key: cord-0746517-ibfcfdcw authors: Arenas, María Dolores; Villar, Judit; González, Cristina; Cao, Higinio; Collado, Silvia; Crespo, Marta; Horcajada, Juan Pablo; Pascual, Julio title: Management of the SARS-CoV-2 (Covid 19) coronavirus epidemic in hemodialysis units date: 2020-04-15 journal: nan DOI: 10.1016/j.nefroe.2020.04.001 sha: 792e29bfb5918f4672f9e18c4516ad70dad13ff9 doc_id: 746517 cord_uid: ibfcfdcw Summary The current outbreak of SARS-CoV-2 represents a special risk for renal patients due to their comorbidities and advanced age. The usual performance of hemodialysis treatment s in collective rooms increases the risk. The specific information at this time in this regard is very limited. This manuscript includes a proposal for action to prevent infection in the N ephrology S ervices, and in particular in H emodialysis U nits, with the objective of early identification of patients who meet the definition of a suspected case of infection by SARS-CoV-2 and propose circuits and mechanisms to carry out hemodialysis treatment s. They are recommendations in continuous review and can be modified if the epidemiological situation, the diagnostic and therapeutic options so require. On January 31 st 2020, the World Health Organization declared the outbreak of SARS-CoV-2 in China, a public health emergency of international dimension ( 1 ) . According to the information provided by the China Center for Disease Control and in more recent publications, the majority of cases reported came from the Hubei province and in 80% the disease was mild. The proportion of deaths among confirmed cases has fluctuated between 2 and 3%, being higher in Hubei than in the rest of the country that reported a 0.4%. Most cases detected in China are older than 30 years, and among severe and deceased cases there is a high proportion of patients with comorbidities and advanced age ( 2 ,3 ) . To date the hemodialysis cases reported are from a Hubei Hemodialysis center , in which 37 out of 230 dialysis patients, tested positive for COVID-19 in addition 4 of the 33 health personnel were also positive. Six patients with COVID -19 die ( 16.8% ) mainly from cardiovascular causes , with less probability of developing pneumonia than the general population (4) . Up to now, the source of infection is unknown and there is uncertainty about the severity of the disease and the capacity of virus transmission. As other known coronaviruses, SARS-CoV-2 is believed to be transmitted primarily by respiratory droplets larger than 5 microns and by direct contact with the secretions of infected individuals. Other possible transmission routes are being evaluated. The incubation period of the disease in the first cases has been estimated at 2 to 14 days ( 5 ) . The Ministry of Health of the Government of Spain publishes periodically a technical report describing actions to adopt; no special indication for dialysis units have been included at this time ( 6 ) . American Society of Nephrology has issued a note with frequently asked questions and some guidelines ( 7 ) very similar to the Center for D iseases control in Europe and USA (8.9 ) and there are recommendations made by the Nephrology Societies of Taiwan and China . The present manuscript contains a proposal for action to prevent infection in Nephrology Services particularly Hemodialysis facilities. These hemodialysis centers are especially prone to transmission and these patients are a high -risk population with associated comorbidities (2 , 4 ) . The proposal what we consider pertinent at the time of its drafting. With this changing epidemic development, some of the proposed approaches could be overcome in the short term by the real upcoming events. The recommendations included in this document are aligned with the general protocol for the detection and management of SAR-Co V -2 infection at the Hospital del Mar in Barcelona ( 10 It is essential to have and adequate training of all professional in the Hemodialysis Unit on the prevention and identification measures of COVID-19 is essential . It is highly advisable to have one or two of the following options1) a portable ambulatory hemodialysis monitor with bags to be able to dialyze anywhere in the hospital without the need of relocating the patient and maintain isolation , 2) a box for adequate hemodialysis under conditions of contact and drop isolation . As any health professional nurses and doctors attending dialysis facilities should wash their hands with soap and water and applied alcoholic solutions systematically. Patients may have a wide spectrum of symptoms, from asymptomatic infection to severe clinical symptoms of fever, cough, and shortness of breath, although most cases the symptoms are limited to fever and mild cough . Symptoms may appear in only 1 day or up to 14 days after exposure , however the average incubation period is 5 to 6 days (5) . To identify patients that could be infected with SAR-Co V -2 the following measures will be observed prior to the entry into the Dialysis Unit: 1) Nursing personnel equipped with gloves and mask will interrogate all patients about: -Sudden onset of any of the following symptoms: cough, fever and / or , dyspnea, of any intensity . -Relevant information about the 14 day period prior to the onset of symptoms relative to epidemiological measures: o Travel history to areas with evidence of community transmission , as previously discussed. o History of close contact (less than 2 meters) with a probable or confirmed case. 2) Infection will be suspected in any person requiring hospitalization for severe acute respiratory infection (pneumonia, distress acute respiratory failure syndrome multiorgan, septic shock, ICU admission or death) in whom other possible infectious etiologies have been ruled out. 3) In the hemodialysis unit:  If patients have fever or respiratory symptoms, they must inform by phone the dialysis staff even before entering the public transport. The staff of the unit will be be prepared for the patient arrival or classify them in a more appropriate environment (route of entrance to be designed according to hospital protocol). In these cases do not use the collective transport regularly utilized to move to the Dialysis Center; rather use individual transportation which must have separation from the driver. There will be a transport individual with the means of protection that can be offered, the minimum required is a surgical mask and gloves for the patient and companion ; and a surgical mask for medical transport personnel. After completion of the transport the vehicle will be disinfected and proceed with management of waste products  All patients will enter the dialysis facilities through the locker room, where hands will be washed. In the Hospital Hemodialysis unit:  Should any suspected case be identified upon arrival to the unit , this patients will be separated from the other patients, it will be given gloves and a surgical mask and will be conducted immediately to the room or box that had been previously prepared for contact and drops isolation.  