Journal Pre-proof

Telemedicine for Pediatric Nephrology: Perspectives on COVID-19, Future Practices,

and Workflow Changes

Rupesh Raina, Nikhil Nair, Aditya Sharma, Ronith Chakraborty, Sarah Rush

PII: S2590-0595(21)00063-7
DOI: https://doi.org/10.1016/j.xkme.2021.01.007
Reference: XKME 269

To appear in: Kidney Medicine

Received Date: 14 October 2020

Accepted Date: 18 January 2021

Please cite this article as: Raina R, Nair N, Sharma A, Chakraborty R, Rush S, Telemedicine for
Pediatric Nephrology: Perspectives on COVID-19, Future Practices, and Workflow Changes, Kidney
Medicine (2021), doi: https://doi.org/10.1016/j.xkme.2021.01.007.

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© 2021 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.
Telemedicine for Pediatric Nephrology: Perspectives on COVID-19, Future

Practices, and Workflow Changes

*Rupesh Raina1,2+, *Nikhil Nair3, Aditya Sharma4 Ronith Chakraborty5and Sarah Rush 5

Complete author and article information provided before references.

Abstract:

While the use of telemedicine in rural areas has increased steadily over the years,

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its use was rapidly implemented during the onset of the COVID-19 crisis. Due to this

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rapid implementation, there is a lack of standardized workflows to assess and treat for

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various nephrotic conditions, symptoms, treatment modalities and transition processes in

the pediatric population. In order to provide a foundation/suggestion for future

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standardized workflows, the authors of this paper have developed standardized
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workflows via the Delphi method. These workflows were informed based on results from
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cross sectional surveys directed to patients and providers. The majority of patients and
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providers were satisfied, 87% and 71% respectively, with their telemedicine visits.

Common issues that were raised with the use of telemedicine included difficulty in
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procuring physical laboratory results and a lack of personal warmth during telemedicine

visits. The workflows created based on these suggestions will both enhance safety in

treating patients and allow for the best possible care.

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Introduction

The swift rise of telemedicine in the age of COVID-19 has had large implications

for the current and future practice of medicine. While the growth of telemedicine has

been slow over the past few years, the sudden onset of the COVID-19 pandemic has led

to the rapid growth of telemedicine. Not only can telemedicine be used as a direct virtual

contact between the physician and the patient, known as the tele-visit, but it can also be

used to triage patients with mid-level provider virtual visits through the use of “tele-

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supervision” (1). Since much of the care delivered by pediatric nephrology is based on

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laboratory results, many of the in-person visits can be conducted through telemedicine.
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Although the physical examination, an important part of each visit, can not be done with
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telemedicine, recent studies have shown that the use of telemedicine is associated with
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positive outcomes as outlined in Table 1. However, deciding when a patient is an

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appropriate candidate for a telemedicine visit and how to evaluate and treat via

telemedicine have not yet been standardized in pediatric nephrology. Therefore, we

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discuss the benefits and drawbacks of telemedicine, as well as perspectives on the

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standardization of workflows for common pediatric nephrology pathologies.

Methods

The literature search, article review, data extraction and results were completed

by the authors, who submitted their results to the workgroup for discussion. All

individuals were responsible for reviewing and proposing recommendations for the

telemedicine workflows. Disagreements between members were resolved by quantifying

votes using the RAND Corporation/University of California Los Angeles (UCLA)

appropriateness method and subsequently calculating a disagreement index (2,3). The

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modified Delphi method was used to establish the strength of each recommendation.

