COVID-19: Infection Prevention and Control Measures for Hemodialysis Units

As there is insufficient data on vaccine’s effects on transmission, we cannot modify the various recommendations:

  • Healthcare workers (and patients, when applicable) must continue to respect all infection prevention and control measures, regardless of their vaccination status (hand hygiene, physical distancing, wearing of personal protective equipment).
  • It is too early to determine the impact of vaccination status on exposure criteria of healthcare workers or patients. The recommendations put forward in this document are therefore still in effect.

This document presents the infection prevention and control (IPC) recommendations to apply during the COVID-19 pandemic for the evaluation and care of dialysis patients, specifically in ambulatory hemodialysis units, regardless of their origin. The evaluation step is crucial as some of the literature appears to demonstrate that dialysis patients may show few symptoms. Hemodialysis in particular does not allow for modified treatment plans like other hospital activities (appointment postponement, telemedicine, etc.). For certain facilities, it may be impossible to modify treatment schedules.

The measures recommended in this document are issued based on the scientific data available to date and recommendations regarding SARS-CoV-2 from experts at recognized international authorities. They are updated as the epidemiological situation and new knowledge on this virus and the effectiveness of preventative measures evolve.

Units concerned

All ambulatory hemodialysis units (ambulatory clinics in acute care or other environments, mobile clinics and other non-conventional dialysis units). The risks and benefits should be assessed by the hemodialysis and infection prevention and control services to determine the measures to implement.

For patients with a suspected or confirmed case of COVID-19 who require intermittent hemodialysis in acute healthcare setting, this procedure should be carried out in the patient’s room.

Recommendations

General information

  • Patients presenting signs and symptoms compatible with COVID-19 must be identified before entering the treatment area. The priority is to recognize such patients and quickly apply the required additional precautions.
  • Modify the treatment schedules to have confirmed and suspected COVID cases on the same days or during the same shifts, or schedule them for the end of the day when possible.
  • Advise patients to call in advance to report any presence of symptoms compatible with COVID-19 so that the facility can be prepared for their arrival. If this is not done, the patient must inform the personnel of their symptoms as soon as they arrive at the facility. The facility can also call patients the day before each visit to assess their situation by completing a questionnaire for this purpose.
  • If the patient is coming from another facility (e.g., long term care home, etc.), the facility must inform the hemodialysis unit if the person is a suspected or confirmed COVID-19 case, a contact of a confirmed case or from a facility where there is an outbreak.
  • From the point of arrival at the facility, there must be visible posters clearly indicating when and how to practice hand hygiene and providing information on hygiene and respiratory etiquette.
  • Upon arrival, the patients must go directly to the hemodialysis unit. Ideally, have a reserved entrance.
  • Before entering the treatment area, all patients must go to triage (questionnaire) on arrival, at each visit. This will direct the patient to the cold zone, warm zone or hot zone, depending on how they respond to the questionnaire.
  • For the waiting and treatment areas, it is recommended to set up three separate zones as follows:
    • Hot zone: patients with laboratory-confirmed SARS-CoV-2 or presenting a clinical picture compatible with COVID-19 and with an epidemiological link to a confirmed COVID-19 case. It is strongly recommended to always confirm cases with a laboratory test before transferring them to a hot zone.
    • Warm zone: patients presenting a clinical picture compatible with COVID-19 or awaiting the results of a laboratory test for SARS-CoV-2.
    • Cold zone: patients who do not have a clinical picture compatible with COVID-19 or who have a negative laboratory test for SARS-CoV-2.
  • In the waiting and treatment areas, implement two-metre spacing between patients. If not possible, ensure that there is a physical barrier (plexiglass or a curtain divider).
  • Following the medical assessment, carry out testing on patients directed to the warm zone according to the indications, if required.
  • All patients undergoing hemodialysis must wear medical masks from the moment they arrive at the facility until they leave. Medical masks worn by patients must be ASTM Level 1. If the mask is worn over a sustained period or is wet, soiled, or damaged, it must be changed more frequently. Exemptions remain possible (e.g., for patients who cannot tolerate wearing a mask, patients who are sleeping, or interference with the care). Local evaluation is required. Refer to the document SRAS-CoV-2 : Choix et port du masque médical en milieux de soins [in French only] (link to come) and SRAS-CoV-2 : Port du masque médical en milieux de soins en fonction des paliers d’alerte [in French only].
  • Numerous studies demonstrate that controlling the source (mask worn by the infected patient) reduces the expulsion of respiratory particles. When combined with mask-wearing by healthcare workers (HCW), this measure is more effective than having only HCWs wear masks (reduced risk of acquisition). The data shows a significant reduction in nosocomial transmission when masks are worn by both patients and HCWs (Mermel, 2020; Nguyen, 2020; Seidelman, 2020; Zhang, 2020).
  • Minimize the time spent in waiting areas. Medically stable patients can choose to wait in their personal vehicle or outside the healthcare facility, where they will be contacted at the time of their treatment.
  • Medical and professional teams that visit patients during their treatment must make their rounds in the following order: cold zone, warm zone, then hot zone.
  • At the end of their treatment, patients must leave the hemodialysis unit only when their transportation is ready to pick them up. They must not wait in the common areas at the facility’s entrance.
  • Have separate transport for patients with confirmed COVID-19 as well as for those with suspected COVID-19. These two cases must not be transported together.

