Dialysis Centers
Topic Collection
April 25, 2019
Topic Collection: Dialysis Centers
Disasters can significantly impact patients who are being treated with maintenance dialysis in several ways. Structural damage to roadways or to the dialysis and healthcare facilities can hamper a patient’s access to their treatment site, delaying scheduled treatment. Disasters may also contaminate water supplies or compromise other utilities. This may affect a facility’s ability to provide safe dialysis treatments to their patients. Some disasters, such as earthquakes, may result in crush injuries that injure the kidneys and therefore increase the demand on inpatient dialysis services.
When disasters strike, dialysis clinics and healthcare facilities will need time to recover from the impacts on their services. This includes staff affected by the disaster who may not be able to report to work. These resources highlight lessons learned from recent events, information on dialysis center recovery, strategies for post-disaster dialysis patient care, and plans, tools, and templates that can be modified for facility-specific needs.
Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.
Must Reads
ASPR TRACIE presents findings from resources and references related to post-disaster dialysis operations in response to numerous requests for technical assistance. A previously completed technical assistance response on the post-Sandy improvements to dialysis patient management is included for additional reference.
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This emergency operations plan manual includes templates that can be tailored to the needs of dialysis and end stage renal disease facilities.
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The authors review the improvements in preparedness for dialysis care between 2005 and 2015, and recommend additional efforts to enhance preparedness. Recommendations include increased patient education around emergency diet needs; encouraging patients to carry dialysis plan information and medication lists at all times; and state-level legislation requiring dialysis facilities to have back-up generators.
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The author identifies and discusses the five steps a dialysis clinic should take to ensure their water systems are safe and functional after a disaster.
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The authors of this study address the variation in dialysis care patterns and mortality for patients with end stage renal disease in New York City and the State of New Jersey after Hurricane Sandy. They discuss their findings and conclude that members of the study group (those living in areas affected by Sandy) had higher rates of post-storm visits to the emergency department, hospitalizations, and 30-day mortality than members of the comparison groups.
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The authors share the story of a peritoneal dialysis center's experience with Hurricane Katrina, from the planning, response, and follow-up phases of the event.
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The authors of this article review the disaster-specific patient care recommendations that have been put forward by the Kidney Community Emergency Response Coalition. They also provide a detailed overview of the disaster planning process from the perspectives of kidney patients, dialysis facilities, and volunteer nephrology professionals who may participate in disaster relief.
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The authors review lessons learned after recent disasters and provide "the cardinal features of kidney failure disaster preparedness."
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The authors conducted a retrospective cohort analysis to determine the effect of early dialysis before Hurricane Sandy on outcomes for hemodialysis patients in New York and New Jersey. They found that patients who received early dialysis had significantly lower odds of having an Emergency Department (ED) visit (20%) and hospitalization (21%) in the week of the storm and of dying within 30 days (28%).
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The authors share tips for people with kidney disease to consider in preparation for various types of disasters.
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Preparing Emergency Personnel in Dialysis is a just-in-time training program that aims to teach those with minimum familiarity with basic dialysis to support dialysis staff during a disaster. The authors pilot-tested the curriculum and found a nearly 30% improvement in knowledge as a result of the program.
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This report includes steps facility staff can take to reopen clinics after water or power outages.
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Dialysis Center Recovery
The author provides a timeline of events following an earthquake that struck New Zealand, and discusses how the event impacted dialysis centers.
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The author identifies and discusses the five steps a dialysis clinic should take to ensure their water systems are safe and functional after a disaster.
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The authors of this study discuss the nuclear power plant accident and the impacts it had on hemodialysis facilities. They discuss their methodological approach and their findings and emphasize the need to clarify the maximum safety level of radiation in dialysate for chronic hemodialysis patients.
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The goal of this study was to highlight the challenges associated with damage to water supply facilities (including dialysis centers) in Japan after the 2011 earthquake and tsunami.
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This report includes steps facility staff can take to reopen clinics after water or power outages.
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Education and Training
This 57-minute webinar discusses how disasters, particularly those with water or prolonged power outages, adversely impact individuals who rely on regular dialysis services. It covers basic emergency planning for the renal community, and managing dialysis patients in the shelter, and during the triage process.
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This 21-minute video educates dialysis and opioid treatment program facilities on responding to events that can impact operations, and on emergency preparedness before, response to, and after a critical event. It includes topics such as recognition of an event that would compromise the provision of critical services, patient and staff communications, and service recovery.