Delphi Method panelists were selected based on their skills and previously displayed

expertise in different areas of pediatric nephrology. The Delphi Method is an iterative

method of determining consensus toward clinical problems. An initial list of problems

were identified and multiple rounds of voting and discussion took place both over email

and via online meetings until agreements were reached. The panel did not grade the

evidence, but instead used them as part of a suggested guideline, as in pediatric literature

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there are very limited RCTs to support the strength of gradation. The

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PubMed/MEDLINE, EMBASE and Cochrane databases were searched to identify
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publications relevant to telemedicine and nephrology in the pediatric population.
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For the survey we characterized the telemedicine experiences by patients and
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providers in a cross-sectional fashion. The physician survey was created by a team of

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pediatric nephrologists and intensivists from the delphi panel. The survey was pilot tested

with 10 pediatric nephrologists at Akron Children’s hospital. Pediatric nephrologists were

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approached electronically through the pedneph and the pcrrt list servers. The physician
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survey had 17 questions with both open-ended and closed-ended responses on a Likert

scale. The survey collected information related to the experiences of telemedicine by both

patients and providers and was gathered between February 28th, 2020 to June 30th, 2020.

The patients’ responses on telemedicine clinical services were collected in the

United States. This assessment was sporadic and not center-based, with data available

from various surveys that were either hospital or institution based, including satisfaction

surveys from Healthgrades and HCAHPS (Hospital Consumer Assessment of Healthcare

Providers and Systems). The patient questionnaire was collected from March 30th, 2020

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to June 30th, 2020. These reports were anonymous, voluntary, and not compensated.

Patients were given the survey by the authors of this manuscript along with help from

providers who were approached to fill out the physician questionnaire. Consent to publish

the de-identified findings was obtained with the completion of the survey through an

informed statement at the beginning and conclusion of the survey, gathering the consent

of the parent/guardian in situations where necessary.

Data was collected and underlying components were identified using principal

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components analysis. Questions that measured the same concepts were loaded onto the

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same factors. Factor loadings range from -1.0 to 1.0 with factors being grouped together
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when they are ±0.60 or higher. Internal consistency of questions loading onto the same
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factors were checked by the Cronbach’s Alpha (CA) test, with values of 0.60 to 0.70
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being acceptable to the research group. The results of the principal components analysis
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found that Questions 7, 11, 14, 16, and 17 were loaded onto the same factor that was

determined to represent practice pattern in our cohort. The Cronbach’s Alpha for
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questions representing personal commitment to practice pattern and geographical location

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was 0.91, indicating excellent internal consistency in the responses. Data was analyzed

and gathered among the different partner institutions and all results were analyzed

anonymously for the purpose of the article.

Fr om Bedside to Website: The change in par adigm of the patient visit

Pediatric nephrology consultations are largely based on laboratory assessment,

with patient interaction centered around disease education and explanation of treatment

choices. Thus, much of what transpires in an in-person interaction can be translated to a

video interaction (4). Even prior to the onset of the COVID-19 pandemic, it had been

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shown that the use of telemedicine is associated with decreased rates of hospital

admissions, greater patient follow-up, and increased patient satisfaction when compared

to the traditional in-person visit. In a randomized controlled trial, Gallar et al. showed a

significantly lower rate of hospitalization among patients using telemedicine compared to

traditional in-person services (4). Furthermore, Reddy & Aronoff reported a 44%

reduction in missed appointments when using telemedicine services versus in-person

consultations (5). As such, telemedicine has proven to be a developing alternative to in-

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person visits. In the field of pediatric nephrology, the traditional in-person visit often

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includes establishing patient rapport, meeting with families, discussing laboratory results
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and prognosis, much of which can be completed through the use of telemedicine, with the
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exception of the physical exam.
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During a telemedicine visit, providers need to learn to remain “present”. If the

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provider and patient are together in a room and the provider happens to look away or

move a short distance away, the patient will generally still have a sense that the provider
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is “present” (6). However, when the clinician can only be seen on the monitor and he or
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she looks away, the patient may feel like the provider is no longer “present.” To avoid

this, it is particularly important to be sure to review the patient’s chart before the tele-

visit, instead of doing so while on screen. One way to maintain a presence is to have

proper eye contact. Providers can practice looking at the camera, instead of at the image

of the patient on the screen, so that the patient feels that the clinician is “looking them in

the eyes”. Conveying emotional support over a screen is harder to achieve than in person

(7). Pediatric nephrology consultation often involves delivering difficult information.

