Credit to Keith Ozaki who is co-originator of this information

Apropos discussion of elective vs urgent/emergent cases. – Our program does on average 9-10 cases per day, 1-2 thrombectomies, 2-4 fistulograms with angioplasty that were on the verge of thrombosis, 1-2 tunneled catheter procedures, and the rest more or less elective stuff (not so urgent fistulogram stenoses, central vein recanalization, hand pain [depending on degree of pain may be urgent], etc.).

Our concern has been that we cannot distinguish without patient contact which of the fistulogram referrals are urgent/emergent versus relatively elective. We find that if a dialysis unit thinks there is a problem there usually is a very advanced problem and we know that we cannot deal with 5-6 thrombectomies every day.

For this reason we have made almost all referral indications “high priority” (see pasted below), similary for OR procedures. – We also have access to two procedure rooms and designated one of the rooms a Covid-19-+ve space to brings patients directly into the room, improve staff/provider adherence with PPE policies, and facilitate room cleaning/air exchange [the latter is an overkill policy by hospital that will likely fall by the wayside, it holds true for TB/airborne, but should not apply to Corono/droplet]. – Lastly, all consents are done verbally.

The experience in Asian and Europe suggest a 40-50 days curve without flattening and something (much) longer with flattening. So our question is “Can this access problem wait for 3 months or not?”. Most interventions buy at least 3 months time, so anything we can do now prevents an emergency procedure during a period when everybody is sick, staff is out, providers are cross-covering.

Baseline assumptions:

1. There will be more Covid19 exposed / infected (:= Covid19+) dialysis patients than hospitals can manage to dialyze as inpatients (so admitting all of these patients is unlikely to be a solution)
2. Consequently, some Covid19+ dialysis patients will dialyze in the community, possibly dedicated HD units, and will look for dialysis access care in the usual way
3. There will be a subset of Covid19+ dialysis patients who will require dialysis at hospital after an emergency access procedure due to volume/hyperkalemia/scheduling issues, 20-33% of thrombectomy patients seems a reasonable estimate
4. We will not decline care for Covid19+ patients
5. Care may return to “normal” in 3 months (40-50 days for rise and fall of cases with a tail)

Process of care questions:

1. Is there a way to create/dedicate “isolated” pre-post-evaluation/monitoring space? 
2. What are room cleaning and air exchange requirements after a Covid19+ case?
3. Can procedural space be dedicated to Covid19+ patients?
4. Timing of Covid19+ cases during the day to allow for cleaning procedure if dedicated space limited?
5. Where will Covid19+ outpatients receive emergency post-procedure dialysis ?
6. How is EMS and The Ride handling Covid19+ patients?
7. Will the waiting room be able to accommodate Covid19+ patients in a safe way? If not, what space is available for Covid19+ patients to wait?

Triage Process for Dialysis Access procedures - Endovascular

High Priority (access := fistula/graft/PD catheter/tunneled hemodialysis catheter that are used for dialysis):

1. Outpatient thrombectomies without other access
2. Outpatient bleeding access
3. Outpatient access with clinical/laboratory signs of extreme dysfunction or inability to use
4. Outpatient access with signs and symptoms of cardiac strain, limb ischemia and impending tissue loss (high flow)
5. New initiations with volume or electrolyte emergencies/urgencies
6. AKI in ICU/floor with need for dialysis
7. Outpatient access with new onset arm edema jeopardizing use of access or incapacitating limb use/movement
8. Inpatients thrombectomies
9. Inpatients access dysfunction (may not be as extreme as above) if this keeps patient in hospital
10. Outpatient access, not in use, with impending signs of occlusion
11. Catheter removals (as long as staff and resources available, to prevent infections during time when staff and resources are overwhelmed)
12. Venograms for access creation on specific urging of nephrologist when surgery is also pressing ahead (See Open Surgery HD Access Cases Performance Plan)

Low Priority:

1. Venograms for access placement (occasionally they may be necessary to guide urgent/emergent revision of a dysfunction/non-functional access)
2. Scheduled follow-up exams – institute enhanced screening by phone asking specific data on access function: trend of access flow past 4-6 months, trend of clearance 4-6 months, change in bleeding after needle removal, obtain photo of access  

Open HD Access Cases Performance Plan

Joint HD access clinics will continue with individual visit review the week prior for appropriateness and opportunity for delay/virtual or phone visit

Delay these types of cases:

• New HD access placement in stable, minimally to asymptomatic patients with eGFR of >15
• Permanent HD access placement in patient with functioning catheters and no known issues with catheter infections, thrombotic complications
• Asymptomatic non-used fistula ligation
• Asymptomatic AV access aneurysms without threatening signs (large thrombus, thin skin, etc.)
• Difficult augmentation/cannulation in patient without ESRD

Continue with example cases below:

• Thrombosed/failing access unable to be managed by endovascular approach
• Steal syndrome
• High flow access with complications such as Bleeding, CHF, Steal
• Infection
• Difficult augmentation/cannulation in patient with catheter in place
• Failure to mature with impending access loss
• Procedures requested for expedited care by referring nephrologist
• Inpatients in which access procedure will expedite patient progression
• Tunneled hemodialysis catheter placement or exchange that otherwise cannot be accommodated

To be reviewed real time for iterative as needed modifications