PRACTICE FORUM
Ali Alharbi, Dujanah Mousa, Jennifer Samson, Moustafa Ahmad, Lidia Romero Gomez, Meshal Alkhulayfi, Eyad Suleiman, Saeed Alghamdi, Fayez Alhejaili, Abdullah Alhweish, Naglaa Maddh, Waleed Bediwi and Mohammed Al-Homrany*
Diaverum AB, Riyadh, Saudi Arabia
Coronavirus disease 2019 (COVID-19), a disease caused by a novel coronavirus, is a major global human threat that has turned into a pandemic. Elderly patients and patients with comorbid conditions have a higher risk of complications and morbidity. Patients suffering from kidney disease on hemodialysis have an intrinsic fragility combined with a frequent burden of comorbidities in hemodialysis centers, a setting in which many patients are repeatedly treated in the same area. Moreover, if infected, the intensity of dialysis requiring specialized resources and staff is further complicated by requirements for isolation, control and prevention, putting healthcare systems under additional and exceptional strain. Therefore, all measures to slow if not eradicate the pandemic and to control unmanageably high incidence rates must be taken very seriously. Diaverum is a renal health services company playing a major role in providing end-stage kidney disease (ESKD) patients with optimum dialysis services. The aim of the present review is to shed light on the challenges and steps taken by an outsourcing dialysis program to provide recommendations for the prevention, mitigation, and containment of the emerging COVID-19 pandemic in hemodialysis centers.
Keywords: COVID-19; coronavirus; renal dialysis; infection control; pandemics; Saudi Arabia.
Citation: Int J Infect Control 2021, 17: 20619 – http://dx.doi.org/10.3396/ijic.v17.20619
Copyright: © 2021 Ali Alharbi et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Received: 21 July 2020; Accepted: 11 September 2020; Published: 22 July 2021
Competing interests and funding: The authors declare that there is no conflict of interest with any part of this paper and no funding received.
*Mohammed Al-homrany, Diaverum Alkarimat Clinic (9030), Abha, Kingdom of Saudi Arabia. Email: Mohammed.alhomrany@diaverum.com
COVID-19 is short for coronavirus disease 2019, the name the World Health Organization (WHO) gave to the illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). Following the outbreak of the novel coronavirus, the Kingdom of Saudi Arabia started implementing multiple preventative measures including a screening form for patients in healthcare settings and considering any person coming from China, Iran, South Korea, Japan, or Singapore to be an exposure risk. Hemodialysis patients are at increased risk of COVID-19 and its complications, owing to the presence of multiple comorbid conditions and impaired immunity (2). Dialysis patients are a susceptible population because of their older age and less efficient immune systems, and they are therefore more prone to develop severe infectious diseases than the general population (3, 4). Dialysis patients are exposed and re-exposed to a higher contamination risk than the general population because their routine treatment usually requires three dialysis sessions per week. Moreover, if infected, the intensity of dialysis requiring specialized resources and staff is further complicated by requirements for isolation, control, and prevention, putting healthcare systems under additional and exceptional strain. In addition, hemodialysis is a lifesaving modality of treatment and cannot be stopped or delayed; therefore, measures are needed to adapt and provide care during crisis and pandemics. Therefore, all measures to slow if not to eradicate the pandemic and to control unmanageably high incidence rates must be taken very seriously. Preventing the epidemic spread of infection requires early recognition of infection, isolation, meticulous tracking of contacts, and enhancing the awareness of both patient and healthcare worker (HCW); it also entails the implementation of strategies to prevent further spread such as social distancing, widespread use of face masks for patients with suspected or confirmed disease to limit transmission, and appropriate personal protective equipment (PPE) for HCWs and others who have direct contact with patients infected with COVID-19 (5).
Diaverum is a renal health services company playing a major role in providing end-stage kidney disease (ESKD) patients with optimum dialysis services. Currently, more than 4,400 patients are receiving hemodialysis services in 39 dialysis clinics distributed throughout Saudi Arabia, as part of an outsourcing program adopted by the Ministry of Health of Saudi Arabia (MOH) in 2013. Diaverum Saudi has been closely monitoring the COVID-19 situation since the first confirmed cases in the country on March 2, 2020. A modified visual triage checklist was implemented, with the COVID-19 virus added to a visual triage form that had been used since the outbreak of SARS to screen all patients prior to entering treatment areas. We have used a specific scoring system adopted by the MOH to identify suspected cases and refer them to the nearest designated hospitals for further evaluation and diagnosis including testing for COVID-19 reverse transcriptase polymerase chain reaction (PCR), and for dialysis treatment if proven positive.
