As COVID-19 continues to sweep through the nation, researchers are realizing what groups of people are especially affected by it and are more susceptible to it, such as dialysis patients.
Maya N. Clark-Cutaia, PhD, ACNP-BC, RN, Assistant Professor of Nursing and Medicine at the NYU Meyers College of Nursing, spoke to us about the patients she works with in her research studies to shine a light on exactly what is happening to certain marginalized populations.
The dialysis patients whom you care for/track, are they at high risk for getting COVID-19? Please explain.
The majority of the patients I work with on my research studies are African American, aged 50-60 years, disabled, living off of federal subsidies, with low health literacy and educational attainment. They tend to live in crowded, multi-generational homes, in neighborhoods that are under-resourced. This population of patients is at increased risk for COVID-19 because of the disproportionate incidence of the underlying conditions most associated with COVID-19: heart disease, diabetes, kidney disease, and lung conditions, such as asthma.
According to Medicare COVID-19 data, hypertension and diabetes are the first and fifth most common comorbid conditions for COVID-19 and the top causes for chronic kidney disease (CKD). CKD is the third most common comorbid condition, among Medicare recipients, with COVID-19.
They are also at increased risk because of their way of life. My patients or their family members are essential workers. They are the bus drivers, security guards, grocery clerks, and sanitation workers that keep our cities running. They often have to go to work to be paid and thus are at great risk for exposure. Living conditions are ripe for spread of disease and little, if any, was invested in these communities in regards to prevention, testing, and contact tracing.
What are the greatest needs of people with kidney disease who require dialysis?
TRANSPLANTS! While it remains true that the majority of transplants are cadaveric, 40% of transplants result from living donors. Similarly, conversations with your patients about palliative care and transplantation are vital. Ask your patients about what they know about transplants. Are they on the transplant list (why or why not)? How long do they expect to live on dialysis? Do they have a living will and advanced directives? The fact of the matter is that these patients are critically ill and their multimorbidity makes them highly complex. They need to understand their prognosis and have a say in how they live and how they die.
What are their socioeconomic challenges? What about getting the right foods to eat? Transportation to dialysis, etc.? Please explain.
Many of our patients are supported by federal subsidies. Due to the complexity of their disease and treatment regimens, many are unemployed. Treatments last 3-4 hours, three times a week, and that does not include transportation time, and getting on and off of the dialysis machine.
Patients often describe choosing between purchasing meals, paying for prescriptions, and transportation to and from dialysis sessions.
Basic necessities are often hard to come by, and the current federal programs, while they provide support, it does not mean that the support is ideal. For example, gas stations and convenience stores accept SNAP, and while this translates into food accessibility, they are not healthful food options. True groceries are limited in the neighborhoods my patients live in or require transportation to and from.
Patients often do not feel well enough on their days “off” or non-dialysis days to meal prep and typically do not have the resources to do so. The inability to maintain dietary and fluid restrictions result in patients often not feeling well, having unpleasant dialysis sessions, and can lead patients to skip sessions on account that they do not feel well enough to complete them, or dread the symptoms they will experience as a result of their need for increased filtration related to “non-adherence.” It becomes a viscous cycle that often results in hospitalization.
What can nurses do to help make sure that these patients have what they require—both to stay healthy while keeping their risk for COVID-19 down.
We all need to recognize that wearing masks and other COVID-19 precautions are not about us as individuals, but as a community. We are protecting our seniors, the immunocompromised, and those with underlying conditions, like my dialysis patients.
Educate yourselves, your friends, your family, your neighbors. If you have not been directly impacted by COVID, you will be. Stay informed about the risks to the general patient population and advocate for them. I am reminded of a news bit of a part of our administration touring a dialysis center without a mask or other personal protective equipment. It was unacceptable then, and it is unacceptable now.
No one spends as much time with patients as we do. No one is going into COVID and ICU rooms more than we do. And while I hate to make any of this political…it is. We need to not only advocate for our patients in the hospital, we also need to advocate for them in society. Advocacy groups are not for everyone, but every single vote counts, and we need to make informed decisions as medical professionals about the type of care we want to deliver to our patients and who is going to advocate for them. Vote. Vote often. Vote informed.
How else can nurses support these patients? Is there anything that they should not do?
Most nurses are well informed regarding standard precautions and contact precautions. Dialysis nurses in particular, have been donning and doffing PPE long before COVID. Those of us who do not know this patient population well need to ensure that we take the time to look up hospital policies and abide by them.
Anything else about COVID-19 and dialysis patients?
It is not over. In fact, it is far from over. COVID-19 is surging in states all over the country and as states continue to open, we need to remain vigilant and adhere to COVID precautions. Wear your masks, wash your hands, and limit exposures. Protect yourselves and protect those not capable of protecting themselves. Remain up-to-date with your local statistics and protocols. It will inform the care you provide.
