Table 1.

Operational considerations for and steps and strategies implemented during facility-wide testing for SARS-CoV-2 at outpatient dialysis facilities^*

Operational considerations	Steps and strategies
Facility layout and sample collection
Identify a location for sample collection that will minimize potential exposure to patients and healthcare personnel during collection of respiratory samples	○A separate area inside the facility with a door that could be closed (ie, exam room) and that was not being used for other purposes or a designated area outside the facility (ie, for patients with stretchers) was used for sample collection ○Staff remained flexible and adjusted the sample collection location for some patients, particularly those with mobility issues ○ Ventilation, including directional airflow and air exchanges, in the sample collection area was reviewed† - During sampling, patients faced away from other patients and from equipment to avoid dispersing respiratory droplets if coughing or sneezing. Tissues were available for patients to cover any coughs or sneezes - Patient wore masks for duration of specimen collection procedure, only removing them just before sample collection and immediately replacing it once sample collection was complete - If patients coughed or sneezed on supplies or equipment (eg, table), equipment was cleaned and disinfected, or discarded if it could not be cleaned and disinfected - Efforts were made to identify at least 2 potential sample locations in a facility to help ensure timely sample collection could continue if an area needed to be temporarily closed

Staff involvement

Define roles and responsibilities of staff in advance

○ Multiple individuals were needed on the day of testing to ensure all tasks were completed in a timely manner. For example, 5 - 6 staff were involved in sampling and questionnaire administration for a dialysis shift with 40-50 patients - Two staff were dedicated to sample collection - Two staff were involved in interviews - One to 2 staff were dedicated to overseeing the process (ie, consenting, interviewing, and reminding patients to get tested prior to or following dialysis treatment)

Patient communication
Communicate facility-wide testing plans to patients in advance Ensure staff are prepared to explain the rationale behind facility-wide testing and sample collection procedures	○Patients were told in advance that they should arrive 15 min ahead of their normal arrival time or anticipate staying 15 min after their dialysis treatment for sample collection ○Trusted facility staff and other providers were involved in patient education

Patient consent
Review organization policies and determine how patient consent will be obtained (e.g., will patients be required to sign a consent form or will verbal consent be sufficient) Make a plan for approaching patients who are unable to provide consent (eg, cognitive impairment)	○Consent forms were provided to patients in advance so they could review and be prepared to ask any questions on the day of testing ○Staff reviewed consent form with patients on the day of testing and consent was obtained prior to performing interviews and collecting respiratory samples

Patient interviews

Identify a location where patient interviews can be performed while ensuring patient privacy

○ Facility layout determined appropriate location to perform interviews - At some facilities the layout of the dialysis treatment floor and distance between patient stations allowed for patient interviews during dialysis treatments - In some facilities, the treatment floor layout was not amenable to performing interviews during treatments, so a separate area was identified. Ideally interviews were performed in a location separated in time and space from respiratory sample collection, to ensure expeditious sample collection and minimize patient exposures

Timing of sample collection
Define when sample collection will be performed in relation to the different dialysis shifts (ie, before or after shift) Ensure efforts are made to minimize interferences with dialysis start times to avoid disruptions to normal facility operations	○Patients on the first shift were only tested after dialysis treatments and patients on the last shift were only tested before dialysis treatments. Patients on other shifts were tested either before or after dialysis treatments

Receiving and responding to SARS-CoV-2 test results

Ensure clear coordination with laboratory to avoid diagnostic delays in testing specimens and receiving results Ensure patients positive for SARS-CoV-2 can dialyze in a space that does not expose other patients Ensure a plan for proper test result interpretation (eg, determining when a positive test may represent persistent SARS-CoV-2 positivity following a resolved prior infection) that considers test performance characteristics, clinical symptoms, and prior SARS-CoV-2 infection ǂ. Follow local regulations regarding reporting newly identified infections to public health.

○Patients with positive SARS-CoV-2 infections were dialyzed together in a cohort at the last shift of the day with dedicated staff ○Testing was performed at public health lab (Centers for Disease Control and Prevention) and test results were delivered to a nephrologist at the facility the day of or the day after test results were available

^⁎This list highlights some, but not all, operational considerations in the outpatient dialysis setting. Each facility will have unique characteristics that will impact implementation of these considerations.

^†https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

^ǂhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html