Categories
Outpatient Practice

Optimizing Telemedicine Into Outpatient Clinical Practice

The medical field has been dabbling in telemedicine for decades but until now was held back largely by reimbursement. Quite simply, Medicare and insurance would not pay for it except in a few very specific situations. But COVID-19 has opened the door for broad adoption of telemedicine into regular outpatient practice. When COVID-19 first emerged in the United States, Medicare allowed physicians to see patients via telemedicine and get paid the same as they would have if they had seen patients in a regular physician office. Although the future of telemedicine is subject to the vagaries of Medicare decision-making, my suspicion is that it is now here to stay – Americans have tried it and they like it.

Being old-school, I believe in the value of a well-performed physical examination and so telemedicine is not going to replace all office visits. For some specialties, for example wound care, telemedicine may only be able to be used in a minority of visits. However, not every office visit requires a physical examination – in my practice, I believe that I can do about one-half to two-thirds of my office visits by telemedicine and deliver the same quality of medical care. But with a mixture of in-person and telemedicine visits, how does a physician most efficiently design their schedule templates? As I am setting up my own templates, I’ve found that there are several factors to consider.

Patients like telemedicine

With telemedicine, patients no longer have to take several hours off of work to travel to and from the doctor’s office. For patients like many of mine who are on home oxygen, they don’t have to worry about their oxygen tank running out during the trip to  the doctor’s office. Patients who live a hour or two away from the doctor can now see their doctor without having to travel to the city that their doctor practices in. And patients don’t have to endure the aggravation of waiting in a crowded waiting area for the doctor who is running behind schedule. With COVID-19, patients don’t have to fear going out of their homes to a place where they could become infected by someone with the virus.

Telemedicine-only schedules

Most physicians think in terms of half-day templates. In my own practice, I take care of administrative and teaching responsibilities in the mornings and then see outpatients in the afternoons. By making an afternoon telemedicine-only, a physician can greatly reduce overhead cost. You don’t have to pay for rent for examination space and the office staff can do patient registration, medication list confirmation, etc. anytime that day or even the day before so that their time can be utilized more efficiently. The physician does not even have to be physically in the office – he or she can be in the hospital or even at home. This frees up the office space for another physician to use it for in-person visits.

Another advantage of telemedicine-only schedules is that by giving the patient a time range that the physician will contact them for the telemedicine visit (for example, between 1:00 – 2:00 PM), the patient does not need to sit in the exam room waiting for the doctor, they can be in the comfort of their own home or workplace. This way, if the physician is running a few minutes late because the previous patient took longer than anticipated, patients are less likely to become angry from long waiting times.

The disadvantage of telemedicine-only schedules is that the physician has to have enough days that they see outpatients so that some days can be devoted to in-person visits since there are inevitably some patients who must be seen face-to-face. So, if a physician has a very small outpatient practice, this approach is not practical.

Combining telemedicine and in-person schedules

In this strategy, the physician intersperses in-person visits with telemedicine visits. An advantage of this strategy is that the physician needs fewer examination rooms – a doctor who normally uses 4 exam rooms to optimize outpatient practice efficiency may only need 2 or 3 exam rooms. This can cut down on overhead costs. If the doctor gets behind on the schedule, then the doctor can postpone a telemedicine visit by 20 minutes and see the patient already in an examination room – by and large, patients waiting in their own home will be less irritated if the doctor is 20 minutes late for the telemedicine visit than the patients waiting in an exam room or waiting room. Additionally, telemedicine visits generally take a few minutes less than an in-person visit (no physical exam) so alternating telemedicine visits with in-person visits helps keep the doctor on-time for all of the patients.

In the COVID-19 era of social distancing, physician office waiting areas are not able to safely hold as many people as in the past. By mixing telemedicine and in-person visits, the number of people coming into the office is lower and this results in fewer people in the waiting area. Mixed visits on the schedule also give office staff extra time needed to sanitize exam rooms between patients.

The fate of in-person-only schedules

Until 3 months ago, this was the model used by most U.S. physicians. The result was crowded waiting rooms, irritated patients when the doctor was running behind, and the expense of no-show patients. This model is inefficient and costly. It places high demands on office staff and the physician to keep the schedule on time. In the future, this will probably not be a financially viable method of seeing patients.

So how should you structure your schedule templates?

