Nursing home residents who receive dialysis may have a significantly higher chance of contracting COVID-19, the Centers for Disease Control & Prevention (CDC) determined in a new report released this week.
Focusing on an outbreak at single Maryland nursing home with an on-site dialysis clinic, researchers found that 47% of dialysis patients contracted the novel coronavirus — while just 16% of non-dialysis patients tested positive.
“Careful consideration of infection control practices throughout the dialysis process (e.g., transportation, time spent in waiting areas, spacing of machines, and cohorting), clear communication between nursing homes and dialysis centers, and coordination of testing practices between these sites are critical to preventing COVID-19 outbreaks in this medically vulnerable population,” the CDC concluded in the most recent edition of its Morbidity and Mortality Weekly Report (MMWR).
The analysis describes an all-too-common scene that unfolded at the 200-bed nursing facility during the early days of the COVID-19 pandemic: Despite implementing mandatory patient and staff screening protocols and requiring universal surgical masks for all residents on April 1, the facility experienced its first positive case by mid-month.
Once the property was able to secure tests for its entire resident and staff population — with the help of a response team from Johns Hopkins University, which was called in to provide support for an overwhelmed public-health testing system — a total of 37 residents and three staff members tested positive for COVID-19.
Of the 15 dialysis patients that tested positive, eight were hospitalized and six died within 30 days; among the 22 non-dialysis residents with positive cases, four were hospitalized and six were dead within 30 days.
The researchers’ analysis of the outbreak illuminated the difficulty in developing and enforcing infection-control protocols within the dialysis unit.
Run by an independent provider, the on-site dialysis center also serves non-resident patients from the wider community, according to the CDC. On April 21, leaders at the center split patients into four groups as part of a cohorting strategy — confirmed positives, symptomatic patients with pending tests, asymptomatic people who may have been exposed, and non-exposed patients with no symptoms.
The idea was to treat each group separately, but due to scheduling conflicts, leaders elected to allow concurrent dialysis services for residents in the first two groups — positives and suspected positives — as well as in the latter two.
The CDC researchers additionally found problems outside of scheduling.
“Universal masking was strongly recommended for patients in the dialysis center; however, the center reported patients often had difficulty wearing masks for the entire session,” the team observed. “Dialysis center staff members caring for patients with COVID-19 were required to wear gowns, masks, gloves, and eye protection. Efforts were made to separate dialysis machines by 6 feet (2 meters), but because of space limitations, this was not always possible.”
The facility was also unable to test non-resident dialysis patients or asymptomatic staffers due to “testing limitations,” the CDC determined.
On-site dialysis treatment has long been seen as a potential area of specialization for nursing homes, with both clinical upsides for residents and financial benefits for operators. By reducing transfers of frail, elderly patients, proponents of nursing home dialysis centers — sometimes known as “dens” — pitch the service as a way to prevent additional complications that could lead to hospitalization and death.
The new Patient-Driven Payment Model (PDPM) for Medicare skilled nursing reimbursements, which attempts to more closely link payments to resident acuity, has spurred interest in adding dialysis services; a separate proposed payment model for end-stage renal disease would also expand coverage for in-home dialysis services, with nursing homes considered “home” for purposes of reimbursement.
Shimmy Meystel, CEO of Concerto Renal Services, said his company has seen an increase in demand for in-house dialysis care from SNFs amid the pandemic due to concerns about residents leaving the building for off-site dialysis, or mingling with community patients at attached third-party clinics.
Concerto has also begun assisting facilities interested in transitioning existing clinics, such as the ones described in the CDC report, to a more restricted in-house only model, Meystel said.
The CDC report acknowledges that researchers could not determine the exact source of the outbreak in the subject Maryland facility; the scope of the analysis did not include an evaluation of the property’s overall infection control practices, nor did it consider the potential for spread caused by residents who left the campus entirely for routine medical services.
But the researchers concluded that operators with dialysis centers must remain vigilant of the dangers, and implement risk mitigation strategies such as moving dialysis patients to single rooms adjacent to the center, and performing overviews of the entire dialysis process to identify potential coronavirus weak spots.
“Dialysis centers and nursing homes are closely connected with a shared patient population; therefore, early identification of cases coupled with aggressive infection prevention and control actions are needed to protect medically vulnerable populations in both locations,” the team wrote.
The analysis’s authors included representatives from the Johns Hopkins University School of Medicine, the Baltimore City Health Department, and the CDC’s COVID-19 Response Team.