An internal task force group was established at Diaverum Saudi to manage the anticipated new challenges dialysis units will face during the pandemic, across the entire geographical network of dialysis units. The task force objectives were to ensure the implementation of Centerers for disease control and prevention (CDC) (6) and MOH guidelines related to handling suspected COVID-19 cases; create guidelines to protect both staff and patients from contracting the virus; ensure sufficient supplies at all clinics for at least 3 months in advance; raise awareness and conduct serial educational programs for all staff, patients, and relatives to ensure alignment with the new guidelines; and ensure daily follow-up of referred suspected and confirmed cases. A registry of data for all suspected and confirmed cases was established to monitor the outcomes of all referred cases. In addition, direct communication about guideline updates and other developments was established between MOH hospitals and the Central Committee of the Dialysis Outsourcing Project. The management team was provided with daily updates, and support from different functional areas of the company was established.
The task force group held daily virtual conference calls to discuss all updated news and conducted several calls with all medical directors of all units. The main challenge was balancing the continual delivery of excellent dialysis service while facing new challenges that could disturb our workflow. During the first meeting, the following challenges were identified, and action plans were initiated to deal with any developments anticipated to occur during the crisis:
Strategies proposed for the prevention and management of COVID-19 transmission for ESKD patients in the outpatient dialysis facilities have been dynamic and changing according to the new guidelines adopted by CDC (6), in concordance with the MOH updated guidelines (Table 1) and following new learnings from increased experience. The task force members held daily meetings and adopted several policies to overcome the expected challenges noted above, and the following measures were taken:
A backup team was initiated to facilitate easy staff replacement and movement across cities when needs arise. The nursing team identified a backup team of 128 nurses from all clinics to provide support for other clinics.
During April–June 2020, there were widespread curfews, and larger cities went into lockdowns. To overcome such obstacles, clinics were supported as follows:
We followed clear and strict guidelines when dealing with suspected cases to protect our HCWs and other patients. These guidelines were continually revised and updated according to any new development in the management of the COVID-19 pandemic.
Because all international flights were suspended, some of our medical staff were stranded on vacation in their home countries and were unable to return to work. Twenty-one staff from the Philippines were needed to cover the staff shortages expected during the pandemic. A charter commercial plane was hired following arrangement with local authorities, and we managed to get 10 staff back to work after being quarantined for 14 days upon arrival, as per protocol. This was arranged through government initiatives of the MOH and Ministry of Interior to bring back citizens who were locked down in other countries, and the Philippines were a major part of this.
With international flights on hold, many staff with contracts ending were unable to travel. To support clinics, human resources (HR) offered contract extensions to staff willing to continue working until normal flights returned. Around 30 nurses extended their contracts, providing additional nursing workforce during the crisis.
To overcome the challenges of manpower shortage, HR continuously headhunted qualified nurses to join the company. With the support of clinic head nurses, personal and call interviews were conducted. There were around 20 batches of Saudi interviews since March 2020. Among these, there were 12 Saudi nurses hired thus far. In addition, virtual interviews for Philippines recruitment continued in May 2020.
The global pandemic of COVID-19 has led to unprecedented psychological stress on HCWs. COVID-19 imposes a significant level of anxiety and stress on HCWs caring for infected patients, with their main concern being the risk of transmitting the infection to their families or acquiring it themselves (7). Therefore, optimizing the compliance of HCWs with proper infection prevention and control measures is paramount during infectious disease outbreaks to ensure their safety, to decrease the likelihood of getting infected or transmitting the infection to others, and to consequently alleviate their psychological stress and anxiety. The company has supported HCWs through a specialized program, ‘Staff for Life Support’. The main goal of this unique program was to provide HCWs with the social and psychological support needed. The program was built on four pillars aimed at driving a sustainable organization: promoting employee quality of life, promoting healthy lifestyle, investing in staff development, and feeling connected. It also included psychological consultation, arranged by HR through a contracted private health provider, to give psychological support to staff who needed it.
Availability of supplies of all consumables and medications required by dialysis patients receiving treatment throughout the country was a top priority, despite the difficulties following implementation of curfew in all cites and the delay in importing essential hemodialysis products from outside the country. Each dialysis center was provided with a 3-month supply of stock and a minimum 3-month supply in central store.