There is no single best answer and template optimization depends on the medical/surgical specialty, the number of half-day blocks of office hours an individual physician has, and how COVID-19 is affecting the community at any given time. My recommendation would be to:

  1. First, create half-day blocks of mixed telemedicine + in-person office visits. Depending on the size of the waiting room, the number of exam rooms per physician, and the practice specialty, this could be 2:1 telemedicine:in-person or perhaps 1:1 telemedicine:in-person visits.
  2. Second, create half-day blocks of telemedicine-only visits. For many physician practices, this will be approximately 1/3 or 1/4 of the total half-day blocks.
  3. Have more than 1 telemedicine software application that your office uses and educate your patients on how to use the app. Many of the video chat programs currently being used for telemedicine require a specific web browser or a specific cell phone operating system. Also, many of these programs require the patient to update to the latest version of web browser software. In order to accommodate the largest number of patients, have 2 or 3 available options for telemedicine video conferencing in order to tailor each patient’s web browser or operating system.
  4. Know your patients’ technologic limitations. A surprisingly large number of patients do not have a computer or phone with a camera or live in an area where there is insufficient internet bandwidth or cell service to do video telemedicine visits. These patients will need to be scheduled for in-person visits.
  5. Be aware of state-specific rules regarding out-of-state telemedicine visits. Many states have eased regulations in the COVID-19 era but most normally have restrictions about medical licenses being valid only for telemedicine visits performed within that state and not for visits when the patient is in another state. These patients will need to be scheduled for in-person visits.
  6. Train the office staff on how to instruct patients to use the video chat telemedicine app. When we first started using telemedicine at the beginning of the COVID-19 outbreak, I would frequently wait for 5-10 minutes for a patient to join the video visit and then I would have to call them on the phone to talk them through using the applications. Ideally, the office staff should do this before the physician video visit with a practice video visit so that the patient becomes familiar with how to use the program.

Telemedicine is (hopefully) here to stay and promises to improve the efficiency of outpatient practice, reduce no-show rates, and provide care to patients who otherwise would not be able to travel to see the doctor. Creating the right schedule template will allow the physician to function with maximal efficiency and generate maximal patient satisfaction.

June 23, 2020

Categories
Outpatient Practice

Is It Safe To Go To Your Doctor’s Office During The COVID Outbreak?

In March 2020, outpatient medicine as we previously knew it changed, perhaps forever. The COVID-19 outbreak was accelerating in the United States and by the beginning of June, it would kill more than 100,000 Americans. People self-isolated in their homes, businesses shut down, and hospitals prohibited visitors. Patients were scared to go to their doctor’s offices and doctors were scared to be in their offices with patients.

In Ohio, the Governor and the Director of the Department of Health issues orders to stop elective medical testing and procedures. Medicare eased restrictions on telemedicine so that patients could still see their physicians without risking exposure to the virus in the doctors’ offices. All of a sudden, it wasn’t safe to go just about anywhere.

Today, our state’s medical practices and hospitals are opening back up for regular medical care and procedures. But the virus is still in our communities and is still causing hundreds of deaths per day. So, is it safe to go to your doctor’s office or to your hospital for an elective surgery? As usual, the answer is… it depends.

In the era of COVID-19, the moment we step outside of our homes, everything we do is a calculated risk. Going to the grocery store for on-line ordering with curbside pick-up is relatively low risk. Going to a sold-out concert and spending 4 hours in a mosh pit is relatively high risk. In our community, many people have died because they got infected with COVID-19 but many others have died because they stayed home in fear of the virus rather than going out to get needed medical care. So, how do you know if it is safe to go to your doctor’s office? Fortunately, there are several things that you and your doctor’s office can do that will improve the safety of patients coming in for medical care.

