Preparing Outpatient 

Hemodialysis Facilities

for COVID-19

April 13, 2020 

For more information: www.cdc.gov/COVID19
Overview of Presentation

 Describe current epidemiology of COVID-19

 Review how outpatient hemodialysis facilities should prepare for patients 

with COVID-19
Coronavirus Disease 2019 (COVID-19)
COVID-19: Abbreviation for Coronavirus Disease 2019

“CO” stands for “corona”

“VI” stands for “virus”

“D” stands for “disease”

“19” refers to “2019”

COVID-19
COVID-19: Emergence

 COVID-19 is a respiratory illness 

 Caused by SARS-CoV-2, a type of virus called a ‘coronavirus’ 

– Related to SARS-CoV and MERS-CoV

 This novel (new) coronavirus was first detected in China 

 On January 31, 2020, Health and Human Services Secretary Alex M. Azar II 

declared a public health emergency for the United States
COVID-19: How It Spreads

 COVID-19 is a new disease and we are still learning how it 

spreads

 Person-to-person spread is thought to be the primary mode of 

transmission

– Between people in close contact with one another (about 6 feet)

– Through respiratory droplets when an infected person coughs, sneezes, or 

talks

– Some recent studies have suggested that COVID-19 may be spread by 

people who are not showing symptoms

 Contact with infected surfaces or objects

– It may be possible to get COVID-19 by touching surfaces and then 

touching your mouth, nose, or eyes
COVID-19: Symptoms & Complications

Symptoms may include

 Fever

 New cough

 Sore throat

 Tiredness

 Muscle aches

 Shortness of breath

Wide range of illness 

severity has been reported

 Mild to severe illness

 Can result in death

Estimated incubation period

 2 to 14 days

Complications may include

 Pneumonia

 Acute Respiratory Distress 

Syndrome (ARDS)

 Multisystem organ failure

Initial Symptoms might be mild and fever 

might be absent
COVID-19: Prevention

Everyday preventive actions for respiratory illnesses

 Cover your cough or sneeze with a tissue, then throw it 

away

 Cover your mouth and nose with a cloth face cover 

when around others

 Clean and disinfect frequently touched objects and 

surfaces

 Wash your hands often with soap and water for at least 

20 seconds

– Use an alcohol-based hand sanitizer with at least 60% 

ethanol or 70% isopropanol if soap and water are not 

readily available
COVID-19: Clinical Course and Management

 Clinical presentation varies from asymptomatic to mild to severe or fatal illness

 Mortality rate likely varies by age. 

– Mortality rates among confirmed COVID-19 patients in one report (Chinese 

CDC. CCDC Weekly 2020; 8:113-122): 

• 0.2% for patients <40 years

• 8% for patients 70 – 79 years

• 14.8% for patients at least 80 years

 Clinical signs and symptoms may worsen with progression to lower respiratory 

tract disease in the second week of illness

 No specific treatment for COVID-19 is currently available

 Clinical management includes prompt infection prevention and control 

measures and supportive management of complications
Coronavirus Disease 2019 (COVID-19) Cases in the U.S.

(https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html)

COVID-19: Cases in the US on the CDC Website
Interim Additional Guidance for Infection Prevention and Control Recommendations 

for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis 

Facilities (https://www.cdc.gov/coronavirus/2019-ncov/healthcarefacilities/dialysis.html)

COVID-19: Interim Guidance for Outpatient Dialysis 

Facilities on the CDC Website
Preparing for COVID-19 in the 

Outpatient Hemodialysis Setting
COVID-19: Background

 These recommendations supplement the CDC’s Interim 

Infection Prevention and Control Recommendations for 

Patients with Confirmed Coronavirus Disease 2019 

(COVID-19) or Persons Under Investigation for COVID-19 

in Healthcare Settings. 