The first two confirmed positive cases in our dialysis facilities – in Madinah on 20 March and in Makkah on 25 March – affected our practice due to staff, patients, and their relatives not being fully aware of the new threat and some guidelines not being carried out properly. The initial recommendation was to isolate all contact staff for 14 days before allowing them to resume work regardless of their PCR results for COVID-19. However, this protocol would have caused a sudden shortage of medical staff forcing us to mobilize and replace exposed staff in both clinics with staff from units located in other areas. Furthermore, swabbing for COVID-19 PCR is usually carried out in the MOH facilities with some time delay for logistical reasons. Our initial protocol did not implement the wearing of full PPE by all staff because of shortages and unavailability in the local market. Instead, wearing surgical masks was recommended. Immediately after identifying these cases, new policies were implemented and stricter guidelines were established to deal with future cases (Table 2). The lessons learned from the first two cases were tremendous and were reflected positively in our handling of new suspected or positive cases. This experience was quickly communicated to all clinics so that our medical staff were well oriented and gained the confidence to deal with all suspected cases. The task force group continues to supervise, support, and facilitate the workflow in all clinics.
During this crisis, Diaverum remained committed to delivering the usual excellent standard of medical care to our dialysis patients in spite of the challenges. We closely observed our global and contractual clinical performance measures (CPM). We continued to be on the top rank of all global Diaverum clinics during the pandemic, and we managed to meet the required key performance indicators (KPIs) requested by the MOH for all clinical and laboratory parameters. The main issue during this crisis was the delay in creating new arteriovenous fistulas (AVF) due to governments and private hospitals only providing services for emergency cases. The biggest challenge faced during this pandemic was maintaining the functioning catheters and AVFs to avoid the need for any surgical intervention. This challenge was met by following our protocol of handling vascular accesses, and we allocated extra nursing care to avoid any catheter malfunction. During the current crisis, only emergency vascular accesses procedures were carried out.
COVID-19 is a major global human threat that has turned into a pandemic (8). COVID-19 infection presents particular challenges for patients on chronic hemodialysis. Patients with uremia are particularly vulnerable to infection and may exhibit greater variations in clinical symptoms and infectivity (5). Early reports have shown that dialysis patients are a highly susceptible population, and hemodialysis centers are at higher risk for an outbreak of a COVID-19 epidemic (9). The management of patients on dialysis affected by COVID-19 must be carried out according to strict protocols to minimize the risk of cross infection to other patients and to staff taking care of these patients. Implementation of the infection control steps, full protective measures of staff and patients, continuous application of screening, and proper isolation of suspected cases during and post recovery have been shown to be most efficient in these settings (10). From the beginning of the crisis and following the first reported cases in our dialysis units, our strategy was clear and was built on two principles: minimizing the spread of infection among our staff and patients and maintaining the delivery of optimum dialysis care. Establishing strict guidelines and application of protective measures outlined in Table 2 reduced the number of cases among our staff and patients. The majority of the recorded cases were community-acquired infections, and no cross infection was observed within our dialysis units. Ensuring delivery of adequate dialysis prescription was a priority during the pandemic to avoid unwanted complications of poor or shortage of dialysis treatment. For this reason, our task force group was initiated to make sure that adequate supplies needed for hemodialysis treatments were delivered to all dialysis units on time and for a sufficient period of not less than 3 months. Moreover, no suspected cases were denied their dialysis treatments but were modified according to our protocol, with all suspected cases dialyzed in a designated area, and full precautionary measures were taken to protect our medical staff (Table 2). Devoting a backup team helped to manage these patients in an isolated area by applying the ratio of 1:1 (one nurse looking after one patient; normally the ratio is 1:3).
Despite taking all recommended measures, an outbreak in a dialysis unit can potentially occur, during which the goal should be to reduce the number of infected cases and to protect medical staff from contracting the infection. Therefore, strict vigilance is always required by the dialysis unit team with a high level of support to overcome these difficult times. Such major crisis requires group management, good communication, and full administrative supports to navigate peacefully and avoid any interruption of dialysis treatments, and prevent any cross infection within the dialysis units.
The authors declare that there is no conflict of interest with any part of this paper and no funding received.
The authors declare that there is no conflict of interest in this study. All the authors mentioned in the manuscript have agreed to authorship, have read and approved the manuscript, and have given consent for submission and subsequent publication of the manuscript. The manuscript has not been submitted or published anywhere else in part or in full.