Covid-19 is a global pandemic that brought health-care institutions to their knees as they grappled with this highly infectious disease. The National Kidney and Transplant Institute (NKTI) as the tertiary referral center for kidney disease diagnosis and management in the Philippines faced this challenge head-on, knowing that patients with kidney disease, patients on dialysis and transplant patients would continue to come.
NKTI early policy decisions
One of the first major policy decisions of top Management at the start of enhance community quarantine was to expand the Emergency Room facilities to accommodate about 100 Covid-19 suspects or confirmed patients, while areas of the main hospital were retrofitted to accept a highly infectious and deadly disease. The ER Covid Complex as it was called, was composed of 21 tents for various types of Covid-suspects or confirmed patients, dialysis facilities, treatment areas, a satellite operating room and isolation tents. It spanned over 5,000 square meters of parking lots and areas adjacent to the ER. This required a major recalibration of hospital operations, limiting hospital admissions to Covid-19 negative patients with renal emergencies only and re-assigning majority of the hospital staff to the ER.
The dialysis crisis
AT the start of the lockdown due to Covid-19, the provision of dialysis services was a major crisis in itself, as the Institute accepted hundreds of displaced patients on maintenance hemodialysis (HD) from other hospitals or from free-standing dialysis centers, who were diagnosed with Covid-19 but could no longer dialyze in their own dialysis centers.
The reasons are varied, such as closure of the facility itself or a lack of sufficient dialysis nurses to support cohorting a Covid-19 shift. Dialysis centers located in malls or buildings were ordered to shut down when even just one patient or health-care worker (HCW) was found to be Covid-19 positive. In addition, dialysis personnel also developed Covid-19 leading to a lack of adequate personnel to run these dialysis centers. The lack of personal protective equipment for dialysis center staff also led to a lot of resignations for fear of contracting the disease. Health-care institutions were unprepared for this infectious scourge.
The lack of dialysis capacity as a result of the pandemic was a problem of the entire region, and NKTI’s response required an immediate expansion of its dialysis services considering that dialysis is the patient’s lifeline. Without maintenance dialysis, patients with ESRD would die. Many patients went to the NKTI’s ER, after being rejected by many hospitals and freestanding dialysis centers, already severely ill, uremic and congested, from missing weeks of dialysis sessions because of this problem.
Immediate expansion of dialysis services
IN order to accommodate all these patients, we immediately called on our dialysis provider to set up 3 tents configured to provide HD with an additional 16 HD machines, in the NKTI’s ER Covid Complex, running 24-hour shifts. Water lines were connected to these tents running hundred of meters from our main water line, and exhaust fans and air conditioning installed to make these tents pass infection control standards, and to make the treatment as comfortable as possible with the limitations of the set-up. Patients were so grateful to the NKTI for accepting them and saving their lives.
In addition to setting up these additional HD areas, safety guidelines for their use were put in place such as wiping down all equipment with disinfectant and ultraviolet light exposure of the area between shifts. These procedures caused delays of about 1 hour between treatments for proper disinfection. It also gave time for the HCWs to rest due to the extreme heat and humidity from wearing hazmats despite the air-conditioning. A no re-use dialyzer policy was also instituted due to the possible transmission of the disease during the flushing procedure of used dialyzers. The safety of the HD technicians was prioritized.
Both the patients’ and HCWs’ safety were paramount when delivering services by providing a donning and doffing area with a Safety Officer. In addition, plastic separators were also placed between patients as an additional safety maneuver to prevent Covid-19 transmission among the personnel and patients, as exposure would last several hours.
In order to accommodate all the patients who required dialysis, treatment sessions were shortened and sessions reduced to 2 times a week. This allowed us to treat more patients running almost 24 hours a day everyday. These protocols were made into guidelines in the NKTI’s Manual of Operations for the Covid-19 Crisis. These guidelines were shared with nephrologists running HD Centers all over the country.
Granular breakdown of the dialysis patients
The NKTI usually initiates about 100 new patients on dialysis each month. Thus, aside from providing services to displaced HD patients, those who reached end stage kidney failure continued to be accommodated for dialysis initiation. At the peak of the pandemic the Institute dialyzed about 80 patients daily at the ER Covid Complex; 80 percent on HD and 20 percent on peritoneal dialysis (PD). In addition, some patients with Covid-19 suffered from acute kidney injury due to this devastating disease and dialysis would be required temporarily while the kidneys recovered function. All of these patients were accommodated at the NKTI. This life-saving therapy was not denied to anyone who needed it. It is noteworthy that majority (92 percent) of the HD patients coming to the ER were not from NKTI but were from other HD facilities.
Another challenge was that patients recently admitted with Covid-19 needed a temporary HD facility during their quarantine period before they were allowed to rejoin the chronic HD patients. This was likewise needed for patients who still remained Covid-19 positive on RT-PCR testing even after hospital discharge.
The NKTI’s HD Annex for patients on maintenance HD requires one Covid negative swab for re-acceptance. To address this concern several HD shifts of the in-patient HD Unit (HD Main) were utilized to accommodate these patients temporarily. We were therefore able to continuously serve these HD patients who were transitioning back to their own HD Centers.
