Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities

Below are changes to the guidance as of April 12, 2020:

  • To address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms.
    • Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. Facemasks, if available, should be reserved for HCP.
    • For visitors and patients, a cloth face covering may be appropriate. If a visitor or patient arrives to the facility without a cloth face cover, a facemask may be used for source control if supplies are available.
  • Definitions:
    • Cloth face covering: Textile (cloth) covers that are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing. They are not PPE and it is uncertain whether cloth face coverings protect the wearer. Guidance on design, use, and maintenance of cloth face coverings is available.
    • Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.
    • Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare.

Background

These recommendations should be used with the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This information is provided to clarify COVID-19 infection prevention and control (IPC) recommendations that are specific to outpatient hemodialysis facilities. This information complements, but does not replace, the general IPC recommendations for COVID-19.

This guidance is based on the currently available information about COVID-19. This approach will be refined and updated as more information becomes available and as response needs change in the United States. It is important to stay informed about COVID-19 to prevent introduction and minimize spread of COVID-19 in your dialysis facility. Consult with public health authorities to understand if community transmission of COVID-19 is occurring in your community.

As part of routine infection control, outpatient dialysis facilities should have established policies and practices to reduce the spread of contagious respiratory pathogens. This includes the below information and additional recommendations on screening and triage.

Universal Masking

Recent experience with outbreaks in nursing homes has reinforced that residents with COVID-19 may not report typical symptoms such as fever or respiratory symptoms; some may not report any symptoms. Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings and other healthcare settings. Because of this, CDC is recommending that the general public wear a cloth face covering whenever they leave their home. Updates were also made to CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings to address universal source control for everyone in a healthcare facility, including dialysis facilities. Refer to that guidance for more detailed recommendations, including when facemasks versus cloth face coverings could be used.

Early Recognition and Isolation of Individuals with Suspected or Confirmed COVID-19

  • Facilities should implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill healthcare personnel (HCP) to stay home. HCP should be reminded to not report to work when they are ill.
  • Facilities should be aware that recent studies indicate that people who are infected but do not have symptoms likely play a role in the spread of COVID-19.
    • This underscores the importance of having all individuals wear a cloth face covering while in the facility and applying prevention practices to all patients with regard to proper distancing, hand hygiene, and surface decontamination.
    • When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. If there are shortages of facemasks, facemasks should be prioritized for HCP and then for patients with symptoms of COVID-19 (as supply allows). Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required.
  • Facilities should identify patients with fever or symptoms consistent with COVID-19 before they enter the treatment area.
    • Instruct patients to call ahead to report fever or symptoms of COVID-19 so the facility can be prepared for their arrival or triage them to a more appropriate setting (e.g., an acute care hospital).
    • Patients should inform staff of fever or symptoms of COVID-19 immediately upon arrival at the facility (e.g., when they check in at the registration desk).
    • All patients, regardless of symptoms should put on a cloth face covering at check-in (if not already wearing) and keep it on until they leave the facility.  If patients do not have a cloth face covering, a facemask or cloth face covering should be offered (if supplies allow)
  • Facilities should provide patients and HCP with instructions (in appropriate languages) about maintaining a distance of at least 6 feet from all other persons whenever possible, hand hygiene, respiratory hygiene, and cough etiquette.
    • Instructions should include how to use cloth face coverings and facemasks, how to use tissues to cover nose and mouth when coughing or sneezing, how to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
    • Post signs at clinic entrances with instructions for patients with fever or symptoms of COVID-19 to alert staff so appropriate precautions can be implemented.
  • Facilities should have supplies positioned close to dialysis chairs and nursing stations to ensure adherence to hand and respiratory hygiene, and cough etiquette. These include tissues and no-touch receptacles for disposal of tissues and hand hygiene supplies (e.g., alcohol-based hand sanitizer).

Patient placement

  • Facilities should have space in waiting areas for ill patients to sit separated from other patients by at least 6 feet. Medically stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be seen.
    • Patients with suspected or confirmed COVID-19 should be brought back to an appropriate treatment area as soon as possible in order to minimize time in waiting areas.
    • Facilities should maintain at least 6 feet of separation between patients with suspected or confirmed COVID-19 and other patients during dialysis treatment. Ideally, patients with suspected or confirmed COVID-19 would be dialyzed in a separate room (if available) with the door closed.
      • Hepatitis B isolation rooms should only be used for dialysis patients with suspected or confirmed 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.
      • If a separate room is not available, the patient with suspected or confirmed COVID-19 should be treated at a corner or end-of-row station, away from the main flow of traffic (if available). The patient should be separated by at least 6 feet from the nearest patient (in all directions).
        • If the patient is unable to tolerate a cloth face covering, then they should be separated by at least 6 feet from the nearest patient station (in all directions).

Personal protective equipment

  • HCP caring for patients with suspected or confirmed COVID-19 should use all of the following:
    • N-95 or higher-level respirator (or facemask if a respirator is not available)
      • A cloth face covering is NOT considered PPE and should not be worn by HCP when PPE is indicated
      • In times of shortage, special care should be taken to ensure that respirators are reserved for situations where respiratory protection is most important, such as performance of aerosol generating procedures on patients with suspected or confirmed COVID-19 or provision of care to patients with other infections for which respiratory protection is strongly indicated (e.g., tuberculosis, measles, varicella).
      • Respirators should be worn by fit-tested personnel in the context of a respiratory protection program; Consider implementing a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing.
    • Eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face). Personal glasses and contact lenses are NOT considered adequate eye protection.
    • Gloves
    • Isolation gown
      • The isolation gown should be worn over or instead of the cover gown (i.e., laboratory coat, gown, or apron with incorporate sleeves) that is normally worn by hemodialysis personnel. If there are shortages of gowns, they should be prioritized for initiating and terminating dialysis treatment, manipulating access needles or catheters, helping the patient into and out of the station, and cleaning and disinfection of patient care equipment and the dialysis station.
      • When gowns are removed, place the gown in a dedicated container for waste or linen before leaving the dialysis station. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.

Additional Measures

Additionally, when COVID-19 is suspected or confirmed in a patient receiving hemodialysis, the following additional measures apply:

If a hemodialysis facility is dialyzing more than one patient with suspected or confirmed COVID-19, consideration should be given to cohorting these patients and the HCP caring for them together in the section of the unit and/or on the same shift (e.g., consider the last shift of the day). If the etiology of respiratory symptoms is known, patients with different etiologies should not be cohorted (for example, patients with confirmed influenza and COVID-19 should not be cohorted).

Cleaning & Disinfecting

Current procedures for routine cleaning and disinfection of dialysis stations are appropriate for patients with COVID-19; however, it is important to validate that the product used for surface disinfection is active against SARS-CoV-2, the virus that causes COVID-19external icon. Facilities should ensure they are following the manufacturer’s label instructions for proper use and dilution of the disinfectant. The manufacturer’s instructions are specific to the product and should be followed (e.g., this might not necessarily conform to a 1:100 or 1:10 dilution); some products do not require preparation or dilution and are sold as “ready to use.” The product you are currently using may need to be used at a different concentration or a different contact time.

  • Products with EPA-approved emerging viral pathogens claims are recommended for use against COVID-19. Refer to List Nexternal iconon the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.
    • When using products from List N, ensure the products also have a bloodborne pathogen claim (e.g., hepatitis B, HIV).
    • Note about List N: Products may be marketed and sold under different brand names, but if they have the same EPA registration number, they are the same product.

Staff should be educated, trained, and have competency assessed for all cleaning and disinfection procedures in the facility. Ensure staff use appropriate personal protective equipment (PPE) according to manufacturer’s recommendations when cleaning.

Ensure that routine cleaning and disinfection procedures are followed consistently and correctly for patients with fever or symptoms consistent with COVID-19.

  • Any surface, supplies, or equipment such as dialysis machines 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.
  • Follow standard operating procedures for the containment and 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 those performing the cleaning and disinfections is available in the Healthcare Infection Prevention and Control FAQs for COVID-19.

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