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Event-Specific Lessons Learned
The authors examined how power outages in Washington, DC, and five counties in West
Virginia and Maryland impacted operations in a sample of 36 hemodialysis centers. They found that those with pre-existing plans, including provisions for back-up generators and referral agreements with other dialysis centers, offered continuity of care to their patients.
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The authors used a qualitative, interview-based method to study medical surge strategies used at hospitals receiving patients from evacuated healthcare facilities during and after Hurricane Sandy. One gap noted was a challenge associated with the increase in the number of dialysis patients sent to hospitals.
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The authors interviewed dialysis patients and listed the reasons they provided for missing sessions after Hurricane Katrina. As a result, the authors stress the need for emphasizing patient awareness and activating emergency plans early in the response phase.
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After Hurricane Irma struck the U.S. Virgin Islands (USVI), many patients were evacuated to Puerto Rico (PR) to ensure continuity of care. Once Hurricane Maria ravaged PR, however, many USVI residents were evacuated a second time, including renal dialysis patients. This article highlights lessons learned from the evacuation of these patients from a federal patient movement perspective.
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ASPR TRACIE presents findings from resources and references related to post-disaster dialysis operations in response to numerous requests for technical assistance. A previously completed technical assistance response on the post-Sandy improvements to dialysis patient management is included for additional reference.
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The authors discuss their experiences treating dialysis patients after Hurricane Maria, and provide recommendations for future disaster preparedness and response. These recommendations include: creating a registry of patients with updated contact information, as well as contact information for relatives and a physical address where an emergency rescue team can be dispatched; developing a contingency plan to move patients to another center in case the unit is rendered nonfunctional after the storm; and accounting for the needs of staff in response and recovery plans.
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The author provides a timeline of events following an earthquake that struck New Zealand, and discusses how the event impacted dialysis centers.
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This literature review highlights lessons learned from disasters across the U.S. The authors highlight reasons for missing dialysis after disasters, the importance of early dialysis (e.g., when a storm such as a hurricane is pending), and preparedness strategies that can be implemented in advance of predictable natural disasters.
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The authors discuss their study findings, one of which is a positive association between psychiatric symptoms in the year after Hurricane Katrina and hospitalization and mortality in patients with end-stage renal disease. While not specific to dialysis, program managers should be aware of the potential impact and consider screening patients post-disaster.
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The authors investigate the impact of the Great East Japan Earthquake on laboratory findings in chronic hemodialysis patients in Fukushima whose treatment was shortened for up to an hour after the disaster. Results indicated that treatment duration can be decreased without significantly changing effectiveness based on lab results.
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The authors used various tools to measure hemodialysis patients' psychosocial status after Hurricane Katrina. Results suggest the need for more screening and management of psychosocial issues in these patients after disasters, particularly those in shelters or inpatient environments for whom depression was a major issue.
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This article reviews the effects that recent earthquakes have had on dialysis facilities in Japan. The authors discuss how their hospital installed a generator and a water system that could pull in well water so they could continue providing dialysis after the Great East Japan Earthquake, and emphasize the importance of informing local water authorities of dialysis facilities’ needs before, and after, a disaster.
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The authors analyzed more than 175 questionnaires submitted by hemodialysis clinics to better understand how they handled the power outage that followed the 2011 earthquake and tsunami in Japan. Nearly all of the clinics reported that they had established procedures to deal with future planned outages and nearly as many reported implementing lessons learned just after the disaster struck.
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The authors of this study discuss the nuclear power plant accident and the impacts it had on hemodialysis facilities. They discuss their methodological approach and their findings and emphasize the need to clarify the maximum safety level of radiation in dialysate for chronic hemodialysis patients.
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The authors of this study address the variation in dialysis care patterns and mortality for patients with end stage renal disease in New York City and the State of New Jersey after Hurricane Sandy. They discuss their findings and conclude that members of the study group (those living in areas affected by Sandy) had higher rates of post-storm visits to the emergency department, hospitalizations, and 30-day mortality than members of the comparison groups.
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The authors share the story of a peritoneal dialysis center's experience with Hurricane Katrina, from the planning, response, and follow-up phases of the event.
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The authors of this article review the disaster-specific patient care recommendations that have been put forward by the Kidney Community Emergency Response Coalition. They also provide a detailed overview of the disaster planning process from the perspectives of kidney patients, dialysis facilities, and volunteer nephrology professionals who may participate in disaster relief.