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Sitting silently for a few moments with a patient can be helpful if the clinician is sitting in

the same room.

With technology making great leaps and bounds, accessibility to patients via the

virtual world has become a bourgeoning reality. The development of multiple video-

capable applications and technologies has made communication better than ever before.

In response to the COVID-19 pandemic, nephrologists at Mt. Sinai have utilized all

technologies that allow for video communication, including Facetime, Zoom, and

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WhatsApp (8). We recommend the use of these services as they are free to patients and

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are easily accessible to use. In our survey the majority of providers utilized Zoom or

EPIC to conduct their telemedicine visits.

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Perspectives of Providers and Patients During the COVID-19 pandemic
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In order to examine the experiences with telemedicine of both pediatric

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nephrologists and patients, we conducted a survey with 197 pediatric nephrologists and

400 pediatric nephrology patients from February 28th, 2020 to June 30th, 2020. The
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results showed a positive response among both pediatric nephrologists and patients alike.
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The majority of physicians expressed satisfaction with the capabilities of telemedicine

visits, with only 10% expressing dissatisfaction with the clinical aspect of telemedicine

and 4% expressing disappointment with telemedicine overall. In addition, patients

reported their experiences with telemedicine to be as good as if not better than the

traditional in-person visit (Table 2).

Lack of Standardization with Telemedicine: Billing and Workflows

One of the primary limitations posed by telemedicine is the relative lack of billing

coverage from Medicare and private insurance companies throughout the United States.

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Previously, only 20% of states required payment parity between in-person visits and

televisits. However, with the rise of COVID-19, Medicare began providing broader

billing coverage which will extend through the end of the pandemic, allowing for greater

use of telemedicine services. Furthermore, with the 1135 waiver, Medicare allows for

billing coverage for televisits for patients who have been established with their physician

along with new patients. In addition, the Centers for Medicare and Medicaid Services

(CMS) has established codes that should be used for telemedicine visits through

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electronic charting services, phone calls, and digital media consulting (Table 3). While

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this has greatly broadened the coverage and use of telemedicine, the conclusion of the
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pandemic may signify a step back with respect to telemedicine if coverage is not
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continuously present. It is imperative to have standardization of such coverage by
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Medicare and private insurance companies alike in order to further evolve the care of
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pediatric nephrology and other patients alike. The recent Physician Fee Schedule Final

Rule from the CMS, effective January 1st, 2021, finalized the establishment of coding and
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payment schedules for virtual visits on an interim final basis. This has greatly broadened
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the coverage of telehealth, and creates a strong precedent for private insurance companies

to follow. Although payment schedules from the CMS do not typically apply to the

treatment of pediatric patients, private insurance companies that cover pediatric patients

often follow the lead of Medicare. Following the conclusion of the pandemic, it is

imperative that payment schedules, under the lead of the CMS, adapt with the evolution

of medical care in order to advance the treatment of pediatric nephrology and other

patients alike.

Suggested Wor kflows for Telemedicine use in the Futur e for Pediatric Nephr ology

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 While telemedicine has been utilized for many years, a more widespread adoption

of these services has occurred as a result of the COVID-19 pandemic. Given the diverse

nature of hospital systems and insurance coverage, finding a standardized method of

applying telemedicine will pose a challenge in the near term. As both provider and

patient comfort with virtual care increases, delivery will continue to become more refined

and established as a routine component of health care practice. Inclusion of metrics

around quality of telemedicine encounters will also be critical. We have developed

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generalized suggestions and workflows via the Delphi Method that can serve as the

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foundation for standardized telemedicine workflows. We believe that the implementation
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plans we present can serve as guides to assist with standardization of workflows in the
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future practice of pediatric nephrology.
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COVID-19 and the Dialysis Unit

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COVID-19 has significantly changed the dynamics of hospitals around the world.

