Table 4.

Surge levels and recommended responses

DescriptionSurge Levels and Recommended Responses
Stage 1: conventional operations, minor surgeAll dialysis resources levels are fully intact. The hospital HD unit is functioning within usual bed capacity and adequate staffing levels• Disaster preparedness should be emphasized in HD units before an increased surge capacity. Patients should be aware of surge strategies well in advance
• Provide all patients with documents on emergency preparedness, which should include diet and fluid plans
• Assess all patients for fitness for dialysis dose reduction to expand capacity
• Prioritize advance care planning discussions/serious illness and goals-of-care conversations to align care with patient goals and wishes
• Consider cohorting inpatients with COVID-19 out of the HD unit, when possible
• Cohorting of patients with COVID-19 within inpatient units not in critical care areas should be considered, to optimize nursing ratios during off-ward dialysis beyond 1:1
• Consider moving patients with COVID-19 who require dialysis to adjacent rooms or multibed rooms within COVID-19 units, to allow for this
• Work with dialysis vendors and offsite units to optimize resources, communication, and joint decision-making structures across organizations
Stage 2: conventional operations, moderate surgeAll dialysis resource levels remain intact, but there is a possibility that staffing resources may become depleted. The hospital HD unit is functioning within usual bed and staffing capacity• Continue to keep patients informed of emergency stage/surge level
• Identify patients currently dialyzing in-center who can potentially dialyze in community units, and facilitate transfer where possible
• Identify potential home dialysis patients and fast track training
• Review and update Resuscitation Orders (code status/MOST/POLST)
• Maximize the use of all continuous KRT machines in critical care areas
• Determine essential components of sufficient HD care. Consider deferring routine: blood work, access flow surveillance, and medication reviews
• Determine capacity of nurse to support multiple patients at essential service levels
• Determine interdisciplinary supports available to assist in care
• Consider repatriating HD-trained staff from predialysis and transplant clinic–based service areas, and how to provide refresher training
• Explore other roles in health care (included and excluded), and determine how they can support direct care
Stage 3: contingency operations, major surgeAn increase in demand for dialysis services beyond the normal capacity, yet still maintainable with changes to staff ratios and HD treatment duration. Each HD unit remains responsible for determining the most effective approach to manage the increased demand volumes• Activate dialysis dose reduction for patients on long-term HD
◊ Consider HD two times a week for category 1 patients
◊ Consider reduced duration HD for category 2 and 3 patients (may be facilitated by potassium resin binders and very low [K0 or K1] potassium dialysate baths)
• Extend usual nurse-to-patient ratio in ICU to acceptable and agreed upon staffing that includes ICU/HD registered nurses and nephrology technicians. Outline strategies for urgent assistance if patient care needs change
• Consider increasing the utilization of PD urgent starts
• Proactively assess prognosis for patients on long-term HD using the Charlson Comorbidity Index, in preparation for triage if stage 4 crisis is reached
• Increase nurse-to-patient ratio in HD unit, and cohort stable patients to maximize ratio in a team-based approach
• Transfer patients on long-term HD to other geographic regions with dialysis capacity
Stage 4: crisis operations, *emergency triage status*A significant increase in demand for HD services, which affects care at a regional level. More patients are requiring services than available resources. The system is operating at a crisis surge level, and the increase in demand overwhelms the nephrology resources of an individual hospital and region• Organize provincial/statewide response. A coordinated response at the regional network level is required
• At stage 4, the Emergency Operating Center should provide direction to clinical and operational leads and verify they are prepared to shift KRT service delivery to a triage model
• Increase the utilization of PD urgent starts
• Implement triage allocation framework
• Allocation of available dialysis resources determined by the triage team
  • HD, hemodialysis; MOST/POLST, Medical Orders for Scope of Treatment/Physician Orders for Life-Sustaining Treatment; ICU, intensive care unit; PD, peritoneal dialysis.