When COVID-19 began spreading rapidly across the United States, government officials responded with stay-at-home orders, business closures, cancellations of elective procedures, and many other unprecedented measures to slow the spread of the virus. Yet, as Americans did their part to social distance and protect their neighbors and loved ones, kidney patients, and particularly those on dialysis, faced a life-threatening conundrum.
While recognizing the importance of social distancing and staying home, hundreds of thousands of in-center hemodialysis (ICHD) patients were unable to do so. In need of multiple dialysis treatments throughout the week for hours at a time (typically 4 hours each session, three times a week for ICHD), these immunocompromised patients had to balance the need for social distance with the necessity of life-sustaining care. Home dialysis patients were able to avoid the risks associated with leaving home three times a week by virtue of performing their dialysis at home.
Recognizing the threats posed to their ICHD patients, the kidney care provider community came together quickly and focused on ensuring at-risk patients continue receiving treatment as safely as possible. All of these providers developed their own competencies, beginning with the early COVID experience in Washington state, but the truly remarkable development was the level of cooperation among providers.
As an example, providers including DaVita, Fresenius Medical Care, U.S. Renal Care, American Renal Associates, Satellite Healthcare, and others formed the Dialysis Community Response Network (DCRN) to coordinate care for patients when certain units were overwhelmed with either staff or patient-related COVID illness. Through the DCRN network, kidney care leaders developed a centralized tracking system to guide decision making and reduce patient risk, while maintaining high-quality care and services. This allowed the system to function more smoothly, but more importantly, it helped patients avoid the hospital. This enormously complicated task, from a regulatory and practical basis, was accomplished in real time by providers.
Information sharing and development of best practices occurred across the community, and were facilitated through weekly meetings among chief medical officers for dialysis providers and the Kidney Community Emergency Response. Through consultation with infectious disease experts, and the studying and sharing of emerging COVID-related data and information, providers combined expertise and resources to treat COVID-19-positive dialysis patients separately and safely, while protecting others from unnecessary exposure. This was accomplished via establishment of isolation clinics that acted as shared resources among providers in a given community.
Along with protecting dialysis patients, a critical aim of these coordinated efforts was to keep kidney patients out of hospitals whenever and wherever possible. By reducing the risk of community spread among vulnerable kidney patients, hospitals could avoid seeing an unmanageable influx of infected patients, freeing up beds and other limited resources.
While the kidney community came together early in the crisis to protect our fragile population of patients with kidney disease, we didn’t predict the impact the virus would have on patients with otherwise healthy kidney function. As COVID-19 began rapidly proliferating across the country, hospitals saw heightened demand for dialysis machines as many COVID-19 patients required renal replacement therapy due to acute kidney injury (AKI). With some regions facing demand increases by as much as three- to five-fold, the sense of urgency was enormous.
As an example of the response, one of our companies launched a program providing a reservoir of kidney care supplies and PPE, including over 100 portable dialysis machines, which could be easily deployed in critical care settings. Providers involved in this effort also refined their support tools, including remote training for hospital workers to support healthcare professionals and enable them to treat larger volumes of patients just as the crisis reached its zenith.
While the coordinated efforts of kidney providers were highly effective in minimizing the impact of the crisis throughout the initial months of the pandemic, we would be remiss not to point out that the effectiveness of this strategy was dependent on the bravery and selflessness of many dialysis nurses, patient care technicians, and others who volunteered to work in isolation clinics and “hot zones” to ensure patients, whether COVID positive or not, received care. Dialysis providers were tested by the COVID-19 pandemic, and we believe we have demonstrated the competence of our nation’s providers in dealing with complex situations. The COVID-19 response will undoubtedly serve as a roadmap for future public health emergencies should they arise.
With regard to policy going forward, in our opinion, providers’ responses to the COVID crisis have demonstrated their capabilities for care coordination individually and collectively. As the discussion of care coordination goes forward, this partnership should be kept in mind.
Robert Kossman, MD, FACP, FASN, is chief medical officer at Fresenius Medical Care North America. Don Williamson, MD, is executive vice president and chief operating officer at American Renal Associates
Last Updated June 22, 2020