  1. Limit visitors. The risk of getting infected with COVID-19 increases with the more people you have close contact with. By limiting visitors, there will be fewer people in the building and statistics will be in your favor. Ideally, there should be no visitors except for those necessary to accompany patients with impairments.
  2. Screen everyone entering the building. This means asking if people have had contact with persons known to be infected with COVID-19, if they have fever, or if they have cough. Ideally, everyone entering the building should have their temperature checked at the entrance.
  3. Provide masks. The main reason for non-medical people to wear a mask is to prevent them from infecting others – wearing a mask does less to help keep you from getting infected yourself. When I go to a store, I wear a mask to protect everyone else from me, not to protect myself from everyone else. Buildings where everyone else is wearing a mask are buildings that are safer for you to enter.
  4. Improve throughput efficiency. The less time that a person is in the building, the lower their potential exposure risk. Strategies can include pre-visit registration on-line, reducing time spent in waiting areas, and minimizing time between tests and the doctor’s appointments (for example, the time between a doctor’s appointment and getting an x-ray in the same building).
  5. Safe waiting rooms. Most doctors’ offices and hospitals have waiting rooms that are designed to fit the largest number of people comfortably in the smallest space possible. In the era of COVID-19, there should ideally be 6 feet between people in the waiting areas. This means that most waiting areas should only hold about a quarter of the number of people that the same waiting areas held in the pre-COVID-19 era. Waiting areas can be restructured by removing chairs and by putting up plexiglass or other barriers between chairs.
  6. Don’t shake hands. Almost overnight, the handshake has gone from a welcoming greeting to a threatening gesture.
  7. Go before you go. The fewer doorknobs, handles, and buttons that you have to open, press, or push, the lower your risk of acquiring the COVID-19 virus if the person before you opened that door, pressed that toilet handle, or pushed that elevator button. Use the restroom before you leave home.
  8. The smell of disinfectant is perfume to your nose. If the exam rooms smells like fresh bleach or alcohol-based disinfectants, then the office staff are likely sanitizing that room between patients. That will make chair hand rests, examination tables, and counter tops safer for you to touch.
  9. Use telemedicine. Sometimes, an in-person visit with the doctor is necessary. A physical examination may be required. Maybe you need a vaccination, a blood draw, or an EKG. However, many (and maybe most) doctor’s visits can be done by video visits or even telephone visits. Currently, Medicare and many insurance companies are relaxing restrictions on telemedicine so that doctors can get paid to do telemedicine visits whereas in the past, those insurance companies would only pay for face-to-face office visits. If you can get everything accomplished by a telemedicine visit from the safety of your own home, then do so. A side benefit of telemedicine is that if the doctor is doing two thirds of the visits by telemedicine, then there will be fewer patents in the waiting area and fewer patients in the building thus making it safer for those patients who do require an in-person visit. Because I care for patients with COVID-19 in our hospital’s ICU, I am sensitive to the fact that many of my outpatients would rather not be in the same room as I am on the outside chance that I could have picked up the virus and either be asymptomatically shedding it or be in the incubation period before full-blown infection. Therefore, even if my patients have to come in for pulmonary function tests or x-rays, I will still offer them a telemedicine visit so that they can come in, get their tests, go home, and then have a telemedicine visit with me later.
  10. Schedule acutely sick patients for the end of the day. In the past, I often used the last appointment of the afternoon for those patients who I anticipated would need extra time for counseling – that way, if I spent 30 minutes for a 15 minute appointment, I wouldn’t be behind on my schedule for all of the subsequent patients. Now, I’d rather have that last patient of the day be the one who has more acute respiratory symptoms so that most of the other patients are out of the building and the waiting area when a patient who could potentially have COVID-19 shows up.
  11. Show up on time but not too early. If your appointment with your doctor is at 11:00, don’t come to the office at 10:00 or you will have to wait in the waiting area for an hour. But don’t be late either since you might then have to wait an hour or two until the doctor has another opening on his/her schedule to fit you in.
  12. Hand sanitizer everywhere. Ideally, there should be alcohol-based hand sanitizer in waiting areas, hallways, offices, and exam rooms so that office staff and patients can sanitize their hands as often as possible.
  13. Keep COVID-19 patients away from other patients. Most patients with COVID-19 are treated as outpatients but they still need regular medical care. Our medical center has drive-up swabbing stations to safely test patients for COVID-19 infection in their own cars and we also can do blood draws at these sites so that patients with known COVID-19 infection can get regular blood tests, such as INR levels if they are on anticoagulants. This keeps patients with COVID-19 pneumonia from having to go to the clinic lab to get those blood draws and thus keeps them away from healthy people.
  14. Don’t touch your face. One of the side benefits of wearing a face mask is that it will keep you from subconsciously touching your mouth or nose after you have touched a surface that harbors the virus. If you need to blow your nose  or sneeze, use hand sanitizer both before and after you use a tissue.

Most hospitals and physician offices are actually fairly safe, as far as COVID-19 is concerned. There is heightened attention to infection control, hand sanitizing, and masking that is not as universally practiced at other venues such as stores, gas stations, and public spaces. That being said, there are steps that both the doctors and the patients can take that can make outpatient visits even safer.

June 6, 2020

Categories
Epidemiology

When It Comes To COVID-19, Are We Testing The Right Thing?

During this COVID-19 outbreak, I have the dual roles of overseeing our hospital’s response to the pandemic and also of rounding in our ICU and taking care of COVID patients first-hand. One of issues that I struggle with in both of these roles is how accurate is our testing? Currently, we have 3 ways that we test for active COVID-19 infection: a nasopharyngeal swab for a rapid molecular test (made by Abbott Corporation), a nasopharyngeal swab for a PCR (polymerase chain reaction) test, and bronchoalveolar lavage fluid for a PCR test. We use the first two a lot and use the last one rarely. But do we have this backward?

