How Home Dialysis Providers Can Help Staff Deal with COVID-19

Healthcare professionals—including the nurses, dietitians and social workers who support home dialysis patients—must stay at the top of their game during a highly stressful time. Recent research published in JAMA described the fears of 69 doctors, medical residents, fellows, nurses, and advance practice clinicians in eight listening sessions held during the first week of the COVID-19 pandemic.¹ While those who participated weren’t dialysis clinicians, the results may be helpful to dialysis professionals and the organizations they work for.

The researchers wanted to know what healthcare professionals feared most, what messages they needed to hear from their leaders, and rather than providing generic stress reduction techniques, what tangible support respondents would find most helpful.

The healthcare professionals had fears in eight areas:

1. Access to appropriate personal protective equipment,

2. Being exposed to COVID-19 at work and taking the infection home to their family,

3. Not having rapid access to testing if they develop COVID-19 symptoms and concomitant fear of propagating infection at work,

4. Uncertainty that their organization will support/take care of their personal and family needs if they develop infection,

5. Access to childcare during increased work hours and school closures,

6. Support for other personal and family needs as work hours and demands increase (food, hydration, lodging, transportation),

7. Being able to provide competent medical care if deployed to a new area (eg, non-ICU nurses having to function as ICU nurses), and

8. Lack of access to up-to-date information and communication.

The researchers identified requests from healthcare professionals to their leaders:

1. Hear me.

2. Protect me.

3. Prepare me.

4. Support me.

5. Care for me.

HEAR ME

Healthcare professionals—including dialysis staff—may not always ask for help when they need it, despite a heavy workload and an unfamiliar assigned task. Leaders who do not know what help is needed can ask staff and acknowledge that they hear the needs. The article suggested:

• Listening groups

• Email suggestions boxes

• Leaders visiting the treatment area

• Assuring that staff are included in decision-making

How this might work for home dialysis

Dialysis providers focus a lot of attention on in-center treatment. But, home training nurses often work in isolation from in-center staff. For those who provide home training, pandemic- induced isolation may create an added sense of safety—or may feel like being alone with no backup. Dialysis clinic managers can ask home training staff what they need, and help to get those needs met. One way to do that might be to encourage home training staff in multiple clinics to collaborate with and support each other through media like Zoom, Microsoft Teams, etc.

Home dialysis patients need to be heard, too. Many are feeling anxious and depressed. They may not express their concerns, so reach out to them and ask what they need. Some may need suggestions for how to manage their emotions. Others have unmet instrumental needs because of financial strain. Dialysis social workers can teach patients coping skills and direct them to resources that may be able to address day-to-day needs. The dietitian can help patients stay healthy by suggesting what they can eat and how to get the exercise they need.

PROTECT ME

Healthcare workers may worry that their employer won’t take their needs for self- and family protection as seriously as they do themselves. To calm this fear, providers must do their best to source PPE, ensure that staff are trained in its use—and communicate alternatives if there are supply shortages. Assure staff that if they have symptoms, they will be able to get testing and obtain results soon enough to minimize the risk of exposing others if they test positive. Staff who are at higher risk due to age or pre-existing health conditions, and those who care for high-risk family members are likely to require accommodations.

How might this work for home dialysis

Home training nurses as well as dietitians and social workers can communicate with stable patients via phone calls, Zoom, FaceTime, Skype, etc. HIPAA waivers during this pandemic allow healthcare staff to communicate using less secure modes of communication. Those who make decisions about who must work at the clinic need to take seriously concerns of staff whom the CDC says are at higher risk of serious complications if infected. Dialysis providers can ensure that physicians and other staff who work offsite have secure remote access to patients’ medical records for documentation of patient contacts.

Dialysis patients know that they are at higher risk of complications if they contract this virus. Dialysis clinics can make telehealth a priority for stable home patients. When patients must come to the clinic for labs, medications, or to address a problem, implementprotocols such as these to reduce their risk: screen for symptoms, require masks, and schedule so home patients are in the clinic when no other patients are present, to help protect their safety.

PREPARE ME

No healthcare organization wants to send staff to an area for which they are not trained, but crisis sometimes require it. In this case, encouraging cooperation and task-trading, if necessary, can improve patient care and help staff see that everyone is in this together and can rely on and help each other. No one should have to make a difficult treatment decision alone. When there are not straightforward answers to direct decision-making, encourage staff to ask knowledgeable others for advice.