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This brief article discusses the experiences of responders assisting dialysis patients following hurricanes Irma, Maria, and Harvey.
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The authors review lessons learned after recent disasters and provide "the cardinal features of kidney failure disaster preparedness."
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The authors conducted a retrospective study on hospital dialysis services provided after Hurricane Sandy. They found challenges with: lack of dialysis documentation from transient dialysis patients (92.3%); staff shortage (50%); staff transportation (71.4%); and communication with other agencies (53.3%).
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The authors conducted a retrospective cohort analysis to determine the effect of early dialysis before Hurricane Sandy on outcomes for hemodialysis patients in New York and New Jersey. They found that patients who received early dialysis had significantly lower odds of having an Emergency Department (ED) visit (20%) and hospitalization (21%) in the week of the storm and of dying within 30 days (28%).
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The authors review the effects that the Great East Japan Earthquake had on dialysis therapy, and present recommendations for future disaster preparedness and response that may be applied to earthquakes and other disasters.
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The goal of this study was to highlight the challenges associated with damage to water supply facilities (including dialysis centers) in Japan after the 2011 earthquake and tsunami.
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The authors reviewed resources from PubMed, Ovid, and Medline combined with real-life experience treating chronic disease after disasters. They found that the international nephrology community had formed an effective organization (the Renal Disaster Relief Task Force), and emphasize that patients have emergency diet and renal fluid restriction plans and be prepared to modify dialysis schedules and methods. Suggestions for facilities are also provided.
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This paper details the experiences of the author, a nurse unit manager, in 2011 when working for four days in the Wesley Hospital, located on the (then-flooding) Brisbane River.
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The authors share information about two storms that affected Japan's Amami-Ohshima island's dialysis treatment centers. Communication and transportation proved to be challenging, but responders reallocated patients, changed dialysis schedules, and used a satellite phone.
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This article reviews lessons learned shared by 2 physicians who treated dialysis patients after Hurricane Harvey hit the Houston area in 2017. Challenges experienced (e.g., lack of medical record information and transportation for patients), and triage protocols used, are discussed.
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General Resources
This document combines excerpts from the Final Rule and the recently released Interpretive Guidelines from CMS to provide a consolidated overview document of requirements for End Stage Renal Comprehensive Outpatient Rehabilitation Facilities.
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The authors review the improvements in preparedness for dialysis care between 2005 and 2015, and recommend additional efforts to enhance preparedness. Recommendations include increased patient education around emergency diet needs; encouraging patients to carry dialysis plan information and medication lists at all times; and state-level legislation requiring dialysis facilities to have back-up generators.
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The authors note that dialysis patients are particularly vulnerable to disaster and sought to study their levels of preparedness. They found that in general, dialysis patients were not prepared for critical incidents, regardless of demographic characteristics.
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This brochure highlights important facts regarding dialysis patients and facilities for emergency planners.
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The authors conducted a cross-sectional survey of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy in 2012, to determine number of missed dialysis sessions after the storm, and assess their preparedness using a checklist from the National Kidney Foundation. They concluded that, “provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.”
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In every disaster, transportation is the second most common failure to access to dialysis treatment after facility closures. This report examines the relationship between the increase in chronic kidney and end stage renal disease and the use of specialized public sector transportation (e.g., ADA paratransit, Medicaid's non-emergency medical transportation, Veterans Administration vehicles, human service agencies, taxis, and ambulances). Strategies for improving reliability and addressing funding challenges are discussed throughout the report.
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The authors discuss the concept of “disaster nephrology,” which they define as, “the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances.” They review post-disaster clinical and logistical challenges that arise in treating both patients with chronic kidney disease, and those with acute kidney injury as a result of the disaster.
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Preparing Emergency Personnel in Dialysis is a just-in-time training program that aims to teach those with minimum familiarity with basic dialysis to support dialysis staff during a disaster. The authors pilot-tested the curriculum and found a nearly 30% improvement in knowledge as a result of the program.
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Patient Care
This resource reviews key considerations related to dialysis and ebola patients, including how providers should handle dialysate effluent/spent dialysate, and how machines should be cleaned upon patient discharge from isolation.
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The authors of this article review the disaster-specific patient care recommendations that have been put forward by the Kidney Community Emergency Response Coalition. They also provide a detailed overview of the disaster planning process from the perspectives of kidney patients, dialysis facilities, and volunteer nephrology professionals who may participate in disaster relief.