The rapid molecular test by Abbott is very quick and our lab can have the results in < 1 hour. The criticism of this test is that it is less sensitive than the PCR tests so you can miss patients who are infected with COVID-19, particularly if they have mild symptoms or are asymptomatic.

The nasopharyngeal PCR test is currently considered the “gold standard” test for COVID-19. It appears to be more sensitive than the Abbott rapid test so it pick up more patients infected with the virus. However, it takes longer – 8-12 hours if your hospital does testing for it in-house and 2-3 days if it has to be sent to an outside lab. We primarily use this test if the Abbott rapid test is negative and we still clinically suspect COVID infection or if a patient without symptoms needs to be cleared of having the infection prior to undergoing an elective surgery.

The bronchoalveolar lavage (BAL) PCR test requires the patient to undergo bronchoscopy, an invasive procedure that requires sedating the patient and can put hospital staff at risk due to aerosolizing infected lung fluids into the air. Doing bronchoscopy on patients with suspected COVID-19 infection is generally discouraged because of the risk to the staff and the risk to the patient of an invasive procedure. Therefore, we don’t do a lot of BAL COVID tests.

Most respiratory viruses affect either the upper respiratory tract alone or both the upper and lower respiratory tract. The upper respiratory tract consists of the nose and throat; the lower respiratory tract consists of the lungs. COVID-19 is unusual among respiratory viruses in that it primarily causes symptoms in the lower respiratory tract resulting in cough, low oxygen, and shortness of breath. COVID generally does not cause much upper respiratory tract symptoms, such as sneezing or a runny nose.

So one has to wonder, if COVID does not affect the upper respiratory tract, how good is testing nasopharyngeal secretions?  Most of us who care for patients with COVID infection have encountered patients who had 1 or more nasopharyngeal Abbott rapid tests or PCR tests that were negative only to have the 2nd or 3rd PCR test end up being positive. We are also now seeing patients who have multiple negative nasopharyngeal PCR tests who then get a bronchoscopy and their BAL COVID PCR test comes back positive.

We spend a lot of energy debating whether the nasopharyngeal Abbott rapid or the PCR test is the best test. But maybe we ought to be asking whether the BAL is really the best test. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. For those patients who present to the hospital with COVID-like signs & symptoms but have a negative nasopharyngeal PCR test, we may need to start doing more bronchoscopies with BAL COVID testing before pronouncing those patients virus-free.

May 17, 2020

Categories
Intensive Care Unit

The Pandemic Of Dogma Within The Pandemic Of COVID-19

Our generation of physicians prides itself on the practice of evidence-based medicine. Ideally, this means making medical decisions based on peer-reviewed clinical studies and randomized, controlled clinical trials. It means getting away from the “this-is-the-way-you-do-it-because-this-is-the-way-we’ve-always-done-it” approach to medicine to ensure that patients get the best known treatment for any given medical condition.

But what happens when you face a disease and there are no peer-reviewed publications and randomized controlled clinical trials? In that situation, physicians’ definition of what constitutes evidence can vary considerably. Thus enters dogma and nowhere in recent memory has there been a greater pandemic of dogma than in our intensive care units managing patients with COVID-19. As critical care physicians, we hold our convictions about how to best treat patients with COVID-19 respiratory failure more tightly than we hold religious convictions or political convictions. And given that many of these convictions are diametrically opposed, we can’t all be right. Forty years ago, in my first week of medical school, one of the professors told me that 50% of everything I was about to learn was going to ultimately be proven to be wrong. I think those words could be just as easily applied to our approach to managing patients with COVID-19 in the ICU today.

To Ventilate or Not To Ventilate?

That  is the question… or is it? For decades, we have defined patients as having ARDS (acute respiratory distress syndrome) if they have acute onset of diffuse pulmonary infiltrates with severe hypoxemia in the absence of heart failure and in the presence of something known to cause non-cardiogenic pulmonary edema, such as infection. And ever since 1967 when surgeon David Ashbaugh and pulmonologist Tom Petty first described the ARDS in the medical literature, it has been well-accepted that mechanical ventilation with PEEP (positive end-expiratory pressure) is the first line treatment.

But in the era of COVID-19, we read on-line news articles about a hospital in New York that reported 88% of their patients placed on mechanical ventilators died. And then all of a sudden, some critical care physicians are having second thoughts about intubating COVID-19 patients in respiratory failure and instead letting them be hypoxic. On the other hand, we read a blog post from a physician in Europe that he observed hospitalized COVID-19 patients develop sudden severe hypoxemia and go from needing 4 L oxygen by nasal cannula to having respiratory arrest despite 100% oxygen by face mask in just 30 minutes. And all of a sudden, some critical care physicians are intubating every COVID-19 patients who needs 4 L oxygen by nasal cannula.