(https://www.cdc.gov/coronavirus/2019-

ncov/hcp/infection-control-recommendations.html)

 This information is provided to clarify COVID-19 

infection prevention and control (IPC) recommendations 

that are specific to outpatient hemodialysis facilities. 
COVID-19: Educate Patients

 Provide information about COVID-19

 Describe actions the facility is taking to protect them

 Provide education about hand hygiene, respiratory hygiene, and cough 

etiquette 

– How to use cloth face coverings and facemasks

– How to use tissues to cover nose and mouth when coughing or sneezing

– Appropriate disposal of tissues and contaminated items in waste 

receptacles

– How to perform hand hygiene
COVID-19: Educate Healthcare Personnel (HCP)

 Provide information about COVID-19

 Provide information on infection prevention and control measures and 

explain how they protect healthcare personnel (HCP) and patients with an 

emphasis on:

– Hand hygiene 

– Everyone in the facility (including patients, visitors, and staff) should 

practice source control

– Selection/use of personal protective equipment (PPE), 

including practicing how to put on, use, and 

take off PPE

• Cloth face coverings are not considered PPE and should not be 

used by staff when a respirator or facemask is indicated

– Facemasks, if available, should be reserved for staff
COVID-19: Managing Ill HCP and Monitoring for Symptoms

 Implement sick leave policies that are non-punitive and flexible

 Explain how HCP can serve as a source of infections in the facility

 Advise HCP not to report to work when ill

 If HCP develop fever or symptoms of COVID-19 (e.g., fever, cough, sore throat, 

tiredness, muscle aches, shortness of breath) while at work, they should return 

home

 Implement active screening (temp and symptoms) of HCP before their shift:

 During times of community transmission

 If patients with COVID-19 patients in facility
COVID-19: Ensure Access to PPE and Other Supplies

 Conduct an inventory of PPE 

 Make PPE accessible, including: 

– Respirators (if available and facility has respiratory protection program)

– Facemasks

– Gowns

– Gloves

– Eye protection (face shield or goggles)

 Provide alcohol-based hand sanitizer with 60 – 95% alcohol and tissues in 

waiting and treatment areas
COVID-19: Prepare the Waiting Area

 Post alerts such as signs and posters at clinic entrances and in strategic places 

around the facility with instructions for patients with fever or symptoms of 

respiratory infection

 Waiting areas should be organized to divide patients with symptoms from 

patients without symptoms

– Separate all patients by at least 6 feet (if possible)

– The area for patients with symptoms should be at least 6 feet away from 

the area for patients without symptoms

 Provide tissues, alcohol-based hand sanitizer (ABHS), and trash cans

 Post signs about hand hygiene, respiratory hygiene, and cough etiquette
COVID-19: Plans for Triaging Patients (1 of 2)

 Have a staff member call patients before their next treatment to ask them if 

they have any symptoms of COVID-19 (e.g., fever, new cough, sore throat, 

tiredness, or shortness of breath).

 Instruct patients to notify the facility before arriving if they have fever or 

symptoms of COVID-19

– Consider using automated communications to remind patients about 

reporting symptoms (e.g., texts on their dialysis day or robocalls)

– If they have symptoms, they should discuss them with a healthcare 

provider before arriving

• Advanced notice gives the facility time to prepare for the patient’s 

arrival or, if indicated based on symptoms, to refer them to a higher 

level of care
COVID-19: Plans for Triaging Patients (2 of 2)

 Ask patients about fever or respiratory symptoms when they arrive at facility

 Place a staff member near all entrances (outdoors if weather and facility layout 

permit), or in the waiting room area, to ensure patients are screened for 

symptoms and fever before entering the treatment floor

 All patients should be wearing a cloth face covering or facemask on arrival at 

the facility regardless of their symptoms

– If they do not have one on arrival, provide them with a face covering 

 Bring symptomatic patients back to an appropriate treatment areas as soon as 

possible. If not possible, medically stable patients should:

– Sit separated from other patients by at least 6 feet

– Wait in a personal vehicle or outside the facility until it is their turn
COVID-19: Determine Appropriate Placement for 

Symptomatic Patients

 Patient may need to be transferred to another facility for the following reasons

– Based on patient’s clinical symptoms, a higher level of care may be required

OR

– In cases of suspected or confirmed COVID-19, if the facility is unable to comply 

with CDC’s Interim Infection Prevention and Control Recommendations for 

Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons 

Under Investigation for COVID-19 in Healthcare Settings. 

