Episode 15: The Impact of Inpatient Services During the COVID-19 Pandemic with Gina Sharkey and Tana Waack 
Throughout the COVID-19 pandemic, the work of dialysis nurses and technicians working inside hospitals and other major care facilities has been critical as a significant percentage of COVID-19 patients battle acute kidney injury. Gina Sharkey and Tana Waack, both registered nurses who work closely together as Vice Presidents of Inpatient Services at FMCNA, join Field Notes to provide a behind-the-scenes look at the front-lines inside some of the hospitals hit hardest by COVID-19.

Brad Puffer: Welcome, everybody, to this episode of Field Notes. I'm Brad Puffer on the Medical Office Communications Team at Fresenius Medical Care North America and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

As you all know, the work of our frontline care teams extends from our clinics to the home. But our nurses and technicians also work inside hospitals and other major care facilities. Given the pandemic, that work has become even more critical, as a significant percentage of COVID-19 patients suffer acute kidney injury and require dialysis.

Our Inpatient Services Team, also called IPS, include specially trained nurses who are experts in dialysis. They must be ready to meet any situation. And that includes being able to change between treatment modalities and respond to any new challenge.

So why do hospitals and nephrologists need a special inpatient dialysis team at the ready? Here to discuss this with us today are Tana Waack and Gina Sharkey. Both are registered nurses with deep experience in acute care settings. And both work closely together as vice presidents of Inpatient Services at Fresenius Kidney Care. Tana, welcome to Field Notes.

Tana Waack: Thank you so much.

Brad Puffer: And Gina, welcome to Field Notes.

Gina Sharkey: Thank you, Brad. Glad to be here.

Brad Puffer: Well, Gina, let's start with you. Can you explain what we're exactly talking about when it comes to inpatient services? And how does working in a hospital differ from our teams that work in an outpatient dialysis facility or supporting our home patients?

Gina Sharkey:  Sure. So our inpatient teams are a highly skilled team of professionals. And they are proficient and provide care in multiple modalities of extracorporeal therapy. So our Inpatient Services Team takes care of hospitalized patients and includes modalities such as hemodialysis; peritoneal dialysis; extended hemo, commonly referred to as CRRT, SLED, SCUF; and apheresis therapies.

And so this is quite different, Brad, than are more structured in-center and home style programs. Our teams respond and report to their hospitals and care for the needs of those patients and those hospital partners. And they're caring for patients emergently.

These are high-acuity patients that have been hospitalized. So regardless of diagnosis or condition, our teams have the adaptability to care for patients of all types, regardless of where they reside in the hospital setting. And that's what really sets them apart.

Brad Puffer: And what are those range of situations that you encounter in a hospital? I can imagine what you discuss can be both really challenging, but also rewarding.

Gina Sharkey: Absolutely. And as I was mentioning earlier, these are hospitalized patients. So that typically comes with some level of acuity from the highest-- your intensive care unit, your OR, your emergency room-- to just your traditional hospitalized patient that may be there for a procedure or has some illness that has brought them into the hospital setting. And so our teams come equipped to care for that patient, regardless of what brought them into the hospital.

So in an emergent sort of situation, such as an overdose or an acute kidney injury, versus existing dialysis patient that may be in fluid overload, or as I mentioned, coming in for some sort of routine procedure, they really manage that whole trajectory of patient condition and clinical presentation.

Brad Puffer: Well, Tana, when you hear Gina talk about the work of these teams, there's certainly a lot of passion and history there. Is that something you find with our teams in the field? What is required of these nurses who work on our IPS teams?

Tana Waack: Passion is a really great word to actually describe it, Brad. Dialysis is not an easy field to work in, regardless of if you're in-center or inpatient. But I think on the inpatient side, working in the inpatient setting adds additional complexities to what these nurses and technicians face on a daily basis.

There's a running joke in dialysis that if you're an acute nurse, you stay in that acute setting. And if you're not, then you go work in a more stable and scheduled environment, as Gina mentioned previously, in the in center or the home side.

So usually when you come into the acute setting, our staff will know within the first several months if this is something for them. The days can be long. The call adds on to that.