Particularly in settings that require high levels of patient contact, such as in dialysis units,
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it is of utmost importance to enact preventative measures. Dialysis units can prepare for
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COVID-19 using the Centers for Disease and Prevention’s COVID-19 Outpatient

Dialysis Facility Preparedness Assessment Tool (9). The CDC recommends

implementing processes to appropriately and routinely screen patients for any symptoms

or potential exposures to SARS-CoV-2. Once screened, facilities should ideally place

patients six feet apart, with medically stable patients having the option of waiting in their

vehicles to prevent further contact. Transportation to and from the isolation rooms must

follow strict procedures. This step will ensure that they can be treated in an effective

manner with minimal exposure risk to other patients. Patients who are persons under

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investigation (PUI) or have confirmed SARS-CoV-2 infection should ideally be dialyzed

in a separate, closed off rooms. Ideally, three separate rooms for SARS-CoV-2 positive

patients, PUIs, and patients who show no symptoms but have had contact with persons

with confirmed SARS-CoV-2 should be created. However, if a separate room is not

available, SARS-CoV-2 positive patients and PUIs should be treated away from traffic

flow, such as at an end of row station (9). Adherence to universal source control

measures is crucial to prevent spread among dialysis units and should thus be followed by

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patients and staff alike. Healthcare providers on the dialysis shift must not be changed or

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swapped in order to prevent cross-contamination. All caregivers should have increased
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personal protective equipment when treating patients in isolation or defer dialysis and
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testing to a hospital for testing/treatment (Figure 1).
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Acute Nephrotic Syndrome Workflow

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In regard to an emergent in-patient condition such as acute nephrotic syndrome, it

is important to establish clear lines of communication between the specialist and the local
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healthcare team. Daily video visits should take place that include regular blood pressure
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charting and observation for fever, rash, joint pain, heart disease along with absence of

serologic evidence of streptococcal infection. If the patient shows improvement, then

daily video consults can be reduced in frequency and transferred back to the primary

pediatrician for follow-up. Advanced practioners, Nephrology Nurses, dieticians,

nephrology social workers and providers should communicate with each other on the

progress of their patient to ensure all parties are aware of updates. If the patient shows a

rapidly progressing condition, edema, or accelerated hypertension, then the patient needs

to visit the emergency department and be admitted immediately (Figure 2).

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Glomerular Disease Management

There are four key components when managing glomerular diseases:

immunosuppression, monitoring and diagnosis, supportive care, and in-person visits.

Immunosuppression use needs to be carefully managed. In the case of confirmed or

suspected infection, it is important to cease all medication to avoid an exacerbation of

infection (10). Even without a suspected infection, it is important to consider switching to

short reversible agents. This can allow for easy cessation of medication in case of

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infection. Until the end of the COVID-19 pandemic, providers should avoid

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immunosuppressive therapy for patients who are otherwise stable to avoid any undue
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risk. In the case of clinical trials, however, the potential benefits need to be considered,
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especially regarding promising therapies. Medication should be given as an oral or
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subcutaneous agent at home or in an isolated section of the treatment center (10).

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For diagnosis and monitoring, lab tests should be done outside of a hospital to

limit risk if possible. Biopsies should be restricted to cases where it is absolutely

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necessary. This limits the time patients have to spend in hospitals and reduces their risk
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of infection. Supportive care measures do not need to be altered with ACE inhibitors and

ARBs appropriate for use based on current evidence. For stable patients, all visits should

be conducted electronically. Patients with suspected infection should conduct an initial

telemedicine visit to assess symptoms and triage further treatment (7) (Figur e 3).

