procedures to prevent nosocomial transmission while maintaining life-sustaining dialysis treatments for COVID-19 positive patients. 1, 2

Patient Segregation and Facility Organization

Establish dedicated COVID-19 dialysis areas physically separated from non-COVID patients, ideally in a separate room or designated zone with the shortest possible transfer route from the entrance. 3, 1 This segregation is critical because hemodialysis patients must access facilities three times weekly, creating repeated exposure opportunities that distinguish dialysis centers from community settings. 2, 4

• COVID-positive patients should be dialyzed in dedicated shifts, preferably during off-hours or overnight to optimize resource usage and facilitate complete segregation from non-COVID patients who continue requiring care. 3
• Minimize patient movement through the facility by planning the shortest, most direct transfer routes and keeping all doors closed along the pathway. 3
• Maintain the same transport personnel from origin to destination to limit exposure chains. 3

Universal Screening and Testing Protocol

Implement immediate binary triage screening at the entrance before patients enter common waiting areas, screening for fever, respiratory symptoms, cough, myalgia, and fatigue. 5, 6, 1

• Perform SARS-CoV-2 RT-PCR nasopharyngeal swab testing for all patients with symptoms or exposure history, and consider universal screening of all patients and staff during outbreak situations. 5, 4, 7
• Place surgical masks on all non-intubated patients immediately upon identification of any respiratory symptoms, regardless of COVID-19 status. 3, 5
• Screen both patients and medical staff regularly, as asymptomatic transmission accounts for 32-55% of positive cases in dialysis settings. 4, 7

A critical pitfall: symptom-based screening alone is insufficient, as documented outbreaks have occurred despite following symptom-screening guidelines due to high rates of asymptomatic transmission. 7

Personal Protective Equipment Requirements

All personnel in contact with COVID-19 positive dialysis patients must wear full PPE including gowns, gloves, surgical masks (or N95/FFP3 for aerosol-generating procedures), and eye protection (goggles or face shields). 3, 5

• Change gloves immediately after contact with infected material or contaminated surfaces, and perform hand hygiene with alcohol-based hand rub before and after all patient contacts. 3, 5
• Maintain dedicated PPE stations at the entrance to COVID areas with constant replenishment of supplies and hand hygiene stations. 3
• Remove PPE in designated doffing areas outside the dialysis room using proper technique to prevent self-contamination, followed immediately by hand disinfection. 3, 8
• Healthcare workers should shower after each procedure when possible to minimize viral transmission risk. 3

Dialysis Room Preparation and Air Management

High air exchange cycle rates (≥25 cycles/hour) are recommended to reduce viral load within dialysis areas, though negative pressure rooms would be ideal if available. 3

• Minimize equipment in the dialysis area to only what is strictly necessary for each patient's treatment. 3, 8
• Prefer disposable materials including linens, and prepare all required materials before the patient enters to minimize staff movement during treatment. 3, 8
• Keep all doors closed once the patient has entered, including accessory rooms and sterilization spaces. 3
• Limit personnel entering the dialysis area to only those primarily involved in the patient's care, and maintain a record of all operators involved. 3

Environmental Cleaning and Disinfection

After each dialysis session, dispose of all disposable materials and perform rigorous surface disinfection using chloro-derivate solution at concentration ≥0.1% (1000 ppm) with contact time superior to 1 minute. 3, 5

The sanitization sequence must follow this protocol: 3

1. Clean with chloro-derivate solution
2. Rinse and dry
3. Disinfect with chloro-derivate solution ≥0.1% concentration

• Disinfect all surfaces and electromedical devices including dialysis machines, chairs, and monitoring equipment after each procedure. 3, 5, 8
• Sanitize the dialysis area and surrounding donning/doffing areas as soon as possible after each procedure to prepare for the next patient. 3, 8
• Use dedicated infectious waste containers placed immediately outside the dialysis room for contaminated materials. 3, 8

Patient Management During Dialysis

COVID-positive patients must wear surgical masks during transport and while not receiving oxygen therapy. 3

• Medical records must remain outside the dialysis room and be consulted only after proper doffing of PPE. 3
• Personnel should not leave the dialysis area during the procedure to minimize exposure and contamination of other areas. 3
• Handle potentially infected linen appropriately using dedicated containers and minimizing use of machinery for patient transfer. 3

Staff Protection and Cohorting

Consider cohorting dedicated staff to care exclusively for COVID-positive patients to reduce transmission risk and maintain expertise in infection control procedures. 5, 1

• Conduct mandatory training on proper PPE donning/doffing procedures, hand hygiene techniques, and infection control principles specific to dialysis settings. 5, 4
• Healthcare workers with positive SARS-CoV-2 tests must be placed on home quarantine regardless of symptom status until negative RT-PCR confirmation. 7
• Maintain a record of all staff involved in caring for COVID-positive patients for contact tracing purposes. 3

Isolation Criteria and Duration

Patients with positive SARS-CoV-2 RT-PCR tests require isolation with droplet and contact precautions until confirmation of negative test results, even if asymptomatic throughout the infection period. 7

• Provide graded isolated dialysis based on patient status: separate protocols for close contacts, suspected cases, and confirmed cases. 4
• Asymptomatic positive patients require the same isolation precautions as symptomatic patients, as they remain infectious and capable of transmission. 7

This comprehensive approach has proven effective in preventing further transmission during documented outbreaks, though it requires significant resource allocation and strict adherence to all protocols simultaneously. 1, 7