Brad Puffer: Welcome, everyone, to this episode of Field Notes. I'm Brad Puffer, on the medical office communications team and Fresenius Medical Care North America, and your host for this discussion today. Here, we interview the experts, researchers, physicians, and caregivers who bring experience, compassionate insight into the work we do every day.

The COVID-19 pandemic has certainly impacted all of us. But for patients living with a chronic disease, COVID-19 does not only impact daily routines, but creates a higher risk for complications and a greater threat to their health.

So how have we ensured access to safe, high quality, life-sustaining care to hundreds of thousands of patients living with kidney failure during a global pandemic? As we will discuss today, it's about preparedness, clear communication, consistent practices and an ability to quickly adapt with new policies. And it's about dedicated employees who give 100% and more to our mission.

Joining us to discuss our response to the pandemic and the long-term impact on care delivery is Dr. Jeffrey Hymes. Dr. Hymes is the Senior Vice President of Clinical and Scientific Affairs for Fresenius Medical Care in North America and chief medical officer of Fresenius Kidney Care. As one of the leaders of the company's pandemic response, Dr. Hymes was recently invited to present on a similar topic at the American Society of Nephrology's Annual Kidney Week held virtually this year. Dr. Hymes, welcome to Field Notes.

Dr. Jeffrey Hymes: Thank you. Pleasure to be here.

Brad Puffer: Well, Dr. Hymes, before we look back, where would you say we are right now in the effort to protect our patients from COVID-19 and to keep the virus out of our dialysis centers? And what do you see for the months ahead?

Dr. Jeffrey Hymes: So, I think everybody realizes that the course of this pandemic has been characterized by the need for rapid learning and adaptation. We didn't know much about the virus when it was first discovered, and we continue to learn. As a result, our response has taken on a number of facets, which, at this point, I think, have reached a good degree of maturity. Perhaps the most important thing that we are doing and continue to do is the education of our staff in infection control and management of this complicated disorder, and regular communications with them to let them know what's going on in the country, what's going on in the company, and what we are anticipating in the care of our patients.

Brad Puffer: Dr. Hymes, can you tell me why this matters so much for patients with chronic illnesses, especially kidney disease? Why is COVID such a risk to them?

Dr. Jeffrey Hymes: It's been observed, and this was observed relatively early, that the serious cases of COVID, which resulted in hospitalization and mortality, were more common in individuals who had certain risk factors. Things like chronic illness, impaired immune systems, advanced age, and obesity are examples of that. If you look at our population compared to the general population, it should surprise no one that patients with kidney disease, and particularly those on dialysis, are at really increased risk for not only contracting, but having complications from this disease.

Brad Puffer: And that goes right to why our company was so on red alert when we heard about this pandemic initially. I'd like to turn back to last January. As we learned about the pandemic in China, and before it really even reached the US, many were not sure if it would be a global pandemic at that time. But I know we were already preparing. Set the scene for us at that point.

Dr. Jeffrey Hymes: Fresenius is an International Company. And we have dialysis clinics in Europe and in Asia. And as those locations began to experience the pandemic, we were already learning a lot about it. We were learning something about spread, we were learning something about diagnosis, and we were learning something about the vulnerability of our patients.

The awareness of COVID within the United States really didn't begin until about January. And there were few real sentinel events that caught our attention. One was nationally recognized, and that was when a dialysis patient in Washington state passed away from COVID. And that individual was a resident of a nursing home. That told us that the disease was not only potentially fatal to our patients, but also was in the country.

The other thing that we realized as we began to make preparations for this was that the communities were really going to be stressed in terms of their capability of responding to our needs. So, while initially we thought that we might send patients to the hospital for evaluation, they let us know in no uncertain terms that they were anticipating being overwhelmed. We know that PPE was in short supply and we learned that testing was going to be challenging.

Brad Puffer: Our experience with other viruses, such as H1N1 or even the annual flu, really helped us think about our strategy and prepare. This wasn't the first time around for us.

Dr. Jeffrey Hymes: Fresenius, as an International Company, but also in North America, has a very vigorous and competent emergency response organization. The origin of that organization, I would say, really began back in 2009 with the H1N1. It was at that time that the company convened panels of experts, both scientific and medical, but also technical and operational, to decide how we were going to prepare for that. And it included things like stockpiling PPE, putting antiviral agents like Tami-flu in store, and creating policies for isolation.

Over the past several years, the emergency response has really matured and mostly has been dealing with things like hurricanes and flooding. We had not really had another pandemic scare until Ebola. Then again, we were lucky. We dodged that bullet, part because of the aggressive infection control measures were taken around the world. But again, it was another opportunity for us to test our resources. So, I think, both operationally and culturally, we were in the right frame of mind to respond to this kind of threat.

