key: cord-0952063-30a605o3
authors: Kirksey, Lee; Vacharajani, Tushar; Droz, Nathan M.; McLennan, Gordon; Clair, Daniel; Lyden, Sean P.
title: COVID Era “Essential Surgery” Dialysis Access Management Considerations
date: 2020-08-14
journal: Journal of Vascular Surgery
DOI: 10.1016/j.jvs.2020.07.071
sha: aa14788f3cd1f2b7f6ee58b749037b2dc763d6af
doc_id: 952063
cord_uid: 30a605o3

nan

The primary challenge amid the COVID-19 crisis has been the hurdle of matching resources with 2 demand. The predictive models for COVID-19 suggest several temporal phases to the time 3 course of the disease. We describe them as 1) Early (initiation), (2) Surge (acceleration), 3) 4 Peak/Plateau, and 4) Decline (deceleration). Anticipated shortfalls in personal protective Collectively, these quantitative factors determine the healthcare system capacity. As COVID-19 9 represents a public healthcare crisis that taxes the capacity of geographic regions of healthcare 10 delivery and therefore will require the pooling of scarce resources to meet clinical needs; system 11 capacity should be viewed from a geographic regional healthcare delivery perspective not just 12 practice group or hospital. 1 The management of End Stage Renal Disease (ESRD) patients 13 presents unique challenges and opportunities given that it occurs across hospital based, 14 outpatient center, physician office-based and "free standing" procedural facilities. 15 16 Herein, the early phase is marked by the pre-pandemic period and the confirmation of the initial guidance. These tensions are largely focused around the issue of the timing of permanent 10 vascular access (VA) creation. The CMS guidance has been interpreted by many to mean 11 "business as usual" towards the shared long-standing goal of meeting Kidney Dialysis Outcomes 12 Quality Initiative (KDOQI) metrics. Specifically, seeking appropriately timed early creation of 13 VA in advanced chronic kidney disease (CKD) and prompt creation of VA in those patients 14 initiated on IHD with a tunneled dialysis catheter (TDC). 5 

Informed members of the ESRD collaborative care team agree with the "non-crisis" approach to 16 VA i.e., the "fistula first, catheter last" ideal. And the characterization of VA as "essential 17 surgery" is fully endorsed. The problem: a dogmatic interpretation of the guidelines without the an autologous fistula should be addressed with haste to continue dialysis uninterrupted and to 1 prevent an inpatient hospitalization. 2 However, the gray area emerges with the discussion of two groups. One, the non-dialyzed patient 3 who is pre-ESRD and two, the patient successfully dialyzing with a catheter who has yet to 4 undergo permanent access. Unfortunately, USRDS data confirms that 80% of patients begin 5 dialysis with a TDC, (60%-TDC alone, 20%-TDC + fistula/bridge graft). 3

The complete discussion of the decision-making process must not forget several important We utilized this evidenced based rubric to identify those Tier 2 selective patients at higher risk 5 for VA failure and those with high comorbidity profiles or reduced life expectancy profiles. Those "high risk" prevalent patients in whom a TDC has functioned well are considered for 7 deferred VA creation following the Peak/Plateau phase. We utilize a triage team composed of a 8 nephrologist or advanced practice nurse familiar with the patient, vascular surgeon, and 9 interventional radiologist to stratify the patient as Tier 2 selective (see Table) . For those patients dialyzing via a TDC-using the aforementioned rubric-we look to evaluate and 10 to schedule surgery with a careful eye on our healthcare system resource capacity/demand status. 11 We also recognize that some patients are unwilling to come to the hospital for care given what testing is performed. We maintain an "awaiting VA creation" queue within our VA program in 9 coordination with our associated dialysis centers. This registry facilitates identifying if our 10 healthcare facility side capacity limitations are "creating" a back log secondary to VA procedure 11 access. Concomitantly, our healthcare system is following CMS guidance for entering Phase 1 of 12 "Restarting America" program which will involve a strategic focus on broad COVID testing, Tier 1 and all Tier 2 procedures will be performed. Our goals will be several fold. First will be to 17 identify and prioritize VA queue patients based upon clinical need. This will require our 18 multidisciplinary team to have continuous dialogue to reduce TDC exposure. Healthcare 19 facilities in our region may have a back log of patients requiring VA. Collaboration in the 20 offloading of patients may be necessary to meet patient demand and resource availability. Our 21 regional cross healthcare system council will facilitate appraisal of this need. Next, we will need 22 to identify the need and engage in an educational and information providing effort within dialysis 23 J o u r n a l P r e -p r o o f 1 risk to both patient and provider will begin to diminish. This will happen gradually and variably 2 throughout The US and each region will need to grapple with similar discussions of appropriate 3 care. There will be no single appropriate approach that fits all and we will still need to design a 4 VA strategy tailored to the specific patient circumstances. And one, that most importantly, Socially disadvantage persons, low income individuals and racial and ethnic minorities are 8 disproportionately affected by ESRD. In the best of times, the ESRD cohort represents a group at 9 risk for poor outcomes due to healthcare system factors as well as social determinants. 21 Now, in 10 the COVID-19 pandemic, thoughtful strategies and a collective effort are necessary to optimize 11 patient care, minimize morbidity and control healthcare expenditure for this vulnerable patient 12 group.

The need for shared responsibility, dialogue and collaboration is essential between the care 14 providers for this challenging patient population. We must continue to find a way to provide the 

Predicting six-month mortality for patients 11 who are on maintenance hemodialysis

The impact of frailty on outcomes in dialysis

Frailty and dialysis initiation

Hemodialysis vascular access in the elderly-getting it right

A clinical score 1 to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease

CMS Issues Recommendations to Re-Open Health Care Systems in Areas with Low 4 Incidence of COVID-19 | CMS

Opening Up America Again [Internet]. The White House

Institute for Health Metrics and Evaluation

Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective

Multicenter Novel Endovascular Access Trial (NEAT)

Available from: https://supreme.justia.com/cases/federal/us/197/11/