Mo SU, Wan?Ning JIA, Wen?Wen HE, Zhi?Min CAI,Hai?Yan WANG, Liu YANG

Blood Purification Center, China?Japan Friendship Hospital,Beijing, China

ABSTRACT

There are many patients in the blood purification center who need maintenance hemodialysis to maintain life. Those patients generally have low resistance and are easily exposed to coronavirus because they go back and forth the hospital and residence three times a week and closely contact with family, caregivers, community personnel, people in various means of transportation, medical staff, and other patients visiting hospital. Therefore, the blood purification center has become a high?risk environment for the spread of COVID?19 infection. In view of this, our center quickly responded to the formulation and implementation of infection prevention and control measures suitable for the characteristics of the blood purification center and continuous renal replacement therapy (CRRT) emergency plan for fever and suspected patients. According to these measures, we have a positive effect on preventing and controlling nosocomial infection in the blood purification center.

Keywords: Blood purification center, COVID?19, infection prevention and control, management, three?level screening

INTRODUCTION

In January 2020, Chinese scientists found that the pneumonia infection that occurred in Wuhan in December 2019 was caused by a new coronavirus, so it was named novel coronavirus pneumonia. Soon afterward, the World Health Organization announced on February 11, 2020, that the new coronavirus-infected pneumonia was named COVID-19.[1]On January 20, 2020, the National Health Commission of the People’s Republic of China classified COVID-19 as a Class B infectious disease stipulated in the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases, for which the prevention and control measures of Class A infectious diseases are taken.[2]The blood purification center is highly crowded for the life of many dialysis patients who need maintenance hemodialysis to be maintained.Because this group generally has low resistance, goes back and forth the hospital and residence three times a week, with various means of transportation, and contacts with family,caregivers, and community personnel and close contact with medical staff, the blood purification center has become a high-risk environment for the spread of COVID-19 infection.Therefore, the formulation, training, and implementation of infection prevention and control measures of strict screening infection sources and cutting off the transmission routes to protect the susceptible people become our urgent and important duty.

MANAGEMENT STRATEGY

Establishing a core group, measures, and responsibility system for epidemic prevention and control

Our center quickly established an epidemic prevention and control core group composed of head of the department,two head nurses, and two medical team leaders. To further implement prevention and control management measures,the nursing group established a management group composed of head nurses, teaching teachers, department of hospital infection management, and administrator in-charge of protective equipment and articles and strictly followed the principle of “ensuring protection is in place, implementing responsibility system, and ensuring the safety of the dialysis center.” By studying Standard Operating Procedures for Blood Purification,[3]Law of the People's Republic of China on the Prevention and Control of Infectious Diseases,[4]Guidelines for the Prevention and Control of New Coronavirus Infections in Medical Institutions,[5]and Proposal for Hemodialysis Room/Center Prevention and Control of COVID-19 by Chinese Hospital Association,[6]we formulated our center's“Prevention and Control Measures for Blood Purification Center during the COVID-19 Epidemic” and “CRRT Emergency Plan for Fever and Suspected Patients with Blood Purification Treatment”, and continued to improve various management measures with the deepening of epidemic prevention and control work.

Three?level prevention and control screening

First?level prevention and control screening at the entrance to the hospital

Dialysis patients must undergo primary prevention and control screening at the entrance to the hospital [Figure 1].Those with body temperature ≥37.3°C will be directed to the fever clinic, where hemodialysis doctors are responsible for screening the final results of whether dialysis patients are infected and deciding whether to initiate the CRRT emergency plan for them.

