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The appropriate and safe use of hospital resources has been at the forefront in the past few months during this initial wave of the coronavirus disease 2019 (COVID-19) pandemic. New York has been the epicenter of the COVID-19 pandemic in the United States and recent studies report that >20% of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) develop acute kidney injury (AKI), with nearly 15% of individuals requiring kidney replacement therapy (KRT).
Stony Brook University Medical Center is the largest academic medical center in the county and also managed the largest number of patients with COVID-19. In the midst of the COVID-19 pandemic from March 6, 2020, to May 11, 2020, the bed capacity at our academic medical center more than doubled, from 650- to 1,317-bed capacity, including an additional 235 intensive care unit beds. The physical space was gained by converting existing space in the main hospital, ambulatory surgical center, ambulatory care pavilion, and other ambulatory care locations. During this period, 2,918 SARS-CoV-2–infected patients were seen in our emergency department, with 1,580 patients discharged to home quarantine for recovery and 1,338 patients admitted for hospitalization; 56 patients were ventilated. Approximately 22% developed AKI during their hospitalization, with 26% of these patients requiring KRT. During this period, we conducted a total of 729 hemodialysis and 354 continuous KRT (CKRT), averaging 12 hemodialysis and 6 CKRT sessions daily, with >75% of cases requiring respiratory isolation due to COVID-19. Although we implemented measures such as shortened dialysis treatment in maintenance dialysis patients and urgent-start peritoneal dialysis, this increased use of hemodialysis and CKRT placed a significant burden on our health care system, specifically our dialysis nursing staff, who were placed at higher risk for exposure to SARS-CoV-2 during each dialysis treatment session at the patient’s bedside.
To minimize the risk for exposure to nursing and staff while conducting dialysis treatments in COVID-19 isolation rooms, we postulated whether a remote telemonitoring strategy for dialysis treatments in patients with COVID-19 might reduce the overall risk for exposure to our staff. Because we were constrained for time during the pandemic, we were unable to test and optimize multiple telemonitoring platforms in the market. However, we identified that baby monitors could serve as “ready-to-go” telemonitoring of patients receiving hemodialysis. At our academic center, we used the VTech Baby Monitor with a handheld 7-inch display monitor and high-definition 360° camera with the ability for panoramic viewing in COVID-19−infected patients undergoing hemodialysis or CKRT. The dialysis nurse uses the hand-held monitor that connects to the high-definition camera through the Wi-Fi connection to monitor patients in real time and can remotely control the movements of the camera 360° horizontally and 182° vertically and magnify up to 10 times the original capture. This enables close monitoring of the patient, access site, and monitor in real time. In addition to the 1-way video monitoring by the dialysis nurse, the 2-way voice communication provided reliable communication between the patient and nursing staff.
Before the start of the dialysis session, the nurse and/or technician sets up the cameras by the patient’s bedside (1 camera positioned facing the dialysis monitor and the other camera positioned facing the patient and dialysis access). After starting the dialysis session, the dialysis nurse is able to monitor the patient, access sites, vital signs, and treatment parameters through the handheld device in real-time (Fig 1). To ensure safety, the dialysis nurse is positioned directly outside the patient room for any acute emergency with appropriate personal protective equipment and is ready to enter the isolation room for any emergencies. Since implementation of this “ready-to-go” telemonitoring system for COVID-19–infected patients requiring KRT, we observed no positive cases among the dialysis staff in all 729 dialysis sessions, which in part might be due to early implementation of telemonitoring. Because it was in the midst of the pandemic and early implementation of the protocol, we do not have a matching cohort that were not using telemonitoring during the COVID-19 pandemic. In a survey of 22 dialysis nurses, all of whom were managing patients receiving intermittent hemodialysis, 21/22 (95%) reported less anxiety due to reduced exposure and 22/22 (100%) reported that safety was not compromised due to the ability to closely monitor patients in real time. Although in some hospitals intensive care unit rooms are bigger than medical/surgery rooms, in our facility the size of both rooms is similar; therefore, we believe that this likely was not the major driver of anxiety related to exposure.
In conclusion, the use of remote telemonitoring of dialysis treatments in the inpatient setting is safe and reliable and minimizes the exposure of dialysis nurses and technicians to highly virulent diseases such as SARS-CoV-2 infection during a pandemic. The use of ready-to-go telemonitoring devices is an essential resource that should be incorporated into the armamentarium of every inpatient dialysis unit, especially as we prepare for a potential second wave of this pandemic or for future pandemics.
Authors’ Full Names and Academic Degrees
Sobia Khan, DO, and Sandeep K. Mallipattu, MD
Research idea and study design: SK, SKM; data acquisition: SK, SKM; data analysis/interpretation: SK, SKM; supervision or mentorship: SKM. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
The authors declare that they have no relevant financial interests
We thank all our health care providers that served at the frontline during the COVID-19 pandemic.
This study was deemed exempt as human subjects research and was approved as a quality assurance/quality improvement activity under the hospital-recognized departmental quality assurance committee.
Received June 19, 2020. Evaluated by 1 external peer reviewer, with direct editorial input by an Associate Editor and the Editor-in-Chief. Accepted in revised form October 23, 2020.
Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.