Considerations for Providing Hemodialysis to Patients with Suspected or Confirmed COVID-19 in Acute Care Settings

No. For hemodialysis patients hospitalized with COVID-19, decisions about discharge from the hospital should be based on their clinical status and the ability of the outpatient dialysis facility to meet their care needs and adhere to recommended infection prevention and control practices. Decisions about hospital discharge are distinct from decisions about discontinuation of Transmission-Based Precautions.

For patients with suspected or confirmed COVID-19, decisions about discontinuing Transmission-Based Precautions can be based on either a test-based or symptom-based strategy as outlined here.

If the patient is being discharged from the hospital but has not met criteria for discontinuing Transmission-Based Precautions, the outpatient dialysis facility should be prepared to follow all recommended infection prevention and control practices for the care of a patient with COVID-19, including providing recommended personal protective equipment (PPE) to healthcare personnel.

If the patient has met the criteria for discontinuing Transmission-Based Precautions, they do not require additional restrictions in the dialysis facility. However, as part of universal source control efforts, and consistent with guidance for the community, all patients should wear a cloth face covering (if tolerated) at all times while in the facility.

The hospital discharge planning team should communicate as early as possible with the receiving outpatient dialysis facility to ensure arrangements have been made for the patient to receive hemodialysis. The transportation company (if applicable) should also be notified of the patient’s status. They should be aware of precautions they need to take when transporting patients with suspected or confirmed COVID-19, including what PPE transport personnel should wear and how to perform appropriate vehicle disinfection and cleaning. The patient should not take public transportation until they meet criteria for discontinuation of Transmission-Based Precautions.

Based on a patient’s clinical status and the facility’s resources, clinicians can decide to provide either intermittent hemodialysis or CRRT to patients requiring hemodialysis. For infection control purposes, limit the healthcare personnel (HCP) exposed to patients with suspected or confirmed COVID-19 to those essential for their care.

In the intensive care unit (ICU), CRRT is usually managed by an ICU nurse; due to this, use of CRRT may help limit the number of HCP exposed to the patient. For ICU patients with end-stage renal disease with a dialysis fistula or graft, clinicians can weigh the risks and benefits of placing a dialysis catheter for CRRT (in order to limit HCP exposure) or performing intermittent hemodialysis.

For patients with suspected or confirmed COVID-19 requiring intermittent hemodialysis in the acute care setting, dialysis should ideally be performed in the patient’s hospital room with the door closed. This serves to limit the patient’s movement within the hospital.

If the patient is to be dialyzed in the acute care dialysis unit, consider the following:

Transporting patient to the acute care dialysis unit

When a patient with suspected or confirmed COVID-19 is being transported to the acute care dialysis unit, ensure HCP adhere to recommended infection control practices. The patient should wear a facemask during transportation. Additional information about the personal protective equipment recommended for transport personnel is available here.

Dialyzing patient in an acute care dialysis unit isolation room

If the acute care dialysis unit has an isolation room, hemodialysis should be performed in the isolation room with the door closed. Hepatitis B isolation rooms should only be used for dialysis patients with confirmed or suspected COVID-19 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.

The isolation room should be terminally cleaned after the care of each patient with COVID-19. Please refer to Question 5 for cleaning and disinfection of dialysis machine, equipment, and supplies.

Dialyzing several patients with confirmed COVID-19 (cohorting) in a shared room in the acute care dialysis unit

In a situation where there are several patients with confirmed COVID-19 requiring hemodialysis (non-ICU), consider cohorting the patients on the same dialysis shift, preferably the last dialysis shift of the day to allow for terminal cleaning of the dialysis unit following treatment. If possible, patients without COVID-19 should not receive dialysis during the same shift (in the same room); if patients without COVID-19 are dialyzed at the same time in the unit, they should be kept at least 6 feet away from the COVID-19 patients at all times. Patients with confirmed or suspected COVID-19 should continue to wear their facemask during treatment and adhere to appropriate respiratory hygiene and cough etiquette. Please refer to Question 5 for cleaning and disinfection of dialysis machine, equipment, and supplies.

