Disaster Response to the COVID-19 Pandemic for Patients with Kidney Disease in New York City

Abstract

The novel coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China in December 2019.1 Since then, the New York metropolitan region has quickly become the epicenter of the COVID-19 pandemic in the United States, with >175,000 cases and >20,000 deaths to date.2 The Columbia University Irving Medical Center (CUIMC) is a 738 adult inpatient bed tertiary care hospital in the Washington Heights neighborhood of New York City (NYC) and is one of 11 hospitals in the New York Presbyterian Hospital (NYP) system. Nephrology also staffs a second 196-bed hospital in the Inwood neighborhood of Northern Manhattan. The first patient with COVID-19 at CUIMC was diagnosed on March 1. Travel restrictions for clinical staff were instituted on March 4. By April 10, the nephrology service size had increased by 50%, and patients with COVID-19 accounted for 90% of the census (Figure 1A).Figure 1-1.: Nephrology consult service trends over time during the COVID-19 pandemic surge at Columbia University Irving Medical Center. (A) Proportion of patients with COVID-19 on the nephrology service. (B) Trends for new nephrology consults and for prevalent patients being followed by the nephrology service during the COVID-19 pandemic surge at CUIMC. (C) Comparison of the trends for patients with COVID-19 (COVID) admitted to the ICU and the number of these patients requiring CRRT. iHD, inpatient hemodialysis; PD, peritoneal dialysis; SARS-CoV2, severe acute respiratory syndrome coronavirus 2.Figure 1-2.: Nephrology consult service trends over time during the COVID-19 pandemic surge at Columbia University Irving Medical Center. (A) Proportion of patients with COVID-19 on the nephrology service. (B) Trends for new nephrology consults and for prevalent patients being followed by the nephrology service during the COVID-19 pandemic surge at CUIMC. (C) Comparison of the trends for patients with COVID-19 (COVID) admitted to the ICU and the number of these patients requiring CRRT. iHD, inpatient hemodialysis; PD, peritoneal dialysis; SARS-CoV2, severe acute respiratory syndrome coronavirus 2.Although early reports did not emphasize a high prevalence of AKI in critically ill patients with COVID-19,3 it was clear that many patient populations with underlying kidney diseases would be highly vulnerable to COVID-19, such as individuals with underlying diabetes and cardiovascular comorbidities, kidney transplant recipients, patients with glomerular disease on immunosuppression, as well as individuals with ESKD treated with in-center hemodialysis who could not exercise social distancing. In light of the dire predictions of a surge of critically ill patients in NYC and specific concerns for COVID-19 in patients with kidney disease, the Division of Nephrology at CUIMC/NYP started to reorganize in February 2020. Here, we describe the principal elements of our response, early lessons learned during the pandemic in NYC and the major reconfigurations of services (Tables 1 and 2). Table 1. - Columbia University Division of Nephrology Clinical Services at baseline and during the pandemic surge Service Usual (April 2019) Surge (April 2020) Number of ICU hospital beds 139 312 Number of nephrology clinical services 6 9 Total inpatient hemodialysis treatments 911 1114 Total inpatient hemodialysis unit treatments 741 738 Total inpatient hemodialysis bedside treatments 170 376 Hemodialysis bedside/total treatments (%) 23 51 CRRT cases per day <24 67 (peak) Acute peritoneal dialysis cases per day 0 7 Table 2. - CUIMC dialysis capacity at baseline and during the pandemic surge Service Baseline Anticipated Surge Needs Actual Surge Resources Total hemodialysis machines 25 40 28 Total hemodialysis nurses 34 48 37 Hemodialysis unit nursing staffing ratio 1:2 1:2 1:3 Bedside hemodialysis nursing staffing ratio 1:1 1:1 1:1 CRRT machines 27 73 50 (peak) Organization of the Crisis Team and Division Communication Response to the pandemic required a team-based approach that combined multiple competencies. The division benefited from a strong preexisting administrative and communication structure anchored by weekly administrative meetings, during which physician leadership and administrators discussed ongoing clinical, research, and operational issues. The group culture was one of open discussion and shared decision-making, leading to high trust between members. The division’s response to COVID-19 started with a decision to update the contact list for all personnel, order personal protective equipment, and assess existing capacities of clinical services. In addition, we had a series of calls with Dr. Francesco Scolari, the Chief of the Division of Nephrology at the University of Brescia (one of the hardest-hit hospitals in Italy). Dr. Scolari and other nephrology faculty members generously shared their experience and protocols with us, greatly informing and facilitating our early response.4 The existing organizational structure was then reformulated to develop a crisis team gathering unit directors, nursing leaders, and administrators (Supplemental Figure 1). Guiding principles for the crisis team included excellence in patient care, staff safety, data-driven decisions, and an adaptive structure with regular communication. Since March 2020, this leadership group has convened via video calls every evening, following a structured agenda. To make informed decisions based on current needs, physicians rounding on clinical services are invited to attend. The leadership team disseminates information to the division in a variety of communication mechanisms including frequent emails and periodic division-wide video calls where questions are also fielded. To facilitate coordination of nephrology plans