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"In the current environment of coronavirus disease 2019 (COVID-19), it has become obvious that it won’t be business as usual when the economy restarts and social distancing restrictions are relaxed," write Steven A. Kaplan, MD, and Alexis E. Te, MD.
In the current environment of coronavirus disease 2019 (COVID-19), it has become obvious that it won’t be business as usual when the economy restarts and social distancing restrictions are relaxed. Although we are beginning to flatten the curve, there will be significant challenges as we reengage patients with our clinical practices. We have the opportunity to lead and be more prepared when we redeploy to our urologic practices.
But when do we relax restrictions? Might we invite an increase in infections by loosening the constraints on self-isolation? When, exactly, do we get back to work?
COVID-19, declared a global pandemic by the World Health Organization, continues to spread across continents, infecting over 3 million people worldwide and causing over 230,000 deaths.1 Many US states have mandated shelter-in-place policies, as outbreaks cluster in multiple regions across the country. Although the mandates vary from state to state, most urology offices have temporarily closed their doors and the rest have limited surgery to only the most urgent cases. This has left numbers of patients seeking assistance, and a backlog of elective procedures.
Additionally, what seems to be lost amid the rationing of services is the mental anguish of patients with cancer diagnoses and other health issues that is amplified by the isolation and loss of social support that may have made things easier to cope with. Patients have been forced to stay home, stuck with any health issues they have, which are deemed not important enough to be dealt with during the lockdown. They are, according to the headline of a recent New York Times article, “The Pandemic’s Hidden Victims: Sick or Dying, but Not From the Virus.”2
The first question is, when can we begin to ramp up? This will be determined by a combination of factors including, but not limited to, local, state, and federal guidelines as well as patient confidence. An Ipsos/ABC News poll released April 3 demonstrated wide variability when people were asked when they thought they would resume their normal daily routine. Among those who say their daily routine has changed due to coronavirus, 31% believe a return to normalcy will occur by June 1. One month previously, 44% thought June 1 was the target date.3 This suggests that a slowly rebounding private sector with variable confidence will be a major constraint to reopening medical practices.
Industries and financial institutions have recognized that there will be a gradual rather than a dramatic ramp-up of elective procedures recommencing in the United States. A recent Wells Fargo MedTech forecast stated that recovery of elective procedures will be “U-shaped” (gradual) versus “V-shaped” (quick), that hospitals will prioritize more urgent and life-threatening procedures, such as those for patients with cancer, over elective procedures, and that patients will prefer ambulatory surgery centers or office-based surgery over hospital surgery, due to the perceived risk of contracting COVID-19.4
There will be many hospital obstacles to restarting urologic procedures, including anesthesia (with its attendant precautions and pretesting for COVID-19); a backlog of cases; the reconfiguration of operating rooms that were modified to become intensive care units; and employee constraints secondary to furloughs and layoffs. Further obstacles include vendor supply chain constraints, regulatory factors, and the potential for an event heretofore ill-prepared for––a second outbreak in the fall.
On top of all these challenges, another one is becoming a major area of concern: the posttraumatic effects of the pandemic on our heath care colleagues.
The second question is how we will get things moving again. Urologic offices have become very aware of methods designed to safely treat patients while protecting clinical staff. In part, these recommendations have been formulated in partnership with the Centers for Disease Control and Prevention (CDC).5 Naturally, they are subject to change given the rapidly evolving environment surrounding COVID-19, including diagnostics, screening, and therapeutics, among others.
The following are some recommendations for the screening and treatment of patients with suspected COVID-19 in our practice:
• Follow the CDC’s patient assessment protocol for early disease detection for patients presenting to the practice. Patients should be screened using the Criteria to Guide Evaluation and Laboratory Testing for COVID-19.6 Essential visitors to the facility should also be assessed using these criteria and redirected to remain outside if there are any concerns.
• As part of the return to urologic practice, we expect to continue with telemedicine consulting to some degree. We should anticipate an extension of office hours, weekday and weekend, to ensure a minimum number of patients in the waiting room at any one time. Further, we will require temperature checks and COVID-19 questionnaires for each person to protect both patients and staff.
Current issues and guidelines to consider and keep in mind include the following:
• Most at risk are older patients, those with comorbidities, and younger patients with obesity.
• The virus is highly infectious in close quarters.
• Asymptomatic transmission can occur.
• The virus can remain on surfaces for up to 48 hours.
• Symptomatic patients carry the highest viral load for transmission.
Current prophylactic measures that may become permanent include the following:
1. Physical distancing with a recommended perimeter of 6 feet
To maintain physical distancing within the facility, require patients to sit at least 6 feet or more apart. Patients should be asked to wait in their car if that option is available. Remove magazines. Routinely disinfect the waiting room throughout the day.