Treatment zones

  • Have a buffer zone between the cold, warm and hot zones.
  • Ideally, have dedicated staff for each zone.
  • The following materials must be placed near each chair and hemodialysis machine to ensure that hand hygiene and respiratory hygiene and etiquette measures are respected: tissues, a garbage bin and a hydroalcoholic solution.

Hot zone

Opt for a separate room with a toilet reserved for each case. Users with COVID-19 must be prioritized over other users who normally require additional precautions (without the COVID-19 pandemic) unless additional airborne precautions are required.

If unavailable:

  • Maintain a two-metre distance between patients with confirmed COVID-19 and other patients (in all directions) during the hemodialysis treatment. If a two-metre distance is not possible, install a physical barrier (Plexiglass, screen, or curtain).
  • Select a hemodialysis station at the end of a row, away from the main area of circulation. . 

Warm zone

If possible, treat each individual in a separate room.

If unavailable:

  • Maintain a two-metre distance between patients with suspected COVID-19 and other patients (in all directions) during the hemodialysis treatment. If a two-metre distance is not possible, install a physical barrier (Plexiglass, screen, or curtain).
  • Select a hemodialysis station at the end of a row, away from the main area of circulation. 

Cold zone

The usual treatment method.

Additional precautions and IPC measures (warm and hot zones)

  • Apply additional droplet/contact precautions with eye protection unless the diagnosis requires additional precautions, e.g., tuberculosis. For recommendations on wearing eye protection, refer to: Port de la protection oculaire en milieux de soins en fonction des paliers d’alerte [in French only].
  • Ensure that personal protective equipment (PPE) is available at all times.
  • Bring only the required materials and equipment into the patient’s treatment zone.
  • Do not touch the eyes, nose or mouth with potentially contaminated hands.

Personal protective equipment required (warm and hot zones)

Droplet/contact with eye protection

  • Long-sleeved protective gown, either single-use or washable, depending on local procedures. Have a waterproof gown if there is risk of contact with body fluids.
  • Single-use medical mask.
  • Single-use eye protection (visor or safety goggles). Prescription eyeglasses are not considered adequate protection.
  • Single-use, non-sterile gloves that are well-fitting and cover the wrists.

In the context of COVID-19 and in the presence of a real or perceived shortage of personal protective equipment, refer to.

COVID-19 : Mesures exceptionnelles pour les équipements de protection individuelle lors de pandémie [in French only].

Hygiene and cleanliness

Healthcare equipment

Disinfect with a product that is recognized as effective (virucide for coronaviruses) and registered (with a drug identification number [DIN]) by Health Canada.

Visitors or other accompanying persons

  • Refer to the ministerial instructions for managing visitors.
  • The facility must monitor visitors and family caregivers for symptoms compatible with COVID-19 to determine whether they present acquisition risk factors or exclusion criteria.
    • If so, a competent authority must carry out an evaluation. The visit will have to be postponed in this case.
  • Inform the visitor of the risks and show them how to apply the specific recommended measures.
  • The visitor or family caregiver must apply the additional precautions recommended for the situation, for the entire duration of their visit. If IPC measures are not respected, the local procedure to ensure visitors respect IPC measures will be applied.
  • The person must go directly to the patient’s chair and remain with the patient at all times. When the treatment requires that the person leave their side, they must be directed to the cold zone waiting room.

Lifting measures for confirmed COVID-19 cases

Patients with mild or moderate illness

  • Isolation for 10 days after the onset of symptoms (or date of the test if asymptomatic) AND
  • Absence of fever for 48 hours (without taking antipyretics) AND
  • Improvement to the clinical picture for 24 hours (excluding cough, or residual anosmia or ageusia)

Note: It is not necessary to carry out the control laboratory test or take the results into account to lift isolation measures for patients who meet the above clinical criteria.

Patients with immunosuppression (according to the INESSS definition available at COVID-19 et personnes immunosupprimées) [in French only].

  • Isolation for 28 days after the onset of symptoms (or date of the test if asymptomatic) AND
  • Absence of fever for 48 hours (without taking antipyretics) AND
  • Improvement to the clinical picture for 24 hours (excluding cough, or residual anosmia or ageusia)

Note: It is not necessary to make or take into account the results of control PCR to lift the isolation measures after 28 days. However, the isolation measures could be stopped if the user have two negative PCR results between day 21 and 28.