with the institutional response, members of the crisis group were nominated to departmental and hospital workgroups. As the dialysis needs began to challenge resources, the group recognized the need for a coordinated response for RRT across all NYP-affiliated hospitals. A workgroup composed of lead nephrologists from all campuses was formed and the workgroup gathered via video calls daily to track needs and inventory, share dialytic resources, and develop common protocols and innovative solutions. Additional communication channels were maintained with division directors at other academic institutions as well as the American Society of Nephrology. Developing a Data-Driven Approach Early reports from China suggested that only 5%–10% of critically ill patients would require RRT,3 but conversations with nephrology colleagues at the University of Brescia alerted us to a higher incidence of AKI and surge of infected patients with ESKD.4 We made an early decision to develop a data-driven approach to guide our response to the anticipated surge (Table 1, Figure 1B). A baseline assessment of staff capacity and dialysis resources was conducted and our maximum capacity with existing resources was modeled. We developed a daily patient census tracking tool using a cloud-based automated spreadsheet that informed rapid changes in how clinicians were deployed (Supplemental Figure 2). We developed a tool to track our continuous RRT (CRRT) machines to confront the potential challenges of sharing machines across ten traditional and new intensive care unit (ICU) locations (Supplemental Figure 2). We developed similar tracking tools to monitor consumable usage and supplies across the NYP campuses. Nomograms were created to reduce dialysate waste (see below). We modeled best-case and worse-case scenarios using public data from China and Italy to generate projections. We also projected needs for personnel, RRT devices, and supplies, based on the daily census growth in our own nephrology, hospital, and ICU services (Supplemental Figure 3). To date, the ICU census growth has been the best predictor of CRRT needs (Figure 1C). Reorganization of Clinical Services Faculty Redeployment Our faculty includes 30 physicians, and schedules are established 1 year in advance and equitably distributed based on clinical and research responsibilities. Physicians cover 2-week blocks that do not include contiguous weekends. With the surge, the number of physicians needed to cover inpatient services greatly increased. We developed a system of parallel teams of physicians who covered the inpatient services for 7-day stretches including weekends. Each team included a back-up physician in the event the physician on service needed to be quarantined or care for a sick family member (at the time of writing, six physicians [20%] have developed COVID-19 and required quarantine). This system improved continuity of care and limited the risk of exposure of multiple providers to the same patients, particularly early in the pandemic when patient testing was limited and personal protective equipment recommendations were evolving. The week off from inpatient service allowed providers to recover, but also to address urgent outpatient telemedicine visits, outpatient dialysis rounding, and academic or administrative work. Furthermore, services were changed to a geolocalized model. Geolocalization facilitated communication with floor teams, improved efficiency, and reduced movement within the hospital. The daily census tracking tool allowed for the early detection of changing clinical burden, which in turn informed the development of additional geolocalized teams on a regular basis. Ultimately, nine clinical services were deployed. The reorganization of our inpatient teams was developed with close consideration to prioritizing faculty safety. To protect fellows, only attending physicians performed physical exams. A pediatric renal fellow redeployed to the expanded adult inpatient service. Faculty who were considered at high risk for complications of COVID-19 remained off inpatient services and were assigned to a new remote inpatient consultative service aiming to decompress the inpatient services. Consults for straightforward problems whose assessment did not require a physical exam were transferred to the remote-medicine nephrologist who would conduct a chart review, communicate with the primary team, leave recommendations, and conduct follow-up on a daily basis. In addition, these faculty members covered outpatient telemedicine visits and administrative tasks such as communicating with nursing leadership and other units of the hospital and working with vendors to ensure an adequate supply of dialysis consumables. Finally, due to the creation of multiple new ICUs, the department of medicine requested redeployment of physicians to help staff the ICUs. Nephrologists were highly sought after for their expertise in critical care. Ultimately, three nephrologists who volunteered were redeployed to assist the department of medicine. One nephrologist was also redeployed as acting chair of the Allen Hospital. Outpatient Clinics Our projections indicated that the surge of inpatients would adversely affect our ability to staff outpatient clinics. Providers were encouraged to move to telemedicine, which was not previously used in the division but was facilitated by a recent transition to a new electronic medical record with an embedded telemedicine tool. Several patient-level barriers to adopting telemedicine were identified, including unfamiliarity with the smartphone-based application needed to communicate with providers and incorporating translators into telemedicine visits for non-English–speaking patients. Research coordinators were redeployed to call and assist patients with participating