Dialysis staff performing dialysis treatment should use all PPE recommended for the care of patients with suspected or confirmed COVID-19.

Facilities should consider prioritizing respirators for fit-tested dialysis staff who spend several hours in a patient’s room during a dialysis treatment with the door closed.

If possible, dialysis staff should limit time in the room with the patient. The facility should consider having dialysis staff observe and monitor the patient through a window, glass door, or camera while keeping the door closed during the dialysis session. If dialysis staff are working from outside the room, the patient must be closely monitored at all times and care should be taken to prevent complications such as needle dislodgements and exsanguination.

Patients receiving dialysis in their own room or an isolation room do not need to wear a mask if dialysis staff are working from outside the room. If dialysis staff are remaining in the room with the patient, the patient should wear a facemask if tolerated. Dialysis staff in the room should use all recommended PPE.

When patients with confirmed COVID-19 are being dialyzed in the acute dialysis unit, the patient should wear a facemask for the duration of treatment. Dialysis staff in the room should adhere to appropriate Transmission-Based Precautions and use all recommended PPE.

Current standards for routine cleaning and disinfection of hemodialysis equipment are appropriate for COVID-19.

In Room Dialysis Treatment:

It is important to follow your current process for disinfecting hemodialysis equipment, paying close attention to infection control practices to ensure that other equipment or surfaces are not cross-contaminated.
When the dialysis machine, supplies, and equipment are moved out of a patient’s room, the dialysis machine should go through routine cleaning and disinfection procedures. An EPA-registered, hospital-grade disinfectant should be used according to the manufacturer’s instructions. Please refer to List Nexternal icon for products that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2. When using products from List N, facilities should ensure the products also have a bloodborne pathogen claim (e.g., HIV, hepatitis B)
Disposable medical supplies brought to the patient’s room should be discarded.
All non-dedicated, non-disposable medical equipment used for dialysis treatment should be cleaned and disinfected according to manufacturer’s instructions and facility policies.
Follow standard operating procedures for the disposal of used PPE and regulated medical waste.
Review the dialysis machine’s cleaning recommendations to ensure that disinfectants are compatible with the machine.

Treatment on Dialysis Unit:

Any surface, supplies, or equipment such as the dialysis machine, located within 6 feet of symptomatic patients, should be disinfected or discarded appropriately.
Disposable medical supplies brought to the dialysis station should be discarded.
All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies.
Staff should follow standard operating procedures for the disposal of used PPE and regulated medical waste.
If linens or disposable cover sheets are used on the dialysis chairs, follow standard procedures for containing and/or laundering used items.

Additional information about recommended practices for terminal cleaning of rooms and PPE to be worn by environmental services personnel is available in the Healthcare Infection Prevention and Control FAQs for COVID-19.

Dialysis effluent from suspected or confirmed COVID-19 patients can be disposed of per standard facility protocols. HCP caring for the patient in the patient room or disposing of effluent from the CRRT machine should wear recommended PPE (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html).

When the CRRT machine is being moved out of a patient’s room, the CRRT machine should be cleaned and disinfected per routine procedures. An EPA-registered, hospital-grade disinfectant should be used according to the manufacturer’s instructions. Please refer to List Nexternal icon for products that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2. When using products from List N, facilities should ensure the products also have a bloodborne pathogen claim such as for HIV or hepatitis B.

Many CRRT machines do not have internal fluid pathways, so only external surfaces need to be cleaned and disinfected. There are several germicidal wipesexternal icon that can be used.

For touch screens, check manufacturer’s instructions for use for compatible products that can be used; some may not be compatible with chlorine or alcohol containing products. If the machine has an internal pathway, refer to manufacturer’s instructions for disinfection.

When patients requiring maintenance hemodialysis are deemed appropriate for discharge, the accepting dialysis facility should be notified of the patient’s COVID-19 testing status. This will allow the accepting facility to institute appropriate Transmission-Based Precautions as described in the following guidance https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html

The discharging facility and accepting dialysis facility should ensure transportation to and from the dialysis facility can be done safely.

For information on discontinuing Transmission-based Precautions see: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html