Chronic Kidney Disease (CKD) Workflow

The first step for any patient with CKD is to determine their clinical status and the

extent to which treatments can be conducted virtually. Virtual visits are more feasible

with early stage CKD, while in stages 4 or 5 in-person visits may be necessary in order to

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submit and conduct laboratory tests. The health care team, composed provider, advanced

practioners, nurses, dieticians and/or social workers should work together to meet with

both the parent and patient to establish a regular schedule and to train the family on how

to use a given telemedicine service. Once all parties are comfortable with the

telemedicine system, a review of the clinical status and labs should be presented to the

patient and their family, with adolescent children given the opportunity to discuss their

condition with physicians privately. Before concluding the meeting, the healthcare team

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should review recommendations for any lifestyle or medication changes. Patients and

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their families should also be educated on the importance of home blood pressure
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monitoring for early detection of clinical status. Future visits should also be determined
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in accordance with the patient’s current conditions and the risk of their condition
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worsening (Figure 4).

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Urinary Tract Infection (UTI) Algorithm

Physicians should conduct a telemedicine visit with patients for UTI’s if they
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have unexplained fever, vomiting or dysuria. If the patient is under the age of 2, has
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persistent vomiting and a sick appearance after the initial visit, they should be referred to

the Emergency Department. Even if none of those emergent symptoms are present, urine

cultures should be collected. If vesicoureteral reflux, severe lower tract symptoms, or a

high fever with Leukocyturia is present, then empirical oral antibiotics should be

prescribed. If these symptoms are not present, then symptomatic treatment should be

prescribed. In both instances, a follow-up visit should be scheduled within 2 days with

repeat urine cultures taken. If there is no growth in the urine culture, then antibiotic

treatment may be halted. If significant growths are seen, then antibiotic therapy should be

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continued for another 48 hours. Additionally, the antibiotic treatment should be carried

out for 10-14 days with a kidney ultrasound during a follow-up visit 2 weeks later if a

response is noted. If there is no response, then urine cultures should be repeated and

antibiotics should be changed (Figure 5).

Pediatric Transplant Telemedicine Protocol

While the risk of acquiring SARS-CoV-2 from organ donation is low, all organ

donors are required to be screened (10). However, the capability to conduct screenings

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varies according to the transplant center. Any donor or donated organ testing positive for

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SARS-CoV-2 cannot be utilized for transplantation (Figure 6). Patients are asked to not
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travel to high risk areas for at least two weeks before their donations (10). Contact tracing
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and a detailed history for donors are imperative especially if traveled recently. In non-
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emergent situations, these donors are asked to prolong their donation by 14-28 days (10).
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Regardless of where patients are living, those who have undergone transplantation are

presumed to be at a higher risk of SARS-CoV-2 along with other severe diseases. Risk-
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benefit analysis should be done to determine whether a transplant can be postponed to a

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later date (10). Decisions should be made on a case-by-case basis, and concerns should be

shared among the transplant team and patient after carefully asessing the risks and

benefits. All members of the transplant team should assess each patient and consider

using new pandemic-specific consent forms to communicate the increased risk of the

procedure.

Prior to and after a transplant procedure, telemedicine should be conducted

whenever clinically possible. Routine laboratory tests should be deferred and if required,

strict appointments should be kept in order to minimize the risk of the patient being

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exposed to SARS-CoV-2. Any decisions to treat rejection with augmented

immunosuppression need to incorporate the risk of SARS-CoV-2 infection and should be

tailored to each individual patient.

Care of pediatric transplant patients with SARS-CoV-2 must be individualized but

the use of telemedicine enhances the ability of providers to more frequently monitor

patient symptoms and status. For immunosuppressed pediatric transplant patients who

contract SARS-CoV-2, telemedicine may allow those without significant illness to avoid

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hospitalization. Stable pediatric transplant patients may benefit from substitution of a

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telemedicine visit rather than an in person visit for routine care if both their provider and

the parent/patient feels this is reasonable.