– If COVID-19 is suspected, the health department should also be notified.

 If transferring the patient to another facility, inform the receiving facility and 

transport personnel of the suspected diagnosis
COVID-19: Placement of Symptomatic Patients During 

Dialysis Treatment (1 of 3)

 Facilities should maintain at least 6 feet of separation between patients with 

suspected or confirmed COVID-19 and other patients during dialysis treatment.

 Ideally, symptomatic patients would be dialyzed in a separate room (if available) 

with the door closed

 If a separate room is not available:

– Perform treatment at a corner or end-of-row station, away from the main 

flow of traffic (if available)

– The patient should be separated by at least 6 feet from the nearest patient 

(in all directions)

• If the patient is unable to tolerate a mask, then they should be 

separated by at least 6 feet from the nearest patient station (in all 

directions)
COVID-19: Placement of Symptomatic Patients During 

Dialysis Treatment (2 of 3)

 Hepatitis B isolation rooms should only be used for patients with symptoms of 

respiratory infection if:

– The patient is hepatitis B surface antigen positive

OR

– The facility has no patients on the census with hepatitis B infection who 

would require treatment in the isolation room 
COVID-19: Placement of Symptomatic Patients During 

Dialysis Treatment (3 of 3)

 If a hemodialysis facility is dialyzing more than one patient with suspected or 

confirmed COVID-19, consideration should be given to cohorting these patients 

and the HCP caring for them together in the section of the unit and/or on the 

same shift

– Consider the last shift of the day

 If the etiology of respiratory symptoms is known, patients with different 

etiologies should not be cohorted

– For example, patients with confirmed influenza and COVID-19 should not 

be cohorted
COVID-19: Guidance on Personal Protective Equipment 

(PPE)

 HCP caring for patients with suspected or confirmed COVID-19 should use all of the 

following:

– N-95 or higher-level respirator (or facemask if a respirator is not available)

• A cloth face covering is NOT considered PPE and should not be worn by HCP 

when PPE is indicated

• Respirators should be worn by fit-tested personnel in the context of a respiratory 

protection program

 Eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the 

face). 

 Gloves

 Isolation gown
COVID-19: Information About Isolation Gowns

 The isolation gown should be worn over or instead of the cover gown that is 

normally worn by hemodialysis personnel 

 When gowns are removed, place the gown in a dedicated container for waste 

or linen before leaving the dialysis station

 Disposable gowns should be discarded after use

 Cloth gowns should be laundered after each use
COVID-19: Information About Eye Protection

 Eye protection

– Goggles

OR

– Disposable face shield that covers the front and sides of the face

 Personal glasses and contact lenses are NOT considered adequate eye 

protection
COVID-19: When COVID-19 is Suspected or Confirmed (1 of 2)

 Additional Measures:

– Notify the health department about the patient

• Know your local and state health department points of contacts: 

• Contact information for the healthcare-associated infections program 

in each state health department is available here: State-based HAI 

Prevention Activities (https://www.cdc.gov/hai/statebased/index.html)

– Follow the Interim Infection Prevention and Control Recommendations for 

Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons 

Under Investigation for COVID-19 in Healthcare Settings 

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-controlrecommendations.html) 

» Airborne Infection Isolation Rooms (AIIRs) are not required
COVID-19: When COVID-19 is Suspected or Confirmed (2 of 2)