Second?level prevention and control screening at the door of the blood purification center

Figure 1: Flowchart of three?level screening for epidemic prevention and control. Note: CRRT: Continuous renal replacement therapy

The dialysis patients whose body temperature is <37.3°C undergo the secondary prevention and control screening by the nurses in the dialysis room at the door of the blood purification center, which is the “first gate” so that strict precontrol examination, triage, and preliminary screening keep the risk factors out of the “first gate.” The specific operations are as follows: (1) On every day and in every shift,the head nurse goes to the initial screening position at the“first gate” for supervision, management, and mission. (2)Two nurses are arranged there for their duties: They check and record whether all patients entering the center are wearing masks and taking the temperature correctly, asking whether they have any symptoms such as cough and diarrhea,whether they have contacted with fever people or people outside Beijing in the past 14 days, and whether their escorts have left Beijing within 14 days and left the patient’s home.The human body infrared thermometer was used to measure body temperature and record. If the body temperature was re?measured by mercury thermometer and ≥37.3°C,immediately report to the head nurse and doctor, and guide the fever patients to the fever clinic for coronavirus screening and record. Those with body temperature <37.3°C and those who pass the preliminary screening are allowed to enter the blood purification center. Nursing staff opens and closes the door of the center on time and sprays ground mats with 1000 mg/L of chlorine-containing disinfectant when patients enter and exit at every shift.

Three?level prevention and control screening during dialysis treatment

This part need doctors and nurses to work collaboratively.First, nurses strictly manage patients during the entire dialysis process, ask them to wear surgical masks or KN95 masks, complete the whole epidemiological investigation and registration of patients, and make basic questionnaires for comparison. And then, the doctors review the nurses’primary screening work, conduct detailed inquiries, and make epidemiological investigations and records of the patients.

The patient is on the machine for 2 h (at any time if necessary).The responsible nurse uses an infrared thermometer to measure the temperature for each patient and records it on the dialysis record sheet. The quality management nurse is responsible for the inspection and the head nurse re-checks.For those whose body temperature has been re-measured by the mercury thermometer ≥37.3°C, immediately notify the doctor and head nurse to give immediate blood back to stop the dialysis treatment, and guide the patient and accompanying person to go to the fever clinic for coronavirus screening tests.

All patients with fever before dialysis and during dialysis should go to the fever clinic for coronavirus screening.The confirmed cases after the consultation of the hospital expert group will be transferred to the designated hospital;the fever and suspected cases will be transferred to the comprehensive ward setup by the hospital. Meanwhile, our center carries out the CRRT emergency plan for fever and suspected patients with blood purification treatment and assigns CRRT team nurses to perform CRRT treatment for them in the comprehensive ward.

For fever dialysis patients who are excluded from coronavirus infection, with their body temperature normal for a week,the doctor in the blood purification center will make a comprehensive evaluation and decide whether they can return to the blood purification center for regular dialysis.

Occupational exposure protection management

Distribute protective equipment in accordance with the protection level prescribed by the hospital, treat them equally,and check the implementation of each shift. Medical and nursing technicians and workers must receive the training and assessment of COVID-19 prevention and control knowledge,so as to know and abide by the prevention and control principles, measures, and emergency plans. Manager actively does psychological counseling for employees and increases their confidence in overcoming the epidemic.

Protection standard of blood purification center

The disposable caps, medical surgical protective masks,goggles, protective face shields, isolation clothing, work clothes, work shoes, and examination gloves are used. The protective equipment is changed daily.

Comprehensive ward protection standards

The disposable caps, medical surgical masks, goggles,protective face shield, isolation clothing, work clothes, work shoes, shoe covers or boot covers, and examination gloves,etc., are used. The nurse uniforms and protective equipment in the CRRT group are changed daily.

Temperature monitoring

The staff in the blood purification center should monitor body temperature twice a day. Those with abnormal body temperature should report it in time and be given intervention according to the relevant regulations and should report to the hospital in the form of an application which named Questionnaire Star. For those who excluded from screening for coronavirus in fever clinics, it is recommended to go to work after 3 days of rest with normal temperature.

Hand hygiene

Strictly implement a hand hygiene system, use antibacterial hand sanitizer, and complete six-step washing hand methods.

Control shift time

Control medical care shift time ≤10 min to reduce personnel gathering and use WeChat group to issue notices, training,etc., when necessary.

Medical observation

Persons who return to Beijing or medical observers from other places and abroad shall be required for medical observations in accordance with government regulations.