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Transition from the pediatric to the adult world
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Given the pandemic, the process of transitioning patients from pediatric to adult
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care can be disrupted and impact the patient’s ability to conduct disease self-
management. Our suggested protocol for transition is derived from the RISE
(Recognition, Insight, Self-reliance and Establish) protocol from the Akron Children’s
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Hospital, which is based on previously stated survey findings and literature review
(Figur e 7) (11). This protocol specifies four main competency areas for patients to
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achieve prior to transition:

1. Recognition of their disease process, reason for transplant, and the healthcare system;
2. Insight into the short- and long-term impact of their disease, therapy, non-adherence,
and emotional needs;
3. Self-r eliance in scheduling and attending appointments, refilling medications, and
identifying urgent/emergent changes to their health on their own;
4. Establish healthy lifestyle choices, life-long adherence to medications and follow-up,
psychosocial skills, and educational/vocational goals.(11)

These 4 competency areas are key to an effective transition. Helping patients

develop self-reliance and establish healthy choices will improve their autonomy, reduce

the emotional burden of their disease and treatment, and minimize disruptions to their

daily life. The focus of the recognition and insight goals is to educate the patient about all

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aspects of their disease. Transition is a process that begins 1-2 months prior to the

transfer date to prepare both family and patients for the shift in responsibilities. In order

to provide similar levels of education, regular telemedicine visits are essential to check in

on the progress of the family and the patient. Regularly scheduled visits allow for

physicians to check patient understanding of their kidney’s health and the processes

required to keep it healthy. Independent questionnaires that assess their understanding of

their health care rights, how to make follow-up appointments, and manage comorbidities

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can be delivered online. Similarly, other members of the health care team such as social

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workers and dieticians can be reached via telemedicine visits to provide information
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about insurance, support systems, and proper nutrition.
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Home Hemodialysis:
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Home hemodialysis (HD) has been shown to have multiple benefits in regards to
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psychological, clinical, and biochemical parameters (Figur e 8). It is imperative to

transition patients to home units in order to limit their exposure to SARS-CoV-2 in the
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hospital. During the initial CKD diagnosis patients should be educated on the risks of
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each stage and what to do if the need for dialysis arises. If the patient is at stage 4, then

they should be educated on the feasibility of home HD. If the patient can undergo the

treatment at home, then a home assessment and installation of the proper infrastructure

should be done. Patients should be educated and given the means to perform home blood

pressure monitoring as well. At the conclusion of infrastructure installation, patients

should be monitored remotely for cases of infection, transplant or death.

Remote Peritoneal Dialysis:

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 For patients who are on peritoneal dialysis, COVID-19 has created a roadblock to

routine office visits. Furthermore, nephrologists are unable to see each patient’s dialysis

cycle information without such visits. A solution to this has been Sharesource, an online

platform that allows for medical professionals to remotely monitor each patient’s dialysis

information (8). Sharesource has been widely implemented by nephrologists at Mt. Sinai,

where 80% of patients are now being monitored remotely with this technology. This can

provide nephrologists access to dialysis information, and with virtual office visits

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providing an opportunity to meet with patients, the ability for nephrologists to remotely

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monitor and treat patients on peritoneal dialysis has now become a reality.

Limitations and Future Considerations

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There are a few limitations that can serve as avenues for future research. In the
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survey released to both patients and providers, data on demographics and relative access
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to internet was not gathered. This information could be used to better tailor workflows to

various communities and minimize health disparities. As of yet there is no preliminary

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data, beside with peritoneal dialysis, on the efficacy of these workflows in practice.
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Future research and analysis of their implementation will allow for adjustments to be

made to improve their quality.

Conclusion

In order to deliver the most effective treatments for patients, the standardized

telemedicine workflows are imperative. With the COVID-19 pandemic continuing for an

indeterminate amount of time, coupled with the impending flu season, there is an ever-

increasing need for telemedicine services. We believe adaptation of these workflows can

provide the foundation towards delivering standardized care to patients across the nation.

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Health Care Providers Across Medical, Surgical, and Allied Health Specialties:
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Observational Study of 212,933 Providers. J Med Internet Res. 2018;20(5):e176.