2. Use of masks and gloves
• Follow the CDC’s standard precautions and transmission-based precautions, including the use of gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit tested.7,8 This applies to all health care staff interacting with a person under investigation (PUI). If there is a shortage of N95 respirators in the facility, access current CDC respirator recommendations.9
3. Frequent disinfection of public and shared spaces and equipment
4. Quarantining of patients who are symptomatic and possibly of those who are asymptomatic carriers
5. Use of COVID-19 screening for active viral infection and for determining immunity
• Screening may evolve from detection of antigen to assessment of the presence of antibodies
• Consider the likelihood that presence of antibodies may cause a stop-and-go working situation for health care providers and patients reentering work or office environments
6. Recognizing that health care workers can often be the nidus of transmissions
• Limit staff exposure to suspected patients, and keep the exam room door closed. Ideally, the designated exam room should be at the back of the office, far away from other staff and patients.
• Screen health care personnel daily for symptoms, travel, and contacts that may be relevant to COVID-19.
Adopt a clinical suspicion of COVID-19 to protect patients and others. The dynamics surrounding the virus will continue to change in the days and weeks ahead. What must not change are physicians’ and care teams’ vigilance and caution. They should be exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as the CDC makes them available.
Opportunities lie ahead
Our biggest challenge is to ensure everyone’s safety. Until we have reliable point-of-care antibody testing, we will need to proceed slowly. In the interim, there has been a veritable explosion in telemedicine that has accelerated the virtual interaction between health care providers and patients. Among the available options are Epic’s MyChart video visits (which has had bandwidth and sign-on issues), Zoom’s waiting rooms, and virtual physical therapy.
Other modalities such as Uberdoc provide a more seamless method for connecting patients to physicians with a more efficient initial reimbursement. Remote diagnostics will also become a great source of information and revenue. For example, Stream Dx allows the remote evaluation of urinary flow rates. Other companies are working on the remote measurement of post-void residual urine volumes.
Using smartphones to measure heart rate, EKG rhythms, serum oxygen saturation, and serum glucose is already underway, with applications to test other blood parameters on the horizon. This will eventually result in decreased physical office visits as well as emergency department consultations.
Finally, this pandemic will create a new paradigm of how we provide and are compensated for the delivery of more efficient health care. Resource utilization and cost-effective care will become more evaluable, and those who operate more efficiently will be better placed than those who simply do more, in terms of quality- versus quantity-based reimbursement.
Another potential positive outcome could be how we will do business, a rethinking of revenue: for example, expense models that seem antiquated and deleterious compared with a more thoughtful group approach, and unsustainable with the low profit margins of hospitals. Some have suggested that gainsharing may prove to be a better system for physicians and hospitals, with a resulting decease in an overloaded administrative-cost tier.
These are challenging times for our patients, our staff, our peers, and ourselves. In such a unique environment, a useful approach might be to employ these 7 leadership principles for management, as described by John Quelch, a professor of business administration at Harvard Business School and dean of the University of Miami Herbert Business School: calm, confidence, communication, collaboration, community, compassion, and cash.10
Kaplan is professor of urology at the Icahn School of Medicine at Mount Sinai, New York, and Te is professor of urology at the Weill Medical College at Cornell University, New York.
1. COVID-19 Coronavirus Pandemic. Worldometer. Updated May 5, 2020. Accessed May 5, 2020. www.worldometers.info/coronavirus
2. Grady D. The pandemic’s hidden victims: sick or dying, but not from the virus. New York Times. April 20, 2020. Accessed May 5, 2020. https://www.nytimes.com/2020/04/20/health/treatment-delays-coronavirus.html
3. Karson K. Fewer than half of Americans believe their daily routine will return to normal by June, as fears over coronavirus rise: POLL. ABC News. April 3, 2020. Accessed May 5, 2020. https://abcnews.go.com/Politics/fewer-half-americans-daily-routine-return-normal-june/story?id=69940187
4. Warner JJP. Return to post-pandemic in orthopedics as a potential model for factors which may affect other surgical specialties and non-surgical specialties. VuMedi. Accessed May 5, 2020. https://www.vumedi.com/
5. Prepare your practice for COVID-19. CDC. Updated March 31, 2020. Accessed May 5, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-resources.html
6. Evaluating and testing persons for coronavirus disease 2019 (COVID-19). CDC. Updated April 27, 2020. Accessed May 5, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html
7. Infection control basics. CDC. Updated January 5, 2016. Accessed May 5, 2020. https://www.cdc.gov/infectioncontrol/basics/index.html
8. Respiratory fit testing. Occupational Safety and Health Administration. January 2012. Accessed May 5, 2020. https://www.osha.gov/video/respiratory_protection/fittesting.html
9. Clinical questions about COVID-19: questions and answers. CDC. Updated April 16, 2020. Accessed May 5, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
10. Quelch JA. 7 leadership principles for managing in the time of coronavirus. Harvard Business School. March 26, 2020. Accessed May 5, 2020. https://hbswk.hbs.edu/item/7-leadership-principles-for-managing-in-the-time-of-coronavirus