Outbreaks in dialysis units expose difficult juggling act for hospitals

Outbreaks of COVID-19 at several hospitals in Ontario and Quebec have sickened dozens of people undergoing dialysis and cancer therapy, highlighting the growing challenge facilities face in protecting vulnerable outpatients who have no choice but to come in for life-saving treatments.

These at-risk outpatients are going from home to hospital frequently for treatment and are often in close proximity to one another, thereby raising the risk of contracting novel coronavirus infection.

Even though institutions across the country have increased infection-control measures to reduce the spread, it’s a challenge to protect these patients, experts say. More than 20,000 people with kidney disease in Canada are receiving dialysis, with the majority of them going to the hospital for treatment.

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At Montreal’s hard-hit Sacré-Coeur hospital, 30 dialysis outpatients contracted COVID-19 since the start of the pandemic, according to the local health authority. Of those, nine have died. Many of the infected dialysis patients were residents of long-term care facilities, the health authority said in a statement.

Twenty-five cancer patients at the hospital tested positive for COVID-19, including five who died, although the health authority did not clarify how many were outpatients.

At the Ottawa Hospital, about four dialysis outpatients were infected with COVID-19 during a recent outbreak, which appears to have started with a long-term care resident who came in for treatment, said Deborah Zimmerman, a nephrologist at the hospital and president of the Canadian Society of Nephrology. And at St. Michael’s Hospital in Toronto, 11 dialysis patients were infected with COVID-19 as part of an outbreak that appears also to have started with long-term care residents.

“The dialysis population is a very vulnerable population,” said Matthew Muller, medical director of infection prevention and control at St. Michael’s Hospital. “I do worry about dialysis units across Ontario and I think they are at-risk settings.”

“We’re telling people to stay at home, but dialysis patients can’t stay at home,” Dr. Muller said. “There’s no question that that puts them at risk.”

One of the vulnerabilities facing dialysis units is many outpatients live in long-term care, which have become the epicentre of COVID-19 in Ontario and Quebec. Because of the large volume of patients and the need for multiple treatments each week, it isn’t feasible for hospitals to test all dialysis patients prior to treatment. As a result, some care home residents infected with COVID-19 brought the virus into the dialysis unit, which started outbreaks.

About 110 dialysis patients in Ontario had tested positive for COVID-19, as of late last week, which represents less than 1 per cent of all those receiving dialysis in the province, said Scott Brimble, a nephrologist at St. Joseph’s Healthcare in Hamilton and divisional director of nephrology at McMaster University.

“If it’s a long-term care facility, they’re going home to, potentially, an at-risk place as well,” said Dr. Brimble said.

Many dialysis units are now doing increased testing of people coming from long-term care, are adding dividers between patients and using more masks and other personal protective equipment, even if there are no known cases of COVID-19.

“Hindsight is what it is,” Dr. Zimmerman said. “If you had to do it all over again, and especially from the point of view of people coming from nursing homes, maybe you would have done that from the beginning.”

One of the main challenges facing many dialysis units is that they are often cramped and filled with patients, something that is difficult to change even during a pandemic. When patients come in for treatment, they sit side by side in chairs, for hours at a time, several times a week, while a machine filters their blood.

“They have no ability to socially distance the way the population was being told to physically separate themselves," Dr. Zimmerman of the Ottawa Hospital said.

In fact, the demands for in-hospital dialysis are only growing during COVID-19. Because transplant surgeries have largely been put on hold, many of the patients in line to receive a new kidney, which would allow them to get off of dialysis, are being forced to wait until provinces allow non-urgent surgeries to return. And many people with kidney disease who are eligible to receive in-home dialysis can’t access it because it requires minor surgery to insert a catheter, which isn’t currently allowed in many provinces because of COVID-19.

“The units are getting more full, not less full,” Dr. Zimmerman said.

Mary Gospodarowicz, radiation oncologist and medical director of Toronto’s Princess Margaret Cancer Centre, said the hospital has introduced a universal mask policy for staff and patients, increased cleaning and blocking off chairs so people aren’t next to one another. And anyone who is starting treatment must take a COVID-19 test first to rule out infection, Dr. Gospodarowicz said.

About 350 people come to the hospital every day for chemotherapy and radiation. While some of the cancer outpatients have tested positive, so far there hasn’t been transmission to other cancer outpatients, she said.

“It’s a huge change for patients. It’s a huge change for physicians,” Dr. Gospodarowicz said. “We’re doing the best we can to lower the risk.”

Deborah Storozuk, who was recently diagnosed with ovarian cancer, had her first chemotherapy treatment at a Montreal hospital last week, an experience she describes as terrifying. While patients are screened before they can enter the unit, she said some people in the waiting room don’t respect physical-distancing measures. But during her treatment, which lasts about six hours, she has ample space from other patients. Still, it’s hard to not be scared about the risks of infection, she said.

“You’re in a place where all the sick are,” said Ms. Storozuk, who is 57. “You have to live it to understand it. But it’s devastating to have to go through this.”

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