I would also like each of you to know just how proud I am to call you colleagues. We have been redeployed to areas foreign to us. We have worked with limited PPE and limited information. We have traveled across country to work because we felt compelled to do so. We have left our families and cried in our coffee. We have hurt and felt a sense of guilt because we cannot contribute the way we would like to, but the constant is that we show up. We show up, and we have shown up big. Our profession is powerful and invaluable, and my chest swells with pride each passing day.
“Time management has been my best friend,” says Nurse of the Week Cailly Simpson. Although she left nursing in 2017 to study law at Rutgers, when the pandemic hit, the 26-year-old immediately felt an instinctive need to help. While continuing to work two days a week at a law firm and attending six hours of classes, the future malpractice lawyer wielded her time management skills and expanded her schedule to add four 12-hour shifts a week at NYU Langone Health.
Langone was familiar ground to Simpson, who worked there in the pulmonary and step-down units after receiving her nursing degree in 2016. The decision to make a two-month return to nursing—despite being just a few months away from finishing her legal studies—was not difficult. Simpson told NJ.com, “I felt like this was something that needed to happen. I went to nursing school with the thought process that I wanted to help people and take care of patients so that’s just kind of how my brain works.”
Simpson’s shifts as a float nurse were grueling, and she saw little of her boyfriend, family, or friends during her COVID nursing stint. However, revisiting her old profession has its rewards: “People truly want to help. They want to send these people home to their families. The attitudes with everyone I have come into contact with is what really has struck me. Everyone has every right to be completely terrified and not want to do this and complain about it. That was never ever the case. I never came across that. Everyone was always up and ready to help and wanted to be there giving it their all. Walking into that attitude made everything so much less scary.”
Summing up her eight-week combination of law studies with nursing on the COVID frontline, Simpson told the Rutgers Law newsletter, “It was hard to balance with finishing up law school but I would not have changed my decision for anything. I have truly enjoyed being back, even during such challenging times. The nurses were incredibly thankful for all the extra help they received. . . They are incredible individuals who have powered through this crisis with a smile on their faces the whole time and have continued to put patient care first.”
For a full story and interview with Cailly Simpson, visit NJ.com.
When she was just four years old, Taylor had a hairsbreadth escape when her family’s apartment in New York City’s SoHo caught fire. After rescuing Taylor’s mother from the blaze, firefighter Eugene Pugliese rushed back into the building when the frantic mother informed him that her little girl was still inside. Finding young Deidre unconscious in the smoke-filled apartment, Pugliese carried her to safety and brought her around via mouth-to-mouth resuscitation. Following the rescue, in addition to the mother’s thanks, the doughty firefighter received the Walter Scott Medal for Valor… and became a hero to the toddler he saved.
Taylor explains, “The fire obviously shaped the rest of my life. I always knew I was given a second chance at life. The copy of the Daily News was in my keepsake binder since I was a young child. I’ve always had a copy of the cover.”
She saved the newspaper account of the fire and rescue and made many attempts to locate her childhood hero without success. While working a shift at NYU Langone Hospital during the coronavirus outbreak, though, Taylor met some firefighters who had brought pizza for her and her co-workers. As they chatted over their slices, she told them that she owed her life to one of their own. After Taylor informed them that her savior had worked with Ladder 20 in Manhattan, a firefighter phoned the station captain, who—despite the passage of decades—still had Pugliese on speed-dial.
Owing to the pandemic, Taylor and the 75-year old retiree were unable to meet in person and share an embrace. “The last thing I’d want to do is expose him,” Taylor told the Daily News. Nonetheless, the two had a satisfying and emotional reunion over the phone and video calls. Pugliese told CNN, “The two of us just sat there crying on the phone. She turned out to be a remarkable woman with a magnificent life.” Taylor’s hero was profoundly gratified by the course of the life he helped to save long ago, and declared, “You turned out to be a wonderful young woman. You’re a hero, too.”
For a complete account of this story, visit CNN or see the Daily News.
Nurse of the Week Danielle Fenn understands the vital role of communication in nursing.
Fenn, an RN at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, is originally from Brazil, and during the COVID crisis she used her knowledge of Portuguese to make the hospital space more inviting for non-English speaking COVID patients.
It began, she told ABC News, when a co-worker told her, “we were getting a COVID patient that was from Brazil that didn’t speak very much English. They had trouble communicating with him and he was scared. Fenn swooped in to soothe the frightened man as she “walked him through simple questions and gave him my cell number. I told him if he needed anything to call me.” She also left a friendly “Good Morning” message in Portuguese to greet the patient the next morning.