Brad Puffer: And when I look back, I look at just how early some steps were being taken. I mean, communication in January about what was happening, the spread, preparedness, and then in February, even the starting of screening of patients, to protective equipment being instituted in March. When you look back to that period what are the three or four most significant steps you believe we took early on that made a major difference?

Dr. Jeffrey Hymes: I think the education, both of our medical staff and our clinical staff, was hugely important, in part to make sure they understood the challenge that we were facing, but also to give them some confidence that we were going to be prepared to deal with it. We re-enforced all of our infection control training. And as part of our emergency preparedness efforts, we do things called tabletop exercises for the pandemic emergency.

I think everybody was shocked and concerned when it became apparent that individuals infected with COVID could spread the disease at a time where they were either asymptomatic or minimally symptomatic. And at that point, we looked at the CDC recommendations and how they characterized the risk of exposure, and it was obvious to us that if an individual who was potentially infected was wearing a surgical mask, and the person caring for that patient was wearing appropriate PPE, including a mask and goggles or face shield, that the risk of that exposure was dramatically reduced.

And so, in March, we decided that we would mandate masking of all of our patients and anybody who entered the clinic. And, of course, we would enforce our PPE policy, which included facial protection, gloves, gowns, and masks for our staff. We had a little bit of a stockpile that allowed us to be prepared. In fact, we ended up sharing, I think, 10,000 masks or so to another dialysis provider out of that stockpile.

But the leadership of the company decided that we'd make the right medical decision, and then deal with logistic challenge afterwards. And that, I think, turned out to be the right decision.

Brad Puffer: I was really fascinated about how we collaborated with other dialysis providers to create these separate centers and shifts. Take us back to that decision, because it seems, to me, quite unusual that major competitors would be teaming up.

Dr. Jeffrey Hymes: As you can imagine, most providers of dialysis have clinics that are fairly, thoroughly utilized. There is not a lot of empty space in dialysis clinics. The other feature that people need to understand about dialysis clinics is they're not like hospitals. They tend to be open spaces where individuals sit in chairs to get their treatment, but they don't sit in individual rooms. And so, isolation really becomes a challenge.

And, of course, to state another obvious fact, our patients need to come for treatment. So, we can't tell them to stay home until their symptoms pass or stay home till 10 or 14 days have gone by. So, the industry in general began to look at its ability to provide isolation. And the cooperation of the level of the CEOs of the various dialysis companies, as well as the chief medical officers of the various companies, was really very rapid.

We came together in an organization to pool our community resources and to identify places where, if one provider didn't have capacity to isolate patients infected or potentially infected, they could send those patients to the competitor. The doctors who attended those patients would be given privileges, so they could continue to provide continuity of care, and that the priority was to protect the population. So that was, I think, as you point out, a very novel example of industry cooperation.

Brad Puffer: How big a problem was just knowing who's infected? And how did we tackle that testing issue?

So, testing is a particularly fraught problem, and it was quite a challenging one at the beginning of the pandemic. Shortage of testing facilities, the shortage of testing supplies, and the challenge of getting samples to the testing facilities. As we went out into the community, we initially thought that perhaps, through local resources, we could send our patients to hospitals or to testing centers that the government would have set up. But we were very quickly disabused of that possibility, again, because of the challenges they were facing in terms of capacity.

So we, through a very vigorous effort from our leaders in the laboratory department, and through our spectral laboratory, which was able to at least handle the transportation and the delivery of specimens, and, of course, our logistics people, the same folks who-- we located a laboratory provider who did have the capacity, worked with that provider to make kits. We set up outside testing center and tents, and then transported those samples to the labs. From the time that a test arrived at the laboratory, and usually they were overnighted from the testing location, we would get a result usually within 24 to 48 hours. And over the course of this experience, we've done about 55,000 PCR tests.

Brad Puffer: When you talk about all these different procedures we put in place, and all the steps we took to protect both our patients and employees, it strikes me that none of this would have been possible without those employees. It seems like part of our strategy was not just all of these new policies and procedures, which were really helpful, but also making sure our employees were taken care of.

Dr. Jeffrey Hymes: Yeah. You talk about heroes. Our employees, going into situations both in our in-center, that is our outpatient facilities, as well as the 1,000 or so hospitals where we provide dialysis, that they would walk into these circumstances clearly at some risk to their own health is, I think, quite remarkable. We could do nothing to take care of the patients if we didn't take care of our staff. Anything we could do to make sure that the staff felt comfortable that they and their families were taken care of, and they could then, safely turn their attention to our patients.

