Table 3.

Timeline to safety: Factors that influence the time to resumption of dialysis treatmentsa

Timing of FactorPatient LevelDialysis Unit and Provider LevelRegional and National ESRD Community Level (KCERC, ESRD Networks, and Others)Emergency ResponseInfrastructure Level
Before disasterEarly warning (>72 h) and early evacuationEarly warning (>72 h)Early warning (>72 h)Early warning (>72 h)
Dialysis before evacuation when feasibleMedical director or designate active in regional and national disaster planningCollaboration across disciplines, involving private and public entitiesRobust communications network
Individualized step-by-step disaster algorithm, with periodic rehearsal and assessmentComprehensive disaster plan, with regular rehearsal and assessmentPatient tracking system, with interoperability (ready access for all providers and administrators) and securityTransportation for evacuees; DIPP, especially for large-scale evacuations
Buddy system for patientsStandardized predisaster and postdisaster needs analysis, evaluation, and assessment toolsDialysis facility tracking systemResponders and leadership aware of kidney patient needs
Active tracking of patients with stage 5 kidney disease and transplant patientsStandardized resource request, correctly completed to maximize chances of rapid and positive responsePlans for surge capacity in selected dialysis units in each region (especially in predicted peripheral areas)Predesignated special-needs shelters establish partnership with adjacent dialysis facilities before emergency
Physical factors: Dementia, impaired mobility, advanced age, comorbiditiesDialysis facility electrical and water systems redundancy or back-upESRD networks store patient-specific medical information and release when appropriateTransfer of hospitalized inpatients who require dialysis to hospitals beyond immediate area
Psychological factors: Noncompliance, substance abuse, personality styleMedical information systems to store patient data, accessible after disasterStaff augmentation from NDMS, dialysis teams if available
Communication: Literacy; language barriers; access to telephone, radio, and televisionCommunication systems, ideally three independent communication modesSupply depots stocked with dialysis supplies
During disaster, response, and recoveryComplications: Vascular access, medication unavailable, infectionNephrologists showing leadership by sustained presence in the facilityESRD Network coordinates assessment and response, directing patients to functioning dialysis units with surge capacitySeverity and extent of critical infrastructure damage; adequate security
Transportation shortagesExtent of damage to dialysis facilityAssistance with language translation by telephone or other mode of communicationEarly repopulation
  • a The timeline to safety is a critical concept, allowing planners to focus on the critical issues that must be addressed to minimize the delay in resuming dialysis treatment. The table was designed to be read vertically, listing the key factors at each level (patient, dialysis unit and provider, ESRD community, and emergency response infrastructure) at which particular issues manifest or the level that is most responsible for response planning and preparation. Clearly, this is a simplification, and in many cases, responsibility for preparation will cross the arbitrary boundaries described here. DIPP, disaster information public posts.