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Published 2018 May 9. doi:10.2196/jmir.9160

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 clinician was better with the in-
person setting in 60% of cases;
not comfortable sharing
confidential information in 30% of
cases; patients (n=400) reported
inability to show a clinician a
physical problem 80% of times;
the cost of the visit was better for
the in-person clinic visits 33% of
the time
(36%) followed by the inability to
perform physical exams (30%) or
laboratory tests (18%), unfamiliarity
with telemedicine (9%), and being
uninformed about billing (7%); the
321 responders stated that
telemedicine services were not
connected to the electronic health
record in 60% of cases, had no
waiting room feature to queue in
patients in 32% of cases, and had
restrictions in performing
telemedicine services in 24% of
cases

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65% of patients were definitely
willing to co-pay $ 10-25 dollars;

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28% were definitely willing to pay
$ 26-50 dollars and 18% were
definitely willing to pay the full
Cost -p
cost of the televisit
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Table 3: Suggested Billing Codes for Telemedicine use based on the advice of the
American Medical Association.

Telehealth Billing/Documentation Requirements

Updated 5/4/2020

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 time 25 min)
99215 (typical
time 40 min)
Patient evaluated
for SARS-CoV-2
testing need:
online

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 severity,
immediate
significant threat
to life or
physiologic
function)

I n fo r m a ti o n a d a p te d fr o m S p e c i a l C o d i n g A d v i c e d u r i n g C O V I D - 1 9 P u b l i c

H e a l th E m e r g e n c y . A m e ri c a n M e d i c a l A s s o c i a ti o n , 4 M a y 2 0 2 0 . ( 1 9 )

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Figure Legends
Figure 1: Hemodialysis during COVID-19 workflow

Figure 2: Nephrotic Syndrome Workflow

Figure 3: Glomerular disease management

Abbreviations: eGFR estimated Glomerular Filtration rate , RPGN Rapidly progressive

glomerulonephritis, ANCA Antineutrophil Cytoplasmic Antibodies, ACE Angiotensin-
Converting Enzyme , ARB Angiotensin II Receptor Blocker , TMP-SMX Trimethoprim-

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Sulfamethoxazole, PCV13 Pneumococcal Conjugate Vaccine, PPV23 Pneumococcal
polysaccharide vaccine, CDC Center for Disease Control

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Figure 4: Chronic kidney disease workflow

Figure 5: Urinary tract infection workflow

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Figure 6: Pediatric transplant telemedicine workflow
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Abbreviations: AKI Acute Kidney Injury, CBC Complete Blood Count, IS level
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Immunosuppression Level, Urine Albumin, Ur Urea, BK/CMV/EBV

PCR polyomavirus BK/ Cytomegalovirus/ Epstein Barr Virus Polymerase Chain
Reaction, DSA Donor Specific Antibodies,
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Figure 7: Transition from pediatric to adult care workflow

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Figure 8: Home hemodialysis protocol

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Hemodialysis Patient Categories During COVID-19

COVID-19-positive patients
Persons who have tested positive for COVID-19 virus and are clinically stable
to treat in a dialysis center and/or clinically stable COVID-19-positive patients
recently discharged from the hospital setting

Isolations shift within a dialysis clinic

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Persons Under Investigation (PUI) with History and

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Symptoms of COVID-19

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This includes persons who have been tested for COVID-19 and are awaiting test
results and persons who have not yet been tested for COVID-19

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Treatment in a dialysis center must be cohorted into isolation shifts

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dedicated to PUIs

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Asymptomatic Persons Reporting Close-Contact
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Exposure to COVID-19
This includes persons who have been tested for COVID-19 and are awaiting test
results and persons who have not yet been tested for COVID-19
Treatment in a dialysis center must be cohorted into isolation shifts
dedicated to PUIs

Dialysis Shift and Personnel

Avoid having health care staff change dialysis shifts to avoid cross-contamination
and infection; dialyze in place with rigorous use of personal protective equipment
(PPE) and isolation; defer dialysis and refer a patient to a hospital for testing
and/or treatment
 Clinic / Emergency Dept for
Evaluation / Admission
● Systemic infection
● Anasarca

