Dialysis Care in an Emergency: Lessons From Hurricane Harvey

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Staff shortages and lack of medical records surface as problems.
Staff shortages and lack of medical records surface as problems.

Preparedness for the care of dialysis patients during disasters paid off in late August when Hurricane Harvey slammed into the Middle Texas Coast, dropping up to 51.88 inches of rain in places and turning parts of Houston, a city of around 2.4 million people, into lakes. Patients needing dialysis were able to get it, although not necessarily at their usual dialysis center. Still, the monster storm showed that delivery of care could be improved.

“Our emergency preparedness program is always a work in progress,” Stephen Z. Fadem, MD, a nephrologist and medical director of DaVita Medical Center in Houston, a facility with 72 dialyzing stations, told Renal & Urology News. “With this flood, we learned that we didn't have enough staff in the dialysis unit area to dialyze all the patients who were coming in.”

His center, one of approximately 150 DaVita dialysis centers in the path of the storm, was not flooded and did not suffer a power outage. Dr Fadem and his team dialyzed more than 500 patients over 3 days during the hurricane, including 192 patients new to the center because they could not get to the one where they usually dialyze. “We actually had staff sleeping in the dialysis center,” he said. In the future, his center plans to rent a block of rooms at a nearby hotel the next time a major hurricane threatens the Houston area, said Dr Fadem, a clinical professor of medicine at Baylor College of Medicine in Houston.

Doctors were texting one another with regard to which roads were open or closed, he related, and this provided guidance for going to and from the DaVita Medical Center. “I took routes to work that I never traveled before,” he said.

Another problem he encountered was absence of medical records. Even though patients are supposed to bring their records with them in emergency situations such as hurricanes, flooding made it difficult to access them, he said. “One of the biggest delays we had was that we didn't have any information about a patient,” said Dr Fadem, who added that he spent a lot of time on the telephone trying to reach patients' doctors and others who could provide clinical information.

He said this experience makes a case for all dialysis centers in the city to cooperate in establishing an emergency online database that contains each patient's clinical information needed to provide dialysis.

Dr Fadem triaged patients based on their condition. If they had signs of fluid overload or hyperkalemia, they would be dialyzed immediately. Other patients were triaged on a first-come-first-served basis as long as they were healthy.

Hurricane Harvey also exposed problems in getting patients to dialysis centers. “We do need to figure out a better transportation system for patients,” Dr Fadem said.

Individuals rescued from flooded areas were brought to higher ground, where a bus picked them up and took them to a shelter, or a family member took them to a different place to live. His center had an arrangement with shelters and hospitals whereby patients who needed dialysis were brought to the center. “So we had a way of dialyzing patients from all over the city who needed care and weren't able to get it because their own dialysis units were flooded, or their houses were flooded and they were rescued.” However, many individuals unaffected by flooding, and thus not in need of rescue, had difficulty getting to a dialysis center because they do not drive or have a car and the public transportation system had shut down because of severe flooding.

Dr Fadem praised DaVita—which serves 6700 dialysis patients in Houston—for providing medical supplies and support, including a “pop-up” pharmacy. “DaVita was outstanding in providing a pharmacy so that we had medications for these patients from the get-go,” he said. DaVita also provided a gasoline truck to provide fuel for staff vehicles.

Nephrologist Sarah Shearer, MD, of Renal Specialists of Houston and medical director for Fresenius Kidney Care Museum District in Houston, said her center, which has 24 dialyzing stations, was unaffected by flooding and did not lose power. Emergency preparations made long before the hurricane hit worked largely as intended. “We've learned the hard way from previous storms and hurricanes,” Dr Shearer said.

Many patients came to the center with their emergency dialysis packets, “which made all the difference in the world,” she said. The packet contains important clinical information such as dialysis prescription, laboratory test results, hepatitis status, and disaster diet plan.

Patients arrived at her center by bus from the George R. Brown convention center and the Houston police and fire departments. In addition to providing a caravan of boats to transport patients, Fresenius brought in emergency staff to handle the added patient load.

Fresenius has 51 dialysis clinics—including 4 home dialysis clinics—in the Houston area serving 3082 patients.

Dr Shearer said she and her team started triaging on the basis of 2-3 hour treatments. “Our priority was making sure the [dialysis] chair was always full.” She gave priority to patients referred by a hospital based on objective criteria (such as the presence of hyperkalemia or congestion on an x-ray) suggesting the patients should receive dialysis “sooner rather than later.” The vast majority of patients, however, came to the center without that assessment. For these patients, she conducted a physical examination, measured interdialytic weight gain, and otherwise evaluated patients' health status. Patients with the worse signs and symptoms—such as those with worrisome interdialytic weight gain—received priority.

Hurricane Harvey differed from other hurricanes that have hit the Houston area, she related. Weather forecasters were uncertain when the hurricane was going to hit, and when it did, it hovered over the Houston area for an unexpectedly long period. “We did at least know the potential of this hurricane striking us directly,” Dr Shearer said.

In addition, the timing of the storm's landfall was bad from a dialysis care standpoint. The hurricane struck on a weekend, when dialysis patients normally would have their longest time between treatments. “We need to talk to God before the next one,” Dr Shearer said.

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