 Routine cleaning and disinfection procedures are appropriate for COVID-19 in 

dialysis settings 

– Ensure HCP have access to EPA-registered, hospital-grade disinfectants

– Refer to the EPA-website for List N: Disinfectants for Use Against SARS-CoV2 (https://www.epa.gov/pesticide-registration/list-n-disinfectants-useagainst-sars-cov-2)

– When using products from List N, facilities should ensure the products also 

have a bloodborne pathogen claim (hepatitis B, HIV)

 Any surfaces, supplies, or equipment located within 6 feet of symptomatic 

patients should be disinfected or discarded
Additional Considerations
Reporting PPE Shortages

 If your facility is concerned about a potential or imminent 

shortage of PPE, alert your state/local health department 

and local healthcare coalition, as they are best positioned 

to help facilities troubleshoot through shortages. 

– Link to identifying your state HAI coordinator: Statebased HAI Prevention Activities

(https://www.cdc.gov/hai/state-based/index.html)

– Link to healthcare coalition/preparedness: 

HPP In Your State

(https://www.phe.gov/Preparedness/planning/hpp/

Pages/find-hc-coalition.aspx)
Strategies to Optimize the Supply of PPE and Equipment

 HCP and facilities—along with their healthcare coalitions, local and state health 

departments, and local and state partners—will have to work together to develop 

strategies that identify and extend PPE supplies, so that recommended PPE will be 

available when needed most

 All facilities should begin using PPE contingency strategies now

 Facilities experiencing PPE shortages may need to consider crisis capacity strategies, 

which must be carefully planned before implementation

 As PPE becomes available, healthcare facilities should promptly resume standard 

practices

 When using PPE optimization strategies, training on PPE use, including proper donning 

and doffing procedures, must be provided to HCP before they carry out patient care 

activities
Preserving PPE Supply in Times of Shortage (1 of 3)

 Prioritize isolation gowns for aerosol generating

procedures, care activities where splashes and

sprays are anticipated, and high-contact patient

care activities:

– Initiating and terminating dialysis

treatment, manipulating access needles or

catheters, helping the patient into and out

of the station, and cleaning and

disinfection of patient care equipment and

the dialysis station

Produced by the National Institute of Allergy 

and Infectious Diseases (NIAID), this highly 

magnified, digitally colorized transmission 

electron microscopic (TEM) image, reveals 

ultrastructural details exhibited by a single, 

spherical shaped, Middle East respiratory 

syndrome coronavirus (MERS-CoV) virion.
Preserving PPE Supply in Times of Shortage (2 of 3)

 In times of shortage, special care should be taken to ensure that respirators 

are reserved for situations where respiratory protection is most important, 

such as performance of aerosol generating procedures on patients with 

suspected or confirmed COVID-19 or provision of care to patients with other 

infections for which respiratory protection is strongly indicated (e.g., 

tuberculosis, measles, varicella).
Preserving PPE Supply in Times of Shortage (3 of 3)

 Implement extended use of eye and face protection (respirator or facemask)

 Extended use means HCP remove only gloves and gowns and perform hand 

hygiene between patients while continuing to wear the same eye protection and 

respirator or facemask (extended use) 

– The same eye protection and respirator or facemask can also be worn 

(without removing) for repeated contacts with the same patient

– HCP must take care not to touch their eye protection and respirator or 

facemask 

– Eye protection and the respirator or facemask should be removed and hand 

hygiene performed if they become damaged or soiled and when leaving the 

unit
Additional CDC Web Resources

 Steps Healthcare Facilities Can Take Now to Prepare

(https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html)

 People Who Are at Higher Risk for Severe Illness

(https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html)

 COVID-19 Infection Prevention and Control in Healthcare Settings: Questions and Answers

(https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-controlfaq.html)

 Strategies to Optimize the Supply of PPE and Equipment and PPE burn rate calculator 

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html)

 Videos

(https://www.cdc.gov/coronavirus/2019-ncov/communication/videos.html)
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention.