This rapid National Institute for Health and Care Excellence (NICE) guideline in the wake of the COVID-19 pandemic (NG160) relates to the delivery of dialysis services for patients.
According to the charity, Kidney Care UK, there are almost 30,000 patients requiring either haemodialysis (which is more common) or peritoneal dialysis. NG160 is designed to maximise the safety of patients receiving dialysis while at the same time protecting staff from infection as well as ensuring the best use of NHS resources for dialysis patients should these resources become limited because of COVID-19.
The initial focus of NG160 is to ensure that dialysis staff support patients through effective communication. In particular, the guideline emphasises the importance of supporting patient’s mental wellbeing during this time and to try and alleviate any concerns or anxieties about COVID-19. NG160 directs patients to Kidney Care UK which recently (1 April 2020) updated its advice on COVID-19. This follows the standard government’s recommendation to self-isolate in the presence of a COVID-19 symptoms.
Both NG160 and Kidney Care UK instruct patients to inform their dialysis unit if they feel unwell and to report any relevant COVID-19 symptoms prior to attending their appointment. NG160 stresses the importance of staff informing patients of the need to continue with regular dialysis during the pandemic unless informed otherwise by their clinical team. During the pandemic, NG160 recommends minimising face-to-face contact and that staff make use of either telephone or video consultations. In addition, all non-essential follow-up appointments should be reduced, home delivery services used for medicines and local services for blood tests.
For patients without COVID-19 attending dialysis services, NG160 recommends that they travel alone to appointments and to minimise the time spent in the waiting area. One possible solution proposed in NH160 is that patients remain in their car and that staff send them a text message when ready to commence dialysis.
In cases where patients are either known or even suspected of having COVID-19, it is important to follow specific government guidance on infection prevention and control. NG160 also discusses a course of action for patients who present at appointments with symptoms of COVID-19.
As with all the rapid new COVID-19 guidelines, NG160 recommends that healthcare workers who come into contact with dialysis patients follow the guidance on infection prevention and control.
NG160 emphasises the need to maintain outpatient services schedules for dialysis as much as possible in an effort to prevent deterioration of a patient’s condition. The guideline advises units to cooperate with transport providers to ensure continuity of care and to minimise the potential for cross-infection between patients known or suspected of having COVID-19. Since production of NG160, on the 27 March 2020, NHS guidance stated that patients requiring dialysis were one of the priority groups for transport services.
NG160 also advised that where dialysis services cannot be maintained, staff should assess the potential risks and benefits of admitting patients to hospital.
Case ascertainment and cohorting
Given the risk of transmission, NG160 recommends that all patients attending a dialysis unit are screened and triaged for COVID-19. This can be achieved in the reception or waiting area and in addition to enquiring about individual symptoms, staff should also ask whether patients have been in contact with anyone who has a confirmed COVID-19 infection.
To minimise cross-infection, NG160 recommends that patients are dialysed in cohorts based on their COVID-19 status. This should include having separate entrances for infected patients and scheduling appointments to allow sufficient time for cleaning cohorted areas. Patients known to be infected should continue in the COVID-19 cohort for 7 days from the start of symptoms or until they have recovered if this takes longer.
In cases where COVID-19 is strongly suspected, rapid turnaround testing is recommended before dialysis although in many cases it is likely that dialysis is needed before the results of the test are available. NG160 advises that staff assess whether dialysis could be delayed until COVID-19 status is known but equally important that staff also evaluate whether a patient’s symptoms might be due to other causes.
Provision in dialysis units
During the pandemic NG160 advises that all units have agreed protocols in place:
• to restrict unnecessary staff and visitors from the unit
• that explain if or when dialysis treatment may be delayed for new patients
• that risk assessments are agreed with local infection control teams when providing dialysis for COVID-19 patients
• encouraging the uptake of home therapies
NG160 recognises the need for some patients to be treated in other dialysis units, preferably closer to home, to allow for effective cohorting. If service capacity becomes limited due to an increasing number of COVID-19 cases, NG160 suggests that:
• each patient should be considered on an individual basis and that decisions are made by a multi-disciplinary team
• the reasoning behind any decisions are recorded
• any decisions related to rescheduling are clearly communicated to patients, their families/carers with an explanation of any possible risks and benefits associated with this change
Leadership and network planning
NG160 underlines the importance of effective planning by a multi-disciplinary operational team and that contingency staff plans are in place. The guideline also emphases the need to work in partnership with local commissioning teams and to nominate an executive lead to support the service. This individual will maintain responsibility for planning, working within regional networks and to review renal plans in line with national guidance on COVID-19.
Liaison with both local and regional providers, will allow oversight of service provision across the region and the ability to assess capacity. Due to the potential disruption of service provision, NG160 advises that patient pathways are established so that patients on dialysis are not admitted to hospitals without dialysis facilities and to enable rapid transport to a hospital if required.
The guideline advises that units enter into discussion with private sector service providers to agree working patterns and adapt these as needed during the pandemic. In such instances, NG160 recommends that independent providers have the capacity to facilitate COVID-19 testing, sufficient technical renal/clinical staff to review patient-staff ratios, risk review the frequency of routine assessments (that is, only doing those that are necessary) and have home delivery drivers.
Due to the potential for limited dialysis NG160 suggests multi-disciplinary teams develop individualised plans for patients to safely reduce dialysis schedules if necessary. NG160 encourages the development of local policies on fluid restriction and the prescribing of potassium binders to enable to the frequency of dialysis to be reduced.
NG160 recommends that home dialysis services are maintained during the pandemic, ensuring the provision of sufficient staff and equipment. In light of the pandemic, the guideline proposes that units consider the possibility of increasing the level of home dialysis especially for new patients. It also recommends the testing of carers/assistants and patients if they develop any COVID-19 symptoms.
The guideline is available online and interested readers should check for any relevant updates.