Maybe COVID-19 really is different from ARDS from any other infection. But until someone proves that, I know that mechanical ventilation can bridge patients through life-threatening ARDS until time heals the lungs, that PEEP helps, and that low tidal volume ventilation is better than high tidal volume ventilation. We should not throw out everything that we’ve learned about the management of ARDS over the past 53 years because of a blog post.

Steroids Yes or Steroids No?

Over the past 35 years, the steroid pendulum has swung back and forth several times with respect to treating ARDS. First, studies showed steroids were beneficial, then studies showed they were not beneficial, and now studies again suggest they might be beneficial again. Similarly, you can find studies that show steroids improve the mortality rate of other coronaviruses and influenza; you can also find that steroids have no effect on the mortality rate of viral pneumonia. Some critical care physicians believe that steroids are the cure to the “cytokine storm” attendant to COVID-19 respiratory failure. Other critical care physicians believe that steroids paralyze the body’s immune defenses against COVID-19 resulting in increased viral replication. Our resident and fellow trainees are often caught in the middle, hearing that “You’re going to kill your patients if you don’t give then steroids” from one critical care attending physician on Monday and then hearing “You’re going to kill your patients if you give them steroids” from another critical care attending physician on Tuesday.

Hydroxychloroquine?

A non-randomized, non-placebo-controlled study from France suggested that 20 COVID-19 patients who got anti-malaria drug hydroxycholorquine had lower levels of detectable virus than patients previously published in the literature. This made immediate news in the lay press and the U.S. President called the drug a “game changer”. Within 3 days, pharmacies all across the country were sold out of hydroxychlorquine and I had patients calling in and asking me to prescribe it for them to prevent getting COVID-19 infection. Physicians throughout the world began prescribing it for any of their patients sick enough to be admitted to the intensive care unit. But then other studies showed that patients who received hydroxychloroquine actually did worse than those did not receive it because of potential fatal heart rhythm disturbances brought on by hydroxychloroquine. Once again, you’ll find critical care physicians who think it is the standard of care and others who think that it is nonsense.

Tocilizumab?

Patients with COIVD-19 have high levels of the cytokine, IL-6. This occurs during the “cytokine storm” that these patients can get when their macrophages and monocytes produce enormous quantities of pro-inflammatory cytokines. This is also called the “macrophage activation syndrome”. Tocilizumab is an inhibitor of IL-6 and so some physicians believe that by inhibiting IL-6, the cytokine storm can be attenuated. It is one of those “makes sense, no data” treatments that might make patients better, might not do anything at all, or might actually make them worse. But in the absence of randomized, placebo-controlled clinical trials, you can find critical care physicians who are staunch proponents and others who are staunch opponents.

And Everything Else?

Across the United States, there are some critical care physicians who believe that because D-dimer levels are high, that anticoagulation helps by preventing clotting; other critical care physicians thing that empiric anticoagulation just makes patients bleed more. Some physicians believe that inhaled vasodilators such as nitric oxide or epoprostenol improve oxygenation in COVID-19 patients by redirecting blood flow to less affected parts of the lungs; other physicians believe that these drugs can cause patients to become hypotensive and develop cardiac arrest. Other treatments that might or might not work include transfusion of plasma from patients who recover from COVID-19 infection, the anti-viral drug lopinavir/ritonavir, another anti-viral drug remdesivir, and the complement inhibitor eculizumab.

As humans, for thousands of years we have sought ways to control nature. And we base a lot of our attempts at control on anecdotal experience that leads to superstition. For example, a child falls into a volcano and the next day it rains so the village starts throwing lots of children into the volcano the next year when there is a drought. As physicians, we are no different. We see or hear about a patient who got one treatment or another and got better and then that one patient or small group of patients becomes the evidence that we base our practice on when there is a vacuum of randomized, placebo-controlled clinical trials. COVID-19 has overtaken the world suddenly, too fast for science to give us direction about how to best treat patients and so we fall back on medical superstition. Some of those superstitions will ultimately be proven to be right and others will ultimately be proven to be wrong.

So, all of a sudden, what constitutes evidence in evidence-based medicine today is a lot different than what constituted evidence last year.

April 25, 2020

Categories
Epidemiology

Imagining Life After COVID-19

It is mid-April and physicians and hospitals are already planning on how and when to re-institute normal operations, like flowers poking through snow after a cold winter. But it is pretty clear that the normal operations of the future will not be like the normal operations of the past. I’m using this post to speculate on how things may be different.

Hand sanitizer will become the new tabletop condiment

If  you go to a breakfast restaurant, you’ll find pitchers of syrup and honey on the tables. At lunch and dinner, there will be bottles of ketchup, mustard, and hot sauce on the tables. In the future, look for bottles of hand sanitizer on your restaurant tables.