The positive effect inspired her to reach out to other non-English speakers who were being treated, she says. “I developed a relationship with them and decided to create signs around the hospital to help other patients and health care workers. Signs are very important for patients who can’t speak English very well… For the little simple things, it’s nice to be able to use these signs.”
Like many nurses, Fenn’s dedication to the profession was reinforced by personal experience as a caregiver; in this case the patient was her late husband. “I made a promise to myself that if anyone that ever needed my care or any loved one would need something, I would be there. Little did I know that was going to be my husband. My husband was diagnosed with terminal brain cancer. It was very hard. Our children were aged 5 and 3.” Of losing her spouse, Fenn says, ”That was definitely the hardest.” Her loss has failed to dampen her enthusiasm for caregiving, though: “But still, being a nurse is just my favorite. I love to come in and be able to bring a smile to their faces.”
To see a video featuring Danielle Fenn’s story, visit this ABC News page.
With the spread of the COVID-19 pandemic, Jennifer Scott, CNM, realized that she needed to take additional steps to keep her patients safe. As the pandemic rose in severity, Jennifer, whose primary patient base is a local Mennonite community in the Finger Lakes region of central New York, temporarily closed her clinic and began seeing patients in their homes.
The home visits were necessary, according to Scott, who had to rule out telehealth visits because her Mennonite patients don’t have computers or cell phones.
“We provided home visits because it is easier to isolate and wipe down our equipment between homes. This also prevented our clients from congregating in the waiting room. Many women will make appointments on the same day and share a ride. We are also only visited clients who were higher risk or near term. For example, we’ve spaced our four-week visits out to five weeks and are doing more phone calls.”
Jennifer is from the Finger Lakes region and, after working as a full-scope midwife in a community hospital for seven years, she joined other colleagues to open Community Midwives in 2019. She has retained admitting privileges at the hospital, though the Mennonite community prefers home births.
“The reasons are multifaceted,” Jennifer said, noting that she and her fellow nurse-midwife at Community Midwives attend six to 10 births per month in the community of approximately 600 families.
“Many are farmers, have large families and don’t drive cars. In order to have a hospital birth they would need someone to take care of the farm, watch the children and would have to hire a driver to take them to the hospital in labor, possibly in the middle of the night. The closest maternity hospital is 30 to 45 minutes by car. Some are put off by hospital costs and length of stay. Others like the comfort of their own home. They feel safer emotionally to give birth in their own surroundings.”
Making her patients feel safe became an additional challenge amid the COVID-19 pandemic. While the pandemic impacted this somewhat isolated community differently than other parts of the country, the fears were the same. The closing of schools and churches limited primary sources of socialization, entertainment, and information. Because the Mennonite community does not watch TV or listen to music, Jennifer shared news about the pandemic with the families she serves, printing off the latest information from the county and state health departments.
“Like everyone, they were worried for their families, stressed by the social restrictions and having to homeschool their children,” Jennifer said.
“The Mennonite community is very self reliant. They have stocks of canned and frozen produce from their own gardens and bake their own bread. They have fresh eggs and milk also. They may only go once a month to Walmart for other supplies so they are not as exposed to as many crowds.”
Jennifer, whose husband also battled the COVID-19 pandemic as a physician in a local hospital, said she hopes the pandemic inspires others to choose nursing and medicine, just as she was inspired by her experiences as a Frontier Nursing University (FNU) student.
“FNU taught me to grab my saddlebag, get on my horse and ride up that mountain,” Jennifer said.
“It taught me that my calling is to care for the underserved, the vulnerable families, without hesitation. I’ve always believed the education at FNU has prepared me for anything I encounter in the workplace. I remember Kitty Ernst giving a talk at Frontier Bound that I paraphrased as ‘We only educate the strongest, most resilient nurses’.”
Overcoming vaccine hesitancy and access issues has become even more critical because of the COVID-19 pandemic, public health experts argued at a recent webinar hosted by the National Academies of Sciences, Engineering, and Medicine.
“Strengthening vaccine access and confidence today is more important than ever because … all across the globe we are dealing with the [COVID-19] pandemic,” Nancy Messonnier, MD, director for the CDC’s National Center for Immunization and Respiratory Diseases, said at last week’s event.
The pandemic has interrupted and delayed routine vaccinations for many people, including children, Messonnier noted.
Robin Nandy, MPH, principal adviser and chief of immunizations for UNICEF, added that a “substantial setback” in immunizations is expected. He highlighted a study from UNICEF, the World Health Organization, and others estimating that 80 million children across 68 countries were at risk for preventable diseases due to disruptions in care resulting from the pandemic.