If a suspected case is identified inside the unit, once dialysis has been started, the urgent need of dialysis will be assessed and in case of no urgency the patients should be disconnected and separated from to other patients. The patient will be given gloves and a surgical mask and will be immediately taken to the previously conditioned isolation room or box. Dialysis will be continued at another time.  Personnel accompanying the patient to the isolation room will also wear gloves and a surgical mask, keeping a distance of 2 meters from the patient. Try to ensure that the patient does not touch objects (handles, doors, furniture in general, etc.) or people. As soon as possible, a respiratory smear will be performed to detect the virus by PCR, following the protocol established in each hospital for the detection, diagnosis and management of suspected cases. In peripheral hemodialysis facilities dependent on hospital centers:  Identify and select a single room in the facility that can be used to isolate a patient with suspected of SARS-CoV-2 infection (contact and drops isolation). It will be used for further evaluation of the patient while waiting to be transferred. If an isolation room is not available, the patient must be kept with a surgical mask and gloves, and separated 2 meters from the rest of the patients. The isolation measures of these patients are the same as if they had the diagnosed infection: contact and drops isolation, so they can be in the same room as the infected, always trying to respect 2 meters of distance between one patient and another. , and all must wear gloves and a surgical mask.  If the Center can offer isolation to close contacts patients, cases under study or confirmed cases that do not require hospital admission, the patients will be dialyzed at the center. In the event that the center does not have this possibility, these patients will be dialyzed in the reference hospital. 4 . Reusable or non-critical disposable equipment should be used for patient care (eg, blood pressure cuffs). If the equipment has been used on the patient , the equipment must be cleaned and disinfected before using it on another patient according to the manufacturer's instructions. In general, the medical care of patients with respiratory infections without a diagnosis should follow standard precautions to prevent contact and eye protection against drops, unless the suspected diagnosis requires precautions for airborne infections. Evaluate equipment supplies available for individual protection , including masks FFP2 (Figure 2 ) . Eye protection can include a surgical mask with a protective screen . This includes the use of: • Waterproof gown covering 360 degrees , which should be worn over or instead of pajamas normally used by hemodialysis staff. This is particularly important when J o u r n a l P r e -p r o o f accessing a vascular access to connects and disconnects, helping the patient to get in and out of the room and cleaning the room . The same gown should not be used for the care of more than one patient , except if they are isolated together (cohort isolation) . • Gloves, long if possible, to cover and close the sleeves of the gown . • Facial mask: mask FFP2 and surgical mask with screen . • Only when preparing to generate aerosols (anebulization, mechanical ventilation, bronchoscopy, IOT , suction of secretions ), it is required the use requires mask FFP3 (with exhalation valve) and integral glasses of full protection (Figure 3 ) . The personal glasses and contact lenses are not considered appropriate eye protection. Reusable eye protection (eg, glasses) must be cleaned and disinfected before reuse according to the manufacturer's instructions. However, it is recommended to use disposable material with the PPE . Strict hand hygiene must be followed before and after contact with the patient and removal of the PPE. Environmental disinfection:  Follow the protocol for decontamination, conservation and residues disposal (including clothing) commonly used for other types of microorganisms with risk of spread through contact and drops. -The residue are considered Class III or Special Biosanitary waste (Group III, similar to tuberculosis). -There will be 60-liter containers inside the box / room for the disposal for all patient residues, including the PPE used by healthcare professionals. Once it is full, the cleaning staff will be notified immediately for their removal and replacement. -To avoid manipulation of urine and faeces of the patient, it is necessary to use absorbent bags that will be placed on the wedge and / or in the urine bottle. Subsequently they will be closed and thrown into the group III waste container. -Surfaces in contact with the patient or their secretions will be cleaned and disinfected (including the chair or stretcher, the waiting room and the elevator that has been used for the transfer; walls, keypads and elevator -Cleaning personnel must be adequately protected with PPE with a FFP2 mask. Devices and medication:  Devices and materials used in the dialysis session should be used in a single patient and should be cleaned and disinfected on common clean area before being stored or used for another patient.  The materials and medication found in a hemodialysis stations should only be used in the patient dialyzed in that station and should never be returned to the If aerosols are to be produced (administration of nebulisations, mechanical ventilation, fiberoptic bronchoscopy, orotracheal intubation, aspiration of secretions, etc.), a FFP3 mask (with exhalation valve) and full protective glasses are required. It is recommended that all material be disposable. If long sleeves are not available, use the isolation gown (green) and add a plastic apron WHO. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) -China Clinical features of patients infected with 2019 novel coronavirus in Wuhan Documento técnico. Manejo clínico de pacientes con enfermedad por el nuevo coronavirus (COVID-19). 3 de marzo de 2020 Dirección General de Salud Pública Information for Screening and Management of COVID-19 in the Outpatient Dialysis Facility. Release Date Figure 1. Information poster for users of Hemodialysis Units ATENCIÓN/ ATENCIÓ/ ATTENTION Si presenta cualquier síntoma respiratorio (tos, falta de aire) o fiebre, si ha tenido contacto estrecho (menos de 2 metros) con un caso probable o confirmado de Coronavirus, o si usted o alguien de su entorno cercano ha estado de viaje recientemente a China Corea de Sur