How might this work for home dialysis

Dialysis staff receive infection control training, and all should follow best practices. That said, the most frequently cited deficiencies on CMS surveys of dialysis clinics are for infection control breaches. When more dialysis patients had hepatitis, it was scary to work with them. Today hepatitis B is preventable through isolation and vaccination, and hepatitis C is treatable with medication. COVID-19 causes fear because there is no treatment yet, no vaccine to prevent it, and it can be lethal, especially to the vulnerable.

Dialysis staff—including social workers, dietitians, and administrative assistants who do not provide medical care—have been tasked to screen patients entering clinics for in-center dialysis and home clinic visits. If you are among them, you may fear being exposed or worry that you could allow a patient who is pre-symptomatic or asymptomatic to enter, exposing your coworkers and other patients. CDC Special Recommendations for Home Dialysis provide guidance for home dialysis clinics:

• Use telehealth as much as possible.

• Assess for symptoms before arrival at the dialysis clinic.

• Advise patients of symptoms to watch for and how to protect themselves, assure that they have enough medications and supplies, and be sure they know how to reach you.

• Plan ways to help patients keep in touch with loved ones and identify who can help with dialysis if a care partner is ill.

CDC screening recommendations provide further guidance:

• IF there is a physical barrier between a patient and screener, screeners should wear a face covering—but do not need full PPE.

• If a screener must be within 6 feet of a patient for brief interactions, s/he should wear an N95 (or medical-grade) facemask, gloves, and eye protection. A gown is needed as well, for longer interactions.

Screening may not identify all who have this virus, so protection measures need to account for this possibility.

SUPPORT ME

The increased workload and changes in work hours for those caring for COVID-19 positive patients and patients under investigation (PUI) can increase staff stress. The JAMA article recommended that healthcare organizations provide nutritious food, hydration, and even transportation for sleepy staff, lodging for those traveling long distances who are working rapid-cycle shifts, and help with childcare with children out of school due to stay-at-home orders. The authors suggested providing emotional support to staff in-person and through webinars on topics such as self-care, overcoming anxiety and insomnia, and supporting each other. Staff should also have access to counseling.

How might this work for home dialysis

As a home training nurse, you may or may not need the same day-to-day help in-center staff need, and may need emotional support from time to time. It can be stressful to be on call too often and to feel responsible for home patients without backup. By regulation, dialysis clinics must provide patients a number to call 24/7 for help. Home dialysis nurses help manage symptoms and troubleshoot access problems, and may advise on equipment and supply delivery. They may be called when a care partner needs a break or chooses to stop helping. Patient deaths bring loss, sadness, and concerns about having missed something. During this pandemic, home dialysis patients likely prefer to meet with you by phone or telehealth when possible. With fear of the virus, more in-center patients may also be considering home dialysis. Pressure to train patients faster could result in poor outcomes and short retention. Dialysis providers need to consider the physical and emotional needs of their home training staff, including having enough trained home dialysis nurses and backup staff so patients have the 24/7 support they need, even if a home training nurse is sick, on vacation, or quits. Recruiting former home training nurses who are not in a high-risk group as temporary help may help to bridge staffing gaps.

CARE FOR ME

Healthcare organizations need to prepare for how they can help staff who become ill. Those staff need to know they have sufficient paid time off to self-quarantine until they are healthy again. Some staff caring for COVID-positive patients may need food and lodging away from home to avoid exposing their families, and may need help with childcare.

How might this work for home dialysis

It is costly and time-consuming to train a new home dialysis nurse, and home dialysis patient outcomes may decline during a new home training nurse’s learning period. To retain experienced home nursing staff during this pandemic, it may help to add flexibility to paid time off (PTO) policies so nurses do not use all their PTO if they become infected. Those working with COVID-positive patients should get hazard pay to compensate in a small way for the risk they are taking. Staff who are at higher risk of complications due to age or pre-existing health conditions should be offered the option to do their job remotely, when possibly. Those who choose to work onsite can do that with appropriate protection in place. Electronic health records need to allow secure access for documentation of remote interactions with patients.

CLOSING THOUGHTS

During this COVID-19 pandemic, we need to all pull together toward the common goal of providing high quality care to our home dialysis patients while protecting ourselves and our loved ones. This will require us to review established clinic policies and procedures and determine which work and which don’t. Dialysis providers can encourage out of the box thinking and ideas for ways to accomplish our shared goal. We are all in this together and can make it through these challenging times when we work as a team.

CDC COVID 19 RESOURCES

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

• Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

• For Healthcare Professionals.

• Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19).