Discussing the prospect of a COVID-19 vaccine, Messonnier said she hopes some will be available this fall, with more arriving in the winter, but expressed concern that a large number of Americans won’t be willing to be immunized.
One in four U.S. adults said they were not interested in getting a coronavirus vaccine, a recent Reuters/Ipsos poll found. Ongoing research suggests that, at a minimum, 70% of the U.S. population would need vaccine-based immunization, or infection with the virus itself, to achieve herd immunity.
In addition, vaccine confidence levels vary across different ethnic and socioeconomic groups, Messonnier noted.
“It’s very concerning to us that overall confidence in vaccines is lower in Hispanic and black communities, lower in those [of] lower income, and lower in those with lower education,” she said, citing research from the Pew Research Center.
These are also some of the same groups that are disproportionately impacted by COVID-19.
“Vaccinating With Confidence“
Messonnier noted that even parents who report that they are less confident in vaccines are more likely to get their children vaccinated when they have “easy access.”
To that end, the CDC and other public health experts are working on plans for the distribution of a coronavirus vaccine, to monitor the impact of such a vaccine, and on gaining a better understanding of public perceptions of the coronavirus vaccine in order to develop effective messaging.
The anti-vaccination movement is powerful. According to recent research, anti-vaxxers have greater influence on social media than pro-vaccine activists.
However, experts know that the impact of fear as a motivator “doesn’t last very long,” Messonnier said.
As a result, the CDC is pivoting toward a strategy of “vaccinating with confidence,” which involves identifying pockets of low vaccination, working to improve vaccine access, and taking steps to try to stop misinformation.
A child’s doctor is still the “most trusted source of information” for most parents, Messonnier said, adding that, in some cases, the reassurance of those doctors has been enough to get vaccine-hesitant parents to change their minds. Strengthening the conversation between parents and providers will be a critical part of the plan to increase vaccine uptake.
Vaccine Uptake and Access
Immunization rates among U.S. children are strong overall, with more than 90% of those under 2 years of age having received their “primary series,” Messonnier said. High rates are due in part to the Vaccines for Children (VFC) program, which has also reduced disparities in coverage and reduced incidence of vaccine-preventable diseases.
The program provides vaccines for more than half of the children in the U.S., many of whom are uninsured or underinsured, she noted, adding that despite the availability of the VFC program, children without access to health insurance are nine times more likely not to have received a vaccine by the time they’re 2 years of age.
Vaccine uptake among adolescents is a “mixed picture,” said Messonnier, with 86% receiving their Tdap (tetanus, diphtheria, and pertussis) immunization, but only 52% receiving a flu shot, and only 68% receiving one or more doses of the HPV vaccine.
Only about 60-64% of adults receive their routinely recommended vaccines, and somewhere between 35-68% of adults receive the annual flu vaccine.
There are also vaccination disparities related to race, ethnicity, and location. American Indian and Alaska Native children have the lowest MMR (measles, mumps, and rubella) vaccination rates for children under 2 years. Urban-dwelling children are more likely to receive one or more MMR doses versus those in rural areas, according to a 2019 Morbidity and Mortality Weekly Report.
While school vaccination requirements have helped to protect students from vaccine-preventable illnesses, “grace periods” that allow parents to enroll their children in school, with a pledge to visit the doctor for an immunization at a later date, have proven challenging.
The number of kids who fall into these grace periods across different states is anywhere from 0.2-6.7%. Some of these children do eventually get vaccinated, while others may be children of vaccine-hesitant parents who are taking advantage of this loophole in schools’ policies. Most counties and schools lack the staff and resources to follow up with families and determine which children ultimately did receive a vaccine.
If all non-exempt children who fell into these grace periods went on to be vaccinated, most states would see a 95% MMR coverage rate, Messonnier said.
Vax “Drop Off“
Messonnier said she’s worried about the “dramatic drop off” seen in rates of healthcare providers ordering routine vaccinations after March 13, when the White House declared the novel coronavirus pandemic a national emergency. This was particularly true for routine measles vaccination across all ages, with kids under age 2 faring slightly better than other groups, she added.
Parents are worried about exposing their children to COVID-19, and haven’t been going to the doctor, which is an “appropriate concern,” Messonnier stated.
But the CDC and the American Academy of Pediatrics want parents to know that it’s safe to go back to the pediatrician’s office, and are urging healthcare providers to encourage “catch-up vaccinations” through outreach to parents.
Many practices are implementing special preventive measures to help reduce the risk of viral spread. For instance, some are having “well child” visits in the mornings and seeing sick children in the afternoon.
The CDC is also urging public health officials and clinicians to disseminate information regarding the VFC program as there may be more families who are eligible for the program given the increasing unemployment rates, Messonnier said.