Justification

Our recommendations are modified as knowledge on the transmission and duration of contagiousness of COVID-19 develops. Nucleic acid amplification tests (NAATs) are not a good indicator of contagiousness for lifting measures. In addition, the 10-day isolation period was adopted for a non-immunosuppressed case. The following articles support these recommendations:

  • The probability of finding live or replicable virus decreases after the onset of symptoms and it has not been found in patients with mild or moderate illness after 10 days following the onset of symptoms (Wolfel, 2020; Arons, 2020; Bullard, 2020; Lu, 2020; CDC, 2020).
  • A study that presents contact tracing of the first 100 confirmed COVID-19 cases in Taiwan showed no secondary cases among the 852 contacts exposed six days or more after the onset of symptoms in index cases (Cheng et al , 2020).
  • Although SARS-CoV-2 RNA remains present in the respiratory tract for several weeks, studies show that the virus could not be replicated in culture after 10 days (Wolfel, 2020; Li et al, 2020; Xiao et al, 2020; CDC, 2020).
  • The detection of live virus has been documented between 10 and 20 days after the onset of symptoms in patients with severe disease and in some cases, who are immunosuppressed (van Kampen et al, 2020)

References

  • Arons, M. M., Hatfield, K. M., Reddy, S. C., Kimball, A., James, A., Jacobs J. R., … Jernigan, J. A. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. New England Journal of Medicine. May 28, 2020;382(22):2081-2090. DOI:10.1056/NEJMoa2008457.
  • BC Renal, Provincial Health Services Authority. (2020). Guideline: Novel coronavirus (COVID-19) for Hemodialysis Outpatients. Version: 2020-03-17. Online: http://www.bcrenalagency.ca/resource-gallery/Documents/COVID-19_Guideline_for_Hemodialysis_Programs.pdf and http://www.bcrenalagency.ca/resource-gallery/Documents/COVID19-Notice_RE_Visitor_Policy.pdf
  • Bullard, J., Durst, K., Funk, D., Strong, J. E., Alexander, D., Garnett, L. … Poliquin, G. Predicting infectious SARS-CoV-2 from diagnostic samples. Clinical Infectious Diseases. May 22, 2020. DOI: 10.1093/cid/ciaa638
  • Centers for Disease Control and Prevention (CDC). (2020). Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities. Version: 2020-04-12. Online: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html
  • Centers for Disease Control and Prevention (CDC). (2020). Considerations for Providing Hemodialysis to Patients with Suspected or Confirmed COVID-19 in Acute Care Settings. Version 2020-04-09. Online: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis/dialysis-in-acute-care.html
  • Centers for Disease Control and Prevention (CDC). 2020. Duration of Isolation and Precautions for Adults with COVID-19. Version 2020-07-22. Online: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
  • Cheng, H. W., Jian, S. W., Liu, D. P., Ng, T. C., Huang, W. T., & Lin, H. H. Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset. JAMA Internal Medecine. May 1; 2020. DOI:10.1001/jamainternmed.2020.2020
  • Institut national de santé publique du Québec (INSPQ). SRAS-CoV-2 : Port du masque médical en milieu de soins en fonction des paliers d’alerte. January 7, 2021. Version 4.0
  • Lu, J., Peng, J., Xiong, Q., Liu, Z., Lin, H., Tan, X., … Ke, C. Clinical, Immunological and Virological Characterization of COVID-19 Patients that Test Re-positive for SARS-CoV-2 by RT-PCR. medRxiv (preprint). 2020. Online: https://www.medrxiv.org/content/10.1101/2020.06.15.20131748v1  
  • van Kampen, J., van de Vijver, D., Fraaij, P., Haagmans, B., Lamers, M., Okba, N., … van der Eijk, A. A. Shedding of Infectious Virus in Hospitalized Patients with Coronavirus Disease-2019 (COVID-19): Duration and Key Determinants. medRxiv (preprint). 2020. Online: https://www.medrxiv.org/content/10.1101/2020.06.08.20125310v1
  • Wölfel, R., Corman, V. M., Guggemos, W., Seilmaier, M., Zange, S., Müller, M. A., … Wendtner, C. (2020). Virological assessment of hospitalized patients with COVID-2019. Nature. May 2020;581(7809):465-469. DOI:10.1038/s41586-020-2196-x
  • Xiao, F., Sun, J., Xu, Y., Li, F., Huang, X., Li, H., … Zhao, J. Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19. Emerging Infectious Diseases. 2020;26(8):10.3201/eid2608.200681. DOI:10.3201/eid2608.200681

Notes: 

Latest update in French: July 02, 2021.

COVID-19: Infection Prevention and Control Measures for Hemodialysis Units

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