Obstetricians will be busy in January 2021

“Blizzard baby booms” are a debated phenomenon that lie somewhere between urban myth and obstetric reality. I am a member of the baby boom generation, a surge in babies born after soldiers returned to the U.S. after World War II and the Korean War. That baby boom was a reality but whether there is a mini-boom of babies born 9 months after hurricanes and blizzards keep people indoors for a period of time is more uncertain. A blizzard or hurricane keeps people cooped up together for just a few days but COVID-19 keeps couples isolating at home with little to do for weeks. Will the social isolation of March and April result in a lot of babies in December and January?

Infectious disease physicians will be hospital medical directors

In a war, Majors are promoted to Colonels and Colonels are promoted to Generals by demonstrated success in battle. Similarly, hospitals select their medical directors based on administrative success in leading individual hospital programs. Throughout the world, hospitals are having their COVID-19 response led by epidemiologists and infectious disease specialists. Those who successfully steer their hospital through the infection control and financial perils of the pandemic will find themselves in line for promotion to hospital leadership positions.

Surgical masks won’t just be for surgeons any longer

Wearing a surgical mask does help prevent one from becoming infected with respiratory viruses when an infected person coughs or sneezes in your face. But when everyone wears a mask, there are two other important infection control effects. First, if the person wearing the mask is unknowingly infected with a respiratory virus, it helps prevent that masked person from coughing or sneezing on others. Second, when a person is wearing a mask, it reduces the chance that the person will touch their nose, mouth, or eyes with hands that could have picked up respiratory viruses from fomites such as a door handle, shopping cart, or elevator button that harbored viruses. In the future, people may likely feel more safe when those around them are wearing masks and that may be doubly so for their doctors and nurses wearing masks. Look for future masks emblazed with people’s favorite NFL team, alma mater, or beer maker.

A COVID-19 PCR test will become a routine admission order

When most patients get admitted to the hospital through the emergency department, they get “routine admission labs” – generally a CBC and chemistry panel. Look for a COVID-19 test to be added to that list of routine tests. Right now, there is near-paranoia by many physicians that their patients will have asymptomatic and potentially contagious COVID-19 to the point that they will not do procedures unless their asymptomatic patients have a negative COVID-19 PCR test. Even then, many demand that they be allowed to wear an N-95 mask for patients with a negative test because of the theoretic possibility that the test is a false negative.

Public health nurses will have job security

Countries that have been successful in controlling the COVID-19 outbreak have had very strong case isolation and contact identification. This takes manpower – primarily public health nurses that can go out in the community to interview patients and do testing of contacts. Public health departments are often underfunded  and understaffed. There will be increased demand for public health nurses for the foreseeable future.

Don’t expect your hospital to replace the old MRI machine

Although many U.S. hospitals have their ICUs full of COVID-19 patients, their overall medical/surgical census is generally low. That is because elective surgical procedures have all been postponed. Not only are surgeries not being done but neither are non-emergent diagnostic tests such as MRIs, CT scans, cardiac non-invasive tests, and pulmonary function tests. Hospitals don’t make much money off of medical admissions and depend on those surgeries and diagnostic tests to show a positive financial margin at the end of the year. Currently, hospitals are burning through their reserves (“days cash on hand”) with all of these surgeries and procedures not being done. With days cash on hand depleted, hospitals will be postponing large expenditures over the next couple of years.

The handshake will be a custom of the past

When a patient is infected with COVID-19, their hand becomes a fomite that can transmit the virus to everyone that they touch. Overnight, the handshake has changed from a greeting of politeness to a gesture of threat. Look for the handshake to disappear as an American social convention.

Telemedicine will come of age

Until March 2020, telemedicine was relegated to a few specific circumstances and primarily used in rural, sparsely populated areas of the nation. With the federal government relaxing rules for telemedicine, physicians all over the country are realizing that a lot of routine outpatient care can be done by telemedicine. Medical practices are adopting video telemedicine platforms through their electronic medical record or through separate commercial video applications. I have found that video telemedicine works very well for many of my patients, for both new and return visits. For patients who lack transportation or who live long distances from the office, the convenience of a video visit is a game-changer.