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Nephrotic Syndrome

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● Acute kidney injury; complications
Visit for: Proteinuria, relapse, and complications

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Relapse

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● Review history, medications, urine diary
● Details regarding current illness ● Prednisone daily, alternate day

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● Evaluate for complication(s) ● Reinforce ongoing therapies

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● Review after 8-12 weeks
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Recent Onset Proteinuria

● Screen for proteinuria at home
● Blood investigations
● Counsel re: relapse therapy
I m m u n o s u p p r e s s i o n

● Discontinue

antimetabolites

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Chronic KidneyDisease Protocol

Establish telemedicine platformfor
video conference
1 4
AND
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Visit is conducted with a review of (Optional)
clinical status/labs by each discipline, A portion of the visit for the
video assessment of pertinent physical 7
adolescent patient is conducted

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Healthcare team has been trained finding & feedback from patient/parent independently of the parents

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(Optional)

Patient’s clinical status is
2 deemed appropriate for
telemedicinevisit
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Team members (eg, physician, nurse,
5 dietician, social worker, etc) meet online
prior to admitting patient/parent to visit
Visit concluded with review of
recommendations using teach back
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principles and plans are made for

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future telemedicine or in-personvisits

3
Scheduling of visit carried out by
healthcare team member and
patient or parent
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Training of patient/parent by
6 u healthcare team member to
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enable TM visit conducted prior
to the scheduled visit
● Dysuria
●

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Urgency

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T a r g e t

P o p u l a t i o n

Day 90 -

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C a l c i n e u r i n I n h i b i t o r

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A d j u n c t i v e

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●

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180

P e d i a t r i c

R e c o m m e n d a t i o n s

p a t i e n t s

A g e n t

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Transition from Pediatric to Adult Practice Workflow

Identify, select, and include the appropriate Adult Nephrology Hemodialysis or Home Hemodialy
Nephrology Services
1 Problem: Differences in expectations, resources and support provided by pediatric and adult
nephrology units along with often inadequate preparation of the young person by
pediatric units, can compound this problem

• Accurate and relevant information flow between pediatric and adult health services, facilitate
effective communications channels, is a commonly reported factor contributing to successful
2 • An Action Plan Card Tool should be created to guide adult provider to manage, and facilitate
transition process, ensuring minimal disruption to health service provision
• The action plan should be developed in accordance with continuous quality improvement (C
processes and include measurements of the effect of implementation clinical practice guidelin

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Action Plan Tool

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• Transfer of Care Cover letter
• Authorization for release of medical information
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• Checklist of Records for Transfer of Care
• Plan of care, including transition goals and pending actions
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• Emergency care plan
• Guardianship or health proxy documents, if needed
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A) Step 1
a. Develop a self-management ability so that patients can establish an appropri
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have knowledge of their medical history, and understand their medications and
B) Step 2
a. Facilitate discussions that help the patient explore factors interfering with adh
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forgetfulness and poor social planning), identify solutions, and create habits th
adherence
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b. Establishing basic survival skills for an adult clinic so that transitioning adoles
to discuss their own medical condition and present problems to the new provide
appointments, and fill or refill prescriptions

Action Transition
• Ongoing evaluation of assessment and readiness
• Engagement of Combined Pediatric and Adult Transition Team in partnership
young person and family/caregivers
• Combined clinic visit with pediatric and adult nephrologist in the transition cli
the need, define goals, responsibility, and care plan
• Successful transfer to adult services

Integration
• Completed transfer and integration into adult services
• Combined care teleconference at 6 months including all pediatric and adult services
• After three consecutive visits by adult nephrologist, quality outcomes evaluation will be
• Ongoing evaluation at 1, 2, 3 and 5 years
Should

there

be
In c id en t Death

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Pre Transplant

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Ho m e in
Transfer

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M ain t en an c e

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Pat ien t

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D ialy s is
● Improved urea Pat ien t pa

In f r as t r u c t u r e R em o t e m o n it o r i n g

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