During this period, NKTI had several HD Units running simultaneously: 3 HD tents at the ER Covid Complex with 16 HD machines, the chronic HD Unit with 46 machines, and the in-patient HD facility with 16 HD machines. Not once did any of these Units close even if some personnel were absent. The Nursing Leaders augmented the HD staff immediately from a complement of skilled HD nurses in the medical wards. This program is part of a continuous year round rotation of nurses to the various specialty areas, including the HD and PD Units. The entire HD Nursing Staff has our admiration and gratitude for their dedication, courage and resiliency during this pandemic.
Dialysis private partners step-up their response
The NKTI’s HD private partner quickly responded to all the Institute’s needs, providing the additional 16 HD machines, portable water treatment equipment and a crude tank for source water in the ER Covid Complex tents, recognizing the essential role the NKTI plays in the country in the provision of this therapy. We require that our private partners are ready at all times to provide dialysis augmentation during disease outbreaks. This policy was incorporated into the 5-year PPP contract for HD, as a result of our past experience in dealing with leptospirosis surges where as many as 20 new patients are admitted daily, all of whom require temporary dialysis.
The Institute’s PD partner likewise offered more PD cycler machines used to remove more fluid in the Covid-19 patient and agreed to immediately increase deliveries of PD solutions for the more than 700 patients on chronic PD. They facilitated deliveries despite the transportation lockdown and often-inadequate warehouse personnel to attend to these deliveries. The NKTI was able to get approval from PHIC to give one month’s supply of PD solutions for patient’s enrolled in the PHIC Z-PD benefit instead of the usual 2-week supply. This was done to limit patient’s travel to the NKTI that became extremely difficult especially for patients coming from distant cities or provinces during the strict quarantine periods.
Peritoneal Dialysis as another option for ESRD patients
Another innovation to address the need to augment dialysis capacity was to initiate new patients on PD rather than HD. PD is a dialysis treatment performed at home. Thus patients would not need to travel to an HD center and be exposed to both patients and HD personnel since dialysis was performed safely in their own homes.
Patients on maintenance PD who developed Covid-19 continued therapy in the ER Covid Complex. New patients, however, required surgical placement of a PD catheter that had to be performed in a sterile environment. During this early period the hospital’s main Operating Room (OR) was reserved for Covid-19 negative patients only. Thus a satellite OR was built by the Institute’s general services group from the ground up, in a record time of five days, behind the ER Covid complex, for this special procedure. The NKTI was therefore able to provide this alternative life-saving treatment for patients being initiated on dialysis or for those on HD who wanted to convert to PD.
Transitioning dialysis from tents to the ER main building
By the middle of May 2020, the main hospital’s re-engineering was completed and the second floor wards were converted to a Covid-19 hot zone. The tents at the ER Covid Complex were slowly dismantled and HD was transferred from the tents to the ER Extension with 12 machines. This area was likewise refurbished with water pipes for dialysis, patient separators and reconfigured with exhaust fans to achieve sufficient air exchanges. Once all the tents were put away, this temporary HD area was closed and patients confined in the hot zones were accommodated in the main hospital HD facility (HD Main).
Navigating the NEW normal for dialysis in NKTI
The New Normal currently being implemented in the chronic HD Annex and Extension consists of an HD Triage where all patients need to pass before they are accepted for treatment. Only Covid-19 negative patients or aysmptomatic patients are dialyzed in these units. Patients are required to wear masks and face shields at all times in the treatment areas while HCWs wear masks, shields and isolation gowns at all times.
The HD Unit in the main hospital (HD Main) has been designated a Covid-19 “hot zone”, and patients are cohorted depending on their Covid-19 status, with Covid-19 positive patients dialyzed during the last shift. In-patients, out-patient Covid-19 positive patients and those awaiting completion of their quarantine period are all accommodated in HD Main. Adjacent to this area is the IMCU, also designated a hot zone, and rooms there are configured for dialysis.
HCWs working in HD Main and IMCU are suited in hazmats. With these SOPs patients can all be treated and HCWs can do their work in a safe environment.
Future of dialysis for Covid-19 patients
What does the future hold for HD in NKTI? We want to remain capable of dialyzing out-patient Covid-19 patients but separately from our in-patient dialysis unit. We also want to be ready to dialyze patients from NKTI as well as from other HD facilities as part of the NKTI’s service to the country. Thus, through Dr. Rose Liquete, our Executive Director’s efforts, linkages with DPWH and IATF were made so that a separate 20-station HD facility will be built at the Eden grounds, capable of dialyzing up to 80 patients daily. This will be built with no capital outlay from NKTI. Moreover, the provision of dialysis services for this particular unit was bidded out and our current dialysis private partner was awarded the contract for this special facility for 12 months.
In conclusion, the pandemic brought on a huge challenge for the NKTI to absorb a deluge of HD patients from the regions, which was addressed by an immediate expansion of the Institute’s HD capability. We continued to offer PD and initiate newly diagnosed ESRD patients on PD to decrease the burden on the health-care system since dialysis is performed safely by the patient at home. The NKTI was again able to meet the demands of this pandemic and strengthened its emergency response capability.
Dr. Romina A. Danguilan is the Head of the HD Unit of the National Kidney and Transplant Institute.
2 comments
thanks for this great article Dr. Romina Danguilan. Once, you educate the general public.
Thanks for this great article Dr. Romina Danguilan. Big help to educate the general public