Table 2.

Care Pathway for Low Prevalence of COVID-19 in Community.

	P1 Symptoms + Exposure + PROBABLE	P2 Symptoms + Exposure – SUSPECTED	P3 Symptoms – Exposure + EXPOSED	P4 Symptoms – Exposure – MAY BE EXPOSED
Patient wears mask on entry, during dialysis, and in transport vehicle a	YES	YES	YES	NO
“Separated dialysis” b (isolation room)	YES	YES	IF POSSIBLE	NO
Droplet/contact PPE c	YES	YES	YES	NO
Test for SARS-CoV-2 d	YES	WHEN POSSIBLE	NO	NO
Shared transportation e	NO	NO	NO	YES
Wait in waiting room f	NO	NO	NO	YES
Wander in facility	NO	NO	NO	YES
Counsel on home isolation	YES	YES	YES	NO
Discontinue isolation procedures g —also see C3 for special populations	If COVID-19 negative: when symptoms resolve AND >14 days from exposure If COVID-19 positive: See Section B	If COVID-19 negative: when symptoms resolve If COVID-19 positive: See Section B	14 days from exposure	N/A
Caregiver can accompany patient	YES	YES	YES	YES
Visitors can accompany patient h	NO	NO	NO	NO

^aMasks for patients

 When the prevalence of COVID-19 in the community is high (as determined by public health), all patients should wear masks throughout the treatment, including P4. When prevalence is low, patients who are asymptomatic with no known exposures do not need masks.

^bSeparated Dialysis (Isolation Rooms)

 Ideally, P1, P2, and P3 patients should be dialyzed in separate isolation rooms. If this is not possible, maintain droplet/contact precautions by keeping >2 m distance between patients AND using a physical barrier to separate treatment stations, such as plexiglass screens, washable curtains, or disposable plastic sheets.

 P1, P2, and P3 patients should NOT be cohorted together, even with patients of the same category. This is to avoid transmission from positive (but not yet confirmed) patients to those who are negative.

Negative pressure ventilation rooms are NOT required for routine dialysis. They are recommended ONLY if an aerosol-generating medical procedure (AGMP) is anticipated, such as high flow oxygen, intubation, or mechanical ventilation. For this reason, we recommend unstable patients are dialyzed in an appropriate location (see 3.1).

 Cleaning of the treatment area, machines, and isolation rooms should follow provincial public health agency guidelines.

^cPPE (Personal Protective Equipment)

 Health care workers who care for patients in categories P1, P2, and P3 (ie, exposed or symptomatic) require appropriate PPE for droplet/contact precautions when providing treatment or care within 2 m of the patient. This means a procedure mask, visor, gloves, and gown. Airborne precautions (N95 masks) are NOT required, except for AGMPs. Dialysis is NOT an AGMP.

 For patients in category P4: Public health agencies determine whether COVID-19 is highly prevalent in the community. When this is the care, we recommend that health care workers wear a mask and visor for all patients, without changing between patients (ie, they are supplied with 1 or 2 masks for each shift and wear them continuously except for breaks).

 Whether to reuse PPE and how to process PPE for reuse should follow provincial public health agency guidelines.

^dRepeat Testing for P1 and P2 Patients who Are Initially Negative

 When there is a high clinical suspicion for COVID-19 and negative nasopharyngeal swab, the test may be repeated. The sensitivity of nasopharyngeal swabs for COVID-19 may be less than 100%. Whether to do more than 2 tests for a single patient should be determined on an individual basis in consultation with local infectious disease specialists.

^eTransportation

 The recommendations in section 2.5 apply here, except that patients who are P1, P2, or P3 should NOT be cohorted together in the same vehicle.

^fWaiting Room

 If feasible, medically stable patients can opt to wait in their car or transport vehicle and be contacted by phone when their treatment spot is ready, to avoid the waiting room.

 If the patient must use the waiting room, practice distancing measures with patients separated by at least 2 m. This includes moving chairs to the required separation, or taping chairs that are not to be used, to maintain separation.

^gDiscontinuation of Isolation Procedures

 Patients in categories P1 and P2 should remain isolated until they have NO symptoms AND the patient has definitively tested negative for COVID-19.

 The duration of isolation may be longer than 14 days for immunocompromised patients—consultation with local infectious disease experts on a case-by-case basis is suggested.

 Patients in categories P1 and P3 who have been exposed to outbreaks in a group facility (eg, long-term care facility) should be isolated until at least 14 days AFTER THE OUTBREAK IS CLEARED from their group facility.

^hVisitors/Caregivers—see section 2.11-2.12.