Implementing the standard operating procedures for blood purification

The main routes of transmission of COVID-19 are respiratory droplets and close contact. Disinfect air and surface according to the Hospital Air Purification Management Standard[7]and Medical Institution Disinfection Technical Specification.[8]Use chlorine-containing disinfectant, 75% of alcohol, and ultraviolet lamps that are more effective against the spread of COVID-19. The following points need to be paid attention:

1. Maintain air circulation throughout the blood purification center and create as many ventilation conditions as possible. The air purification machine is open all the way,and all windows are opened and ventilated for >30 min before and after each shift. In the case of fever, the ventilation time is extended to 60 min

2. Before and after each dialysis, 1000 mg/L chlorine-containing disinfectant is sprayed and disinfected on the ground, door handles, waiting chairs, toilets, and other environments, and it is to be dried for 30 min. For the environment exposed to fever and suspected cases, spray with 2000 mg/L chlorine disinfectant. After 60 min, the evaluation is made by the infection department whether to continue the next shift of dialysis treatment. Each disinfection is registered

3. Wipe the dialysis machine with alcohol-containing disinfectant after dialysis. After everybody temperature measurement, disinfect and wipe the noncontact thermometer. The mercury thermometer after use must be soaked with 75% alcohol for disinfection every time for another person

4. Make medical waste management and disposal well strictly in accordance with the regulations for the management of medical waste[9]and the measures for the management of medical waste in medical and health institutions.[10]After proper classification,double-layer garbage bag packaging, airtight sealing, and puncture-proof and pressure-resistant carton storage,it will be labeled with “COVID-19” and transported and registered by a dedicated car or person. Masks and caps after use should be disposed of as a medical waster for centralized management to prevent secondary contamination.

Patient health education and management during the epidemic

It is urgent and necessary to educate patients to realize that the dialysis center is a place where everyone entrusts their lives, and everyone who cares for the dialysis center has a responsibility and take the initiative to honestly report fever and other conditions to medical staff. Conducting relevant knowledge explanation and training on protective measures for dialysis patients can not only effectively prevent and control infections but also strengthen patients’self-management. For patients with fever and suspected COVID-19, CRRT team in the general ward should ensure blood purification treatment CRRT for them.

It is required for patients to make on-time dialysis, strictly control their weight gain and high potassium food intake during dialysis, and maintain smooth vessels. In addition,patients should avoid as much as possible going to the emergency room for medical treatment due to acute complications, such as acute heart failure, hyperkalemia, and pathway failure to reduce the risk of infection.

It is necessary to use the WeChat public account of the center to popularize common knowledge of epidemic prevention and control, post the prevention and control regulations of the center in the notification bar, paste the “one-meter line” logo in the patient waiting area, and train the correct methods of wearing masks, coughing, sneezing, and six-step hand washing.

Inform the patient to decline escort in the dialysis room and open two visits during dialysis. It is strictly limited to visit time and person (just one eligible person after screening).

Patients wear medical surgical masks or KN95 masks throughout the blood purification center and should not eat during dialysis.[6]To avoid the occurrence of hypoglycemia, it is recommended that patients prepare easy-to-contain (chocolate candy) to put in the mouth after hand disinfection.

CONCLUSION

The COVID-19 epidemic continues, and we still have many unknowns about it. We must constantly improve various prevention and control measures and emergency plans to ensure the safe operation of the blood purification center. During the epidemic, our center screened out eight patients with fever, of which two actively informed before the hemodialysis and six were normal in the second-level screening but the temperature was ≥37.3°C after 2 h of dialysis during the third-level screening. To sum up experience, the screening must be layer by layer, especially at the start of dialysis, the temperature of the patient who complains of discomfort is measured to facilitate early detection and treatment of the problem. For fever patients who are not infected with COVID-19, CRRT treatment is guaranteed in the general ward, which not only protects the safety of patients and staff in the blood purification center but also avoids unnecessary panic caused by contact with fever patients. During the epidemic, our various prevention and control measures have withstood the trials and tests,laying the foundation and confidence for the prevention and management of COVID-19 infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.