in telemedicine encounters before the actual visit. When “shelter-in-place” orders were announced in New York, all outpatient clinics were closed and clinic staff were provided mobile telephones and laptops to work remotely. Kidney Transplant Program All deceased and living donor kidney transplants were stopped, with the last transplant performed on March 17. Our kidney transplant waitlist was inactivated using the new United Network for Organ Sharing functionality that facilitated this, with the exception of our most highly sensitized patients who might never receive a subsequent kidney offer. Although offers for these patients were considered, no actual transplants were performed. The inpatient service, shared by all solid organ transplant programs, was divided into two geographically separated units: one for transplant recipients who were positive for COVID-19, and the other for those negative for COVID-19. In-person visits to the outpatient transplant center were limited to the most urgent cases who required face-to-face assessments. All in-person recipient and living donor evaluations were cancelled and a small number were converted to telemedicine visits given the constraints of staff and physician redeployment. This allowed redeployment of staff: some to newly opened inpatient areas, and others to join a team that was established to make daily phone calls to monitor and advise homebound patients with COVID-19 or persons under investigation. We established a registry of all patients with either confirmed or suspected COVID-19 and a standardized questionnaire was used for patient monitoring and appropriate triage. The outpatient infusion center continued to serve those who needed infusions of antirejection medications. With an increasing number of recovering patients with COVID-19 needing either in-person outpatient follow-up and/or infusions, Fridays were reserved exclusively for outpatients with COVID-19. Outpatient bloodwork at the transplant center was limited to only those in which a rapid turnaround time was essential, such as those with recent transplants immediately preceding the surge or those with an ongoing acute complication. Patients were otherwise directed to outpatient laboratories near their homes to minimize the need for travel. RRT during the Surge Inpatient Hemodialysis Unit In the initial stages of the pandemic, all patients with COVID-19 were dialyzed at the bedside, preserving the inpatient unit for negative cases. However, over time, the majority of our patients on hemodialysis were positive for severe COVID-19, prompting the creation of a COVID-19 shift at the end of the day with terminal cleaning deployed at the end of the shift. By the time of the peak of the surge, we had transitioned to one COVID-19–free shift in the morning, with the subsequent two to three shifts for patients who were positive for COVID-19. Bedside Dialysis Demand for bedside dialysis treatments increased rapidly given the increased census in step-down units and ICUs. Moreover, about 20% of our nursing staff were quarantined due to COVID-19 exposure. This required the hiring of additional traveling dialysis nurses and technicians to support a two- to threefold increase in bedside dialysis capacity including scheduled bedside sessions on Sundays (Tables 1 and 2). We specific in the department for dialysis for patients with COVID-19 who had severe Finally, six research coordinators and physicians were redeployed to the inpatient dialysis unit to help monitor patients and the dialysis increased This increased nursing capacity for bedside dialysis cases. we were to additional traveling nurses and our needs our capacity and we had to reduce all to or and reduce to two a week for those patients who did not have an urgent for RRT In the of were challenges that required us to The of patients with AKI needing CRRT increased by April (Figure requiring a daily to resources across the multiple geolocalized services. of the an from service with their CRRT was When we shared machines every every to the of and reduce nursing with on or off CRRT. CRRT dialysate were maintained at 25 per However, during our peak surge, working to a supply of dialysate to our needs, for those patients who could dialysate we used a of per coordination with multiple we were to increase our dialysate supplies and to our clinical A nephrology fellow coordinated the CRRT service needs across with research coordinators were redeployed to CRRT machines the hospital and communicate the information to the A spreadsheet was created and on a shared that usage and an of machines and patients in time (Supplemental Figure the of the decisions were to the ICU nurses by the nephrology fellow and redeployed staff track and move machines to their This team approach for coordination allowed clinicians to on patient care. In newly opened ICU by nurses who were not with CRRT devices, were to CRRT under the of ICU nursing concerns for a potential of were created (Supplemental Figure to ensure that was no dialysate either of usage of a dialysate or many were at the of CRRT. about limited consumable supplies to an to bedside hemodialysis to patients on and the of for in patients We also a acute peritoneal dialysis for patients who were with positive end of or to or to generate dialysate for the high ongoing CRRT needs have been The that in the frequent of CRRT was also a challenge that required rapid of our including the of monitoring for these patients in with Finally, the rapid of RRT needs also us to become of our consumable supply that is not a consideration at other The data-driven approach the and departmental leadership to hospital dialysis and vendors of the need for additional machines and were between the six campuses of the NYP system. on CRRT CRRT hemodialysis