We quickly realized that, given the demographics of our workforce, child care and elder care were critically important. And so, we provided daily stipends for childcare and for elder care. We also recognized some of the additional risk in the extra stress that they were experiencing by a temporary increase in compensation, and some additional hazard pay for people who were in the clinics where definitively infected patients were located.

Brad Puffer: I imagine that made a big difference to keep that continuity of care going during a really, really challenging time. One other thing I wanted to touch upon was all the patients who were already at home, perhaps in a good spot where they didn't have to leave their home, but doing home dialysis. And it strikes me the amount of increase in telehealth, both for in center and for home dialysis patients, really helped ensure those patients were protected. How important was that telehealth initiative in your mind?

Dr. Jeffrey Hymes: As it turns out, when you have a pandemic like this, being able to dialyze at home reduces a need to go out and be transported and be in contact with other people. So certainly, that's an advantage. But we also recognize that maintaining the kind of personal interactions that we expect in our centers, and also at home, was going to require a technology that would allow doctors, nurses, social workers, dietitians to be present without unnecessarily exposing themselves or the patients.

And so, we very quickly stood up a platform of telehealth. And we deployed computers and tablets around the company so that patients could make appointments while they were at the treatment center to speak with their doctors or speak to the dietitians and social workers. And our staff would assist them in making that connection, then give them the tablet or the computer, let them have that interaction. Then the equipment would be cleaned and returned for the next patient.

This was enormously successful and very popular. The last figure I heard, which may already be out of date, we've done over half a million telemedicine visits to accommodate both home patients and in-center patients.

Brad Puffer: All of these steps that we've been discussing, how effective in the end were they? We always talk about flattening the curve. But for our own patients, were we successful?

Dr. Jeffrey Hymes: The answer unequivocally is yes. Now, remember, our patients don't live in the dialysis units. They're with us a total of 12 or 15 hours a week. They are subject to the same kind of risks that any of us are subject to if we're not careful about exposures. As much as we could do to protect patients when they're with us, we tried to educate them about taking care at home as well.

But I will tell you that you never know when you're in the middle of this kind of storm whether what you're doing is absolutely correct. But we had an unfortunate but unique opportunity in New York. Because if you'll remember, New York was hit very, very hard early on. And it really tested our capabilities, both in isolation, PPE, safe transportation of patients, laboratory testing. All of those things came together very acutely in New York.

We're fortunate to have a special set of clinics in New York, or the Renal Research Institute, that specifically does renal-related investigations. And they did a number of things that, I think, were reassuring as far as our ability to control infection. One was that they examined the patterns of infection associated with interactions within the clinic. In other words, where do the patients sit in the chair? Where was a patient who had an infection sitting? Where was the staff? Who was the staff treating? If the staff had an infection, who did they take care of? And that analysis found no evidence of transmission from those kind of contacts within our clinics, which was very reassuring.

The second piece of evidence is a little more complicated, and it's epidemiological. But as you know from watching the reports of the waxing and waning of this disease that we refer to a replication factor, that is how many people get infected from a person who is infected with the disease. And a figure of one is sort of a sign that you've passed the crisis.

As we tracked our cases, compared with the general population, and looked at the rate of rise of cases, and the rate at which they abated, and the rate at which we achieved the level of transmission that would indicate control, our rate of increase was slower. Our rate of decline was faster. And our move to that low r naught value was faster than what was observed either in the New York community, and then secondarily, in the United States itself.

But we continue to test and examine what we're doing to make sure that the efforts are necessary and that the efforts are effective. And I'm reassured by that data which the Renal Research Institute provided.

Brad Puffer: Well, now, as we look to the future, Dr. Hymes, obviously we're all waiting to see if a vaccine comes about that could be very helpful to our patients. But I also want to think about some of the larger trends that might affect dialysis care forever. You touched upon home dialysis, for example. How do you think COVID-19 has impacted the way we care for patients? And will some of those trends stay?

Dr. Jeffrey Hymes: This just becomes another argument in favor of home dialysis. The telemedicine efforts that we're doing had already started, to some extent, although it's tightly regulated by the Centers for Medicare/Medicaid that dictate the rules of how we do dialysis. I think the great success of that technology during the pandemic is going to rapidly increase the acceptance of telemedicine, hopefully from a legislative or regulatory perspective, expand our ability to use the technology, and also to expand the acceptance of it by patients and physicians.

Brad Puffer: It's been really great discussing this with you, Dr. Hymes, and getting a behind-the-scenes look at our pandemic response, which, unfortunately, is not over yet. Thank you.

Dr. Jeffrey Hymes: My pleasure.

Brad Puffer: And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play, or right here in FMCNA.COM, where you can also find our annual medical report and other featured articles. We hope you'll come back and join us as we have 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. Take care, everyone.