They don't always know when they're going to go home. So sometimes on days that they're scheduled to work, it's really hard for them to plan, to have a certain time dinner at home with the family, or attend an event at their child's school, or something like that. So they definitely have to have a certain level of commitment and dedication to be able to put in that time of energy into what it is that they do on a daily basis.

Brad Puffer: And Tana, I understand that our staff could actually work in multiple facilities and multiple locations as well, right?

Tana Waack: Yeah, that is not unusual at all in our particular field. So we have nurses in certain metropolitan areas that may work in three, or four, or five different hospitals. They'll be credentialed at all of them.

So whenever the need arises and one hospital's experiencing a higher census than another one, whoever's managing the scheduling for that day has the ability to move these nurses around so that all of the patient needs are taken care of as well as utilizing our staff to the best of our ability.

Brad Puffer: Well, following up on that, Gina, what makes our IPS teams stand out as such important assets to these hospitals and care facilities?

Gina Sharkey: Our IPS teams, they are the leaders and the experts in the industry. They are the hospital's partner. We truly are their partner in renal care.

They assist not only in managing, but they oversee triaging, as Tana mentioned, scheduling. They maintain those quality expectations that we have. They make sure that we have regulatory compliance with every treatment.

Care coordination of these patients-- we know our renal population, coordinating their care is one of the most important things we can do, making sure that we're sharing information back to their in-center programs when appropriate. Our team is there. And they often recognize the clinical presentations that might be overlooked by those without that level of expertise.

And that's really where the hospitals lean on us. They count on us to make sure that that patient's care is managed and that we're a part of their team, ensuring the best outcome for the patient.

Brad Puffer: And I'm sure that's been especially true this year. COVID-19 has certainly hit all of us hard. And all of our teams across all the divisions are really unsung heroes. But how has it changed the work for the IPS team, Gina?

Gina Sharkey: So that has really been striking. Tana and I were actually just talking the other day how our inpatient team serves as the barometer for what's happening locally. We know with COVID, we see hospitalizations go up. And we know the impact that that's going to have for our in-center and our home programs as patients become sick, as we see the incidence of acute kidney injury increase with these patients.

So our teams, from the very beginning, they were on the front lines countless hours. And I'll repeat "countless hours" a day, navigating the unknown. I mean, when we look back just a few months ago, we were dealing with issues like rationing PPE, understanding the impact of AKI in these COVID patients, managing supplies and equipment, wanting to ensure that we were controlling transmission of COVID-19, bringing new modalities in.

With that surge of these patients and with the surge of acute kidney injury with these patients, we needed to bring in some additional modalities to support care within the hospital. And so, Brad, really the list goes on and on and on. And it's incredible to think when we look back to the first quarter of this year and where we are today just how much this has impacted the work that our teams do every day.

Brad Puffer: Well, turning to Tana, is there a personal anecdote that perhaps you could share regarding a patient or perhaps a team member who really went above and beyond during this difficult time?

Tana Waack: Yeah, absolutely, we've had several, but I think one of the first ones that came to light that we were made aware of was pretty striking. We had a nurse in West Virginia who was hearing about the difficulties that some of our staff were going through in New Jersey and New York. And she decided to sign up and answered the plea for help, because she really felt that dialysis is a very specialized skill set. So she had something to provide that not everybody can.

And she signed up for three weeks in New Jersey. She helped there. And then by that time, Chicago had joined one of the hotspot lists. And so she went on to Chicago for another couple of weeks after that, staying in touch with her family, obviously. And that was hard for her but she also felt very rewarded in what she did.

And I can tell you that from the teams on the field in New York, New Jersey, Chicago that got that kind of support from other people, from other areas, was unprecedented. And they were just so, so thankful and have never really fully been able to express those thanks but it's people like her that we had across the country volunteering to go and help.

They saw the need. They answered the call. And they made some sacrifices in order to make sure that they were there for their fellow staff members and also for their patients.

We had to make some changes with our education and our training processes. Our educators for our inpatient staff were not doing some of their usual duties. And so they deployed themselves as a team to New York and New Jersey and Chicago and various places with our local teams in those areas. And that was really striking to see as well, to have them come out of what their usual day-to-day job is in training and education and come out and actually perform treatment side-by-side with the teams.