inventory, and of were The included nursing directors and physicians from facilitated the and of additional CRRT machines and supplies as well as nursing for CRRT and on we also requested and additional nursing and technicians to help dialysis treatments at hospitals that were critically Hospital leadership was in contact with and to communicate our needs and help challenges with the supply and division leadership with multiple vendors to ensure adequate supplies to the increased Outpatient Dialysis Early we recognized the need to communicate with dialysis providers to outpatient dialysis services given the number of patients with ESKD being admitted to our We with outpatient dialysis vendors to open a dialysis This unit allowed of outpatient ESKD patients with COVID-19 to and also facilitated of ESKD patients with COVID-19 when The unit opened on April and patients as of the of Our With the rapidly pandemic, were with information However, these weekly was considered to our academic as well as within the All were converted to a remote system with an increased on directors maintained schedules via video As laboratories were required to research were on remote such as data and All clinical research visits were either or transitioned to for patients in clinical requiring To in clinical we developed a to contact research and provided with COVID-19 and on the of data to kidney in COVID-19 at the time of the surge in New York, the public of our experience and early was within the We developed a division-wide institutional to track data and for our patients. data and were developed in with which included a for patients with of severe acute respiratory syndrome coronavirus 2. Research were coordinated within the division using a team-based approach for data and on of and Several research laboratories were to COVID-19 research in an to the and of disease and to kidney have to early that are in stages of or The of social and the the of for a surge of critically ill patients, and the of providers for and their made to and division Division leadership in close daily communication with faculty or staff under Faculty continued and the increased via to continued as well as that such as faculty and research continued to be were with all physicians on service in a call to ensure no one was The provided a daily update on fellow and to the service including the of a fellow system. This system allowed for working in a surge to at and was well social were created for including research and to minimize of social The hospital and areas, the of which were made on the hospital the initial of the pandemic, the nursing The medical and dialysis nursing leadership had daily and open communication with and their concerns were to the daily and in Additional support from the research coordinators and the of additional staff to help during the surge to a of and improved team and for the As of this writing, we are in the of the pandemic, but are early that hospital in NYC are that be a in ICU with hospital for the patients who are the most critically We are a of of nephrologists in the care of many of these patients. we are for a of outpatient clinical in coordination with the of We that the a on remote coordination of care and telemedicine, patient encounters be particularly for patients who urgent nephrology care during the In response to a pandemic a coordinated approach between nephrologists and other clinical teams, hospital and We our data-driven response to the COVID-19 pandemic that allowed us to reorganize our clinical services to care for a surge of patients safety, our academic and our public of sharing our as as to the and (Table 3). Table - challenges and to the severe acute respiratory syndrome coronavirus pandemic Response Organization of a crisis team with of and administrative staff ICU beds increased from 139 to and were converted to ICUs. CRRT performed in and regular Reorganization of attending and fellow inpatient clinical service structure based on data Communication crisis team video call Figure 1 with institutional and call Communication with Communication with from medical with expertise information daily census on inpatient services New tools for tracking inpatient dialysis and supplies for patient and resources Inpatient services to weekly and of clinical service based on patient Inpatient services increased from six and Allen to nine geolocalized services and one consult service. Number of CRRT patients increased from an of to a peak of A pediatric renal fellow redeployed to the adult inpatient service redeployment of fellows, and research staff Geolocalization of services Inpatient telemedicine service Inpatient RRT workgroup to track dialysis resources 40 new and CRRT machines for six hospitals sharing of RRT resources nurses and technicians were provided by a CRRT CRRT to RRT needs of based on daily and redeployment of CRRT machines or New protocols for dialysate Redeployment of research coordinators to assist in the dialysis tracking CRRT and of CRRT dialysate Outpatient and ESKD care to telemedicine infusions and kidney outpatient dialysis unit Redeployment of research as telemedicine of COVID-19–free and and outpatient Redeployment of nurses and coordinators to telemedicine calls for outpatients of a registry of patients with COVID-19 and calls to all outpatients with COVID-19 and for academic research to remote to in for COVID-19 research plans early experience with COVID-19 with and of staff to telemedicine of all members of the division in clinical or research communication with division members with communication of of administrative and hiring for persons under institutional Sharing The tracking tools have been to our data where are for and The working group has to

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