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Patients who are dialysis-dependent (with end-stage renal disease [ESRD]) are at particularly high risk after disasters. Dialysis may be delayed and the authors write that few physicians are experienced or trained in the nondialytic management of ESRD. Strategies such as dietary restrictions, potassium removal via resins and cathartics, and adaptations of acute treatment can help patients who can not receive dialysis. The authors emphasize the need for medical facilities to plan and stockpile medications such as Kayexalate to help minimize morbidity and mortality.
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Patient Resources
This booklet provides information for people on dialysis that can help them prepare for an emergency. It includes information on go-kits, grocery items to stock in a "3-day emergency diet," how to handle being home bound after a disaster, what people can do when they must leave their homes, and what to do if their dialysis facility is closed. Access the Spanish version of this document here: https://www.kcercoalition.com/contentassets/e1a0ac6fedeb4ba190e64de0cd6a9a9c/spanish_cmspreparingforemergencies_508-compliant-_updated-3.2023.pdf
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DaVita shares emergency preparedness information for patients on dialysis to ensure they can receive necessary treatment or lessen the impact of missing a dialysis session.
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The authors note that dialysis patients are particularly vulnerable to disaster and sought to study their levels of preparedness. They found that in general, dialysis patients were not prepared for critical incidents, regardless of demographic characteristics.
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This graphic demonstrates the 3 steps patients need to take to disconnect themselves from their dialysis machine during an emergency.
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The authors conducted a cross-sectional survey of patients who received maintenance hemodialysis before and after the landfall of Hurricane Sandy in 2012, to determine number of missed dialysis sessions after the storm, and assess their preparedness using a checklist from the National Kidney Foundation. They concluded that, “provider- or facility-oriented enhancement of awareness of the disease and preparedness should be a priority.”
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The authors share tips for people with kidney disease to consider in preparation for various types of disasters.
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This booklet provides dialysis patients with information on emergency preparedness and steps they can take to prepare for disasters/ emergencies. It includes template forms for important contact and health information, as well as useful tips related to food and nutrition and transportation.
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This short video, geared towards dialysis patients, provides information on emergency preparedness. It presents three steps dialysis patients can take before disaster strikes: make a plan, gather supplies, and be informed.
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This 10-second (un-narrated) video emphasizes the point that dialysis patients should learn more about alternate treatment options before a storm or other type of critical incident.
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This 10-second (un-narrated) video encourages dialysis patients to ask their provider about receiving treatment before a storm strikes.
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Plans, Tools, and Templates
This ASPR TRACIE TA response includes information from an ASPR TRACIE SME Cadre member on the needs of dialysis patients post-disaster and the requirements for temporary dialysis facilities. It also includes links to relevant ASPR TRACIE Topic Collections for more resources.
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This manual was created to “assist hospital-based and stand-alone dialysis facilities to cope with disasters which may affect dialysis operations and severely impact patients’ access to care. It includes guidance for each phase of emergency management—mitigation, preparedness, response, and recovery.
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This emergency operations plan manual includes templates that can be tailored to the needs of dialysis and end stage renal disease facilities.
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DaVita shares emergency preparedness information for patients on dialysis to ensure they can receive necessary treatment or lessen the impact of missing a dialysis session.
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This 1-page checklist may be used to triage hemodialysis and peritoneal dialysis patients at an emergency shelter.
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This is an emergency management plan template for chronic dialysis facilities in Kansas that may be adapted for other facilities. (Note that this template was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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This webpage includes information to assist health professionals with preparing for dialysis facility emergency response. Links to tabletop exercise templates for hurricanes and earthquakes are included.
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This fact sheet includes information for patients, providers, and emergency responders to help them prepare to meet the needs of dialysis patients during emergencies and disasters.
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This resource includes a checklist to support emergency plan development, as well as templates for communicating with local emergency management, and power and water suppliers, in advance of an emergency.
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This webpage includes links to toolkits and other resources designed to help certain types of healthcare facilities better understand the Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule. There is both a PDF (toolkit) and Word version (workbook) for each facility type, and the relevant CMS rules for each facility type are included. Each toolkit includes sample templates and planning worksheets that can help facilities develop compliant plans, policies, and procedures.
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End Stage Renal Disease Networks
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Large Dialysis Organizations
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Small Dialysis Organizations (limited list)
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Agencies and Organizations
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