Canaries in the coal mine: Nursing home dialysis patients as sentinels during COVID-19

Background: At least one-third of USA COVID-19 deaths are skilled nursing facility (SNF) residents Since 2016, Dialyze Direct has brought staff-assisted home hemodialysis (HD) on-site to more than 7,000 patients in SNFs HD is performed 5x per week in a den setting Since 3/9/20, Dialyze Direct has screened patients for COVID signs or symptoms before every HD Infection controls include, but are not limited to, patient masks, staff PPE, physical distancing, and cohorting by COVID symptoms or status The penetrance of likely COVID in SNF HD patients in NY vs FL is presented Methods: A symptom diagnostic hierarchy tracked presumptive COVID infection and augmented the limited available COVID testing At every HD, patient symptoms were recorded in an Electronic Health Record Prevalent infection is defined as the proportion of patients with any of the symptoms during the pandemic living in the SNF during the week of interest We report on weekly proportion from 3/9/20-5/16/20 Results: Once COVID symptoms appeared among the HD population, penetrance increased over time In NY, penetrance in week 1,5 (4/5/20), and 10 was 8, 52, and 64% In FL, comparable data was 13, 15, and 25% Prevalence differences (5/10/20) for NY (29/45) vs FL (23/92) (RR 2 6, CI 1 7-3 9;p= 000) Conclusions: COVID symptom penetrance in SNF HD patients differed between NY and FL, likely attributable to differences in community disease prevalence, SNF's infection controls, their relationships to referring hospitals, and state health regulatory environment On 3/25/20, NY mandated SNFs to accept COVID hospital returns and forbade SNFs to demand proof of negative test before accepting the return of suspected patients COVID symptoms in SNF HD residents can serve as sentinel for COVID for the general SNF population as they are the most intensively monitored patients there The more frequent 5x per week HD model in the SNF provides intense and relevant local surveillance compared to less frequent conventional off-site HD This sentinel strategy can inform an urgent pivot of infection containment efforts by the SNF and larger regulatory agents so that lessons learned from successful containment strategies can be implemented early