key: cord-035443-mkba8f1e
authors: Wong, Leslie P.
title: COVID-19 and Elder Health Inequity in Dialysis
date: 2020-11-13
journal: Kidney Med
DOI: 10.1016/j.xkme.2020.11.002
sha: 
doc_id: 35443
cord_uid: mkba8f1e

nan

residents were associated with a higher probability of COVID-19, reinforcing social demographics and proximity as important factors for transmission (8) . Prior history of infection control violations or five-star rating did not predict likelihood of infection in LTC facilities, suggesting the pandemic has created a novel infection control threat for nursing homes (8) .

As the pandemic surfaced, dialysis facilities rapidly implemented new infection control protocols to screen, triage, and cohort patients based on symptoms and history of exposure to COVID-19. This involved major changes in daily operations of dialysis facilities to meet new distancing and personal protective equipment (PPE) requirements (9) . Lack of enough isolation rooms forced creation of dedicated treatment shifts (and in some instances entire facilities) to separate persons under investigation (PUIs) and known cases of COVID-19 from the general dialysis population. But the safety precautions dialysis facilities implement cannot be maintained reliably for many patients in LTC.

Efforts to control COVID-19 may fail due to obstacles faced in LTC that cannot be overcome in the short-term (8) . Maintaining six-foot boundaries is nearly impossible in living quarters where rooms and bathrooms are often shared and distancing efforts are LTC facilities have been the target of much public scorn for their care during the pandemic, but in many respects were "sitting ducks" for COVID-19 (8, 10) . Deficiencies J o u r n a l P r e -p r o o f in staff training, PPE shortages, inadequate space for distancing, and inability to control resident behavior all magnified the problem (8) . Lack of reliable access to diagnostic testing and timely result turnaround enhanced spread by asymptomatic LTC patients and workers (8) . Conversely, dialysis facilities were better able to deploy resources and protocols at a systems level. One crucial advantage for dialysis facilities was a centralized control structure under the leadership of nephrologists, nursing, and senior management.

This enabled dialysis organizations to create and deploy COVID-19 playbooks and support services rapidly on a national level. A highly fragmented LTC industry, in comparison, lacked this level of coordinated leadership and ability to mobilize resources at scale.

COVID-19 has exposed widespread, longstanding health inequity in elder care in the U.S. (10) . Nursing homes suffer from understaffing, heavy workloads, low wages, high employee turnover, and a punitive work environment (10, 11) . Much of the transmission occurring in LTC is traceable to facility workers (8, 11) . Restrictions to visitors and family shifts the brunt of care exclusively to nursing home staff, increasing the burden of responsibility and burnout (10, 11) . The negative emotional impact on patients also affects their caregivers and erodes morale. LTC workers may be especially susceptible to these stressors owing to lower socioeconomic status, multiple caregiving responsibilities at home, and fears of wage losses due to illness (11) . Low living wages means many LTC

A Timeline of COVID-19 Developments in 2019

Addressing community needs and preparing for the secondary impacts of Covid-19. NEJM Catalyst

Caring for dialysis patients in a time of COVID-19

COVID-19 Infection Risk Among Hemodialysis Patients in Long-Term Care Facilities

Mitigating Risk of COVID-19 in Dialysis Facilities

Minimizing the Risk of COVID-19 Among Patients on Dialysis

Playing the Cards We are Dealt: COVID-19 and Nursing Homes

Characteristics of U.S. Nursing Homes with COVID-19 Cases

Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in dialysis facilities

Long-Term Care Policy after Covid-19 -Solving the Nursing Home Crisis

Uncovering the Devaluation of Nursing Home Staff During COVID-19: Are We Fuelling the Next Health Care Crisis?

Connected communities of care in times of crisis