Anti-vaccine proponents will finally be quiet

One of the reasons that anti-vaxxers have flourished is that enough other people get vaccines so that devastating diseases such as polio, measles, and hepatitis B are uncommon enough that herd immunity protects the anti-vaxxers. If there were no influenza vaccines, then even influenza could periodically be as threatening as COVID-19. The current pandemic is a reminder of just how deadly infectious diseases can be and how much they can disrupt the economic structure of a community. An effective vaccine against COVID-19 will hopefully silence the anti-vaxxers since COVID-19 is unlikely to otherwise go away – it will just periodically die back and flare up as long as there are immunologically susceptible people for it to affect. The older the anti-vaxxers get, the more likely they are to become critically ill and die should they become infected and this will hopefully motivate them to forget their conspiracy theories and get a COVID shot.

It will be safe to go outside when your doctor has a beard

All of a sudden, most doctors and nurses in the United States became clean-shaven. That was because they needed to get fit-tested for N-95 face masks and a couple of years ago, OSHA made a rule that men with beards could not undergo fit-testing. Because I normally see patients in the hospital in airborne isolation (for example, those who are suspected of having tuberculosis), I have had an annual N-95 fit test for many years. And each year, I always passed my fit test, even though I had a beard. When OSHA came out with their rule, I was no longer permitted to wear an N-95 mask and had to switch to a PAPR hood but with PAPRs in short supply nationwide, men who provide inpatient healthcare had to shave and be fit tested. Just like robins are the first sign of spring, doctors with beards will be the first sign that the hospitals are no longer full of COVID-19 patients.

April 16, 2020

Categories
Committees

Improving Your Camera Appearance On Video Conferencing

The COVID-19 pandemic has changed business meetings forever. Committees and workgroups previously always met in person in a conference room but the need for social distancing has led to conference calls now replacing in-person meetings. Whether you use WebEx, Zoom, GoToMeeting, Blue Jeans, or some other meeting application, you are now on video camera and how you use that camera can greatly influence how you present yourself to other people. Lighting, background, and camera position can make the difference between you coming across as a professional or as a dud. Here are some tips to make sure that you use video conferencing to best effect.

Be aware of what is behind you

Video conferencing from your kitchen with a stack of dirty dishes behind you or from your basement with that poster of dogs playing poker that you’ve had since college is not going to project a image of competence and dedication to the job. Also, be aware of a plain wall that can create an institutionalized presence. A window with people or cars passing by can be distracting. I prefer an uncluttered bookshelf (just be careful what book titles are on that shelf!).

Be aware of what you are doing

When my mind starts to wander during video conferences, I start to scroll through the various participants to see what people are doing. Inevitably, someone is eating, or doing a crossword puzzle, or watching television. It is easy to forget that just because you are alone in a room, everyone is still watching you. Also, many video cameras will have auto-focusing lenses. if you move, particularly from front to back, you will become blurred for a moment while the lens refocuses. If you move back and forth frequently, then you will appear blurred more often than you appear in focus.

Get the correct camera position

The camera should be lined up horizontal and level with your face. This can be tricky if you are using your cell phone since it is often too easy to just lay the phone flat on your desk next to your computer screen or prop your phone up on the desk below your face. You end up giving the conference call attendees a great view up your nose and of your ceiling. A camera mounted to the top of the computer monitor works well. Don’t forget that when you are talking to other person on a video conference, look at the camera and not the other person – it is very tempting to look at the person whose face is appearing on your computer screen but when you do that, your eyes will appear to be looking down to the other person. It is better to look directly at the camera so that the other person perceives that you are having eye-to-eye contact with them. When I video conference with patients during telemedicine visits, I position their video image in the top of my computer screen, just below my camera, so that they perceive me looking at them. I give them warning that I will sometimes be looking away from them as I enter information into the electronic medical record that I have pulled up on a second monitor.

Lighting makes a big difference

I have moderated our our College of Medicine’s weekly continuing medical education webcast, MedNet for 18 years, and moderated its predecessor satellite television program, OMEN-TV (Ohio Medical Education Network) for 4 years before that. I’ve spent a lot of time in television studios over the past 22 years and have come to appreciate the importance of lighting. Most people don’t have formal studio lights at home but a couple of well-positioned floor lamps or table lamps can make a big difference. If you want to spend a little money, you can get a good quality basic 3-light set of studio lights with umbrellas for about $50. Here is how I have my office set up for video conferencing with the blinds shut, overhead fluorescent lights turned off, and a 3-light studio lighting set. Different lighting can affect how you look on a video conference:

  1. Natural window light. Different types of light bulbs will have a different color of light and this can affect how you appear on a video conference. Natural sunlight is ideal so if you can position yourself so that you are facing directly toward a window, you can get good, even lighting on your face. However, many offices are laid out so that the person is not facing directly at a window because it can create eye strain when a computer monitor is set up on the desk with the sunlight coming directly into the person’s eyes. Therefore most offices will have a window to the side of the desk. This can create asymmetric lighting of a person’s face during a video conference resulting in a shadow across half of the face, such as you see in this photo (I apologize for the stern look). If the sun is shining directly in the window, then that will further accentuate the shadows on one side of the face and cause glare on the other side of the face.
  2. Overhead ceiling light. This is what is generally installed in most offices and is very functional for most day-to-day office work. However, it can create glare on the top of the head, particularly if you happen to be bald or have a large forehead. Furthermore, this will create shadows from your eyebrows that can make you look sinister.
  3. Computer light. One of the problems with using your computer as a light source is that the amount of light and the color of the light can vary from moment to moment, depending on what is on the computer screen at any given time. When doing a video conference, you can’t get away entirely from the computer screen since you will usually be watching other people on video or looking at PowerPoint presentations when you are on camera. But if you rely entirely on the computer screen light, it will make it look like you are living in a cave.
  4. Studio lights. A basic studio light set up will include a right frontal light, a left frontal light, and a back light. The left and right lights will generally be mounted slightly above the subject and the back light will be close to the floor behind the subject. By using umbrellas on the left and right lights, you can diffuse and soften the light. If the light is still to bright, you can reverse the lights and umbrellas so that only light reflected off of the umbrella reaches the subject. If you don’t have studio lights, then a couple of lamps can work nearly as well. This photo uses a 2-light studio lighting set (with the back light turned off).
  5. Be aware of what you are wearing. If you have a dark background, you should be wearing lighter colored clothing. Otherwise, you will fade into whatever is behind you. A back light can help offset this by creating more definition to the border between you and the background but back lights are often impractical in a regular office. If you keep a jacket or sweater in your office that contrasts nicely with the office background, then you don’t have to be constantly planning your wardrobe around whether and where you’ll be doing a video conference later in the day. Ideally, you should choose a background that creates contrast with your skin tone – if you are have a  light complexion, then a dark background is optimal but if you have a dark complexion, then a lighter background helps to create contrast. If you don’t have a choice in the background, then using a back light can help to provide some contrast to help separate your face from the background.

Put the camera at the right distance.

Ideally, the camera should be 2-3 feet from you. You will amplify your nose and chin due to distortion if the camera is too close. If the camera is too far away, then you will appear small and this can negatively affect how others perceive you on a video conference. However, each camera is a little different so you have to experiment a bit to find the right distance. Also, if the camera is too close, then it accentuates things that you may not want accentuated, like your 5 o’clock shadow (all physicians at our hospital were required to shave their beards during the COVID-19 outbreak this year so that they could be fit-tested for N-95 masks so I’ve recently experienced the 5 o’clock shadow for the first time in 35 years!). If your entire face fills the video screen, the people viewing you on a video conference will perceive that you are very close to them and it can create a sense that you are encroaching on personal space.

Humans most effectively communicate with a combination of sound plus visuals. Facial expressions, body positioning, and hand gestures can greatly enhance speech alone. In order to optimize your presence and be as persuasive as possible during a video conference, you need to be aware of how you appear on camera.

April 12, 2020

Categories
Emergency Department Inpatient Practice Intensive Care Unit

With COVID-19, Hope For The Best But Prepare For The Worst

In August 2004, my family was vacationing on the North Carolina Outer Banks. I had been following Tropical Storm Alex as it came north from the Caribbean toward the island that we were staying on. On August 3rd, it was looking like the storm was going to head out over the Atlantic the next afternoon and miss Cape Hatteras. Not wanting to take any chances, I decided to get up early the next morning, pack up the kids, and head inland for the day, just to be sure. When I woke up at 5 AM, the first thing I heard on TV was that overnight, the storm had picked up wind speed, was moving across the ocean faster than expected, and had turned inland – directly toward our rental house in the town in Salvo. The second thing that I heard was that there was that storms overnight had caused sand and water to block the only road on the island leading to the bridge to mainland. The news announcer said to all of the people now stuck on Hatteras Island “Hope for the best but prepare for the worst.”

Having 4 children, my wife and I were used to buying in bulk and since this was at the beginning of our planned 2-week vacation, we were already pretty well stocked with food and supplies. We filled up all of the bathtubs with water for bathing and filled up as many bottles as we could find with drinking water.

By the time the storm hit us, Alex was now a level 2 hurricane. The eye wall passed over our rental house and as the wind changed direction with the passage of the eye, we moved all of the kids from a bedroom in one corner of the house to bedrooms in other corners. As the power went out, the wind sounded like a freight train and I watched as siding and parts of roofs were torn off of houses around us. A 2×4 board flew through the air like a missile across the street. Picnic tables, bicycles, and and lawn furniture were flung a hundred yards like toys. The roads all turned into rivers. Meanwhile, we played games