Brad Puffer: Well, Gina, we've seen the studies that show COVID-19 positive patients are at greater risk for acute kidney injury. And your teams have dealt with this right on the front lines, as we've been discussing. What has it been like for your teams to help patients who for the first time in their lives are suddenly dealing with dialysis?

Gina Sharkey:  Of all the things, this is one of the things that I'm most grateful for on behalf of so many of those AKI patients that were out there-- I mean, probably terrified enough with the COVID diagnosis in and of itself and then now up against the fact that they have acute kidney injury and need to have dialysis for the very first time. And so I think really the blessing there is that our teams have that expertise and knowledge base.

Our nurses and our techs have the ability to help these patients understand the need for dialysis. Why is this happening to me? Why do I need to have this? What does the process look like?

And they really have the ability-- our inpatient team really has the ability to answer questions with confidence based on that expertise. And I know this brought comfort to many patients faced with AKI. And I think that's exactly what makes our team so special. It gave them the ability to push through these challenges, because they understood truly just how important they were to those patients and just how important it was for their family member, for that patient laying there in the bed, to have somebody with that knowledge by their side. And I think that is one of the greatest gifts that our team brought those patients.

Brad Puffer: Well, as you've hinted, it seems really our nurses are cross-trained to be ready for any situation. How do these nurses and these teams keep up to speed with all the latest equipment and all the latest technology?

Gina Sharkey: We are ever grateful. Tana mentioned our education coordinators that are out there and our program managers and our directors of operation. We've got just such a team of dedicated educators and support from the local clinic managers, the program managers at those hospitals, that really ensure that our staff are up to date, they're current, they're competent.

We're fortunate enough to really have the ability to pair folks together, preceptorships and really ensure that our teams are comfortable with the latest technology and the latest modalities. And we saw that a lot through COVID, through the pandemic this year, with different devices and filters that were put on the market. And every single time, Brad, our team, our education team, our clinical team, they rose to the challenge to make sure that the staff and the patients had the most up-to-date modality of care in their treatment.

Brad Puffer: Well, turning to Tana, we have certainly seen great innovations over the last decade and some new technology that's making dialysis even better for patients. Despite all that new technology, it sounds like you believe the team is equally, if not more, important. Why would you say that?

Tana Waack: It's really the skill set of the nurses and the technicians that are working with this equipment and technology to get the best outcome for the patient. Machines can't manipulate themselves in order to provide the desired outcome. It's the training and the knowledge that we arm our staff with that allow them to get the most out of the machine and the technology. And I think that it's their training, it's their knowledge, it's their skill set that allow them to maximize what each one of these pieces of equipment and technology can provide.

Brad Puffer: And Gina, I want to come to you to wrap things up-- just any last words on why the role of an acute or inpatient dialysis nurse is so special. What stands out to you from your years of experience?

Gina Sharkey: So this is the easiest question that you've given me today, Brad. So what stands out to me and what makes the inpatient dialysis nurse so special is their commitment. And I think Tana would probably answer the same.

They are out there 24 hours a day, seven days a week, 365 days a year, taking care of any and all patients that come through those hospital doors. It doesn't matter if it's a holiday, doesn't matter if it's a weekend, doesn't matter if it's a snowstorm, or a hurricane. They make their way, and they get to those patients. And they provide whatever care those patients need. And I really think that's what really sets them apart.

Brad Puffer: Well, it's been really great hearing from both of you about our people and the work that they do. We've talked a lot on this podcast about science, about technology. What you've given us is some insight into the people behind the scenes that are really making all of this care possible and some of the challenges we've had to overcome, especially in the last year.

Thank you, everybody, for joining us with this behind-the-scenes look. And to our audience, we hope you'll come back again. We hope you'll download Field Notes on the Apple Store or Google Play, or listen right here at fmcna.com where you can also find our "Annual Medical Report" and other featured articles.

Come back next time. We'll have many more topics to discuss in the weeks ahead. Until next time, I'm Brad Puffer. And you've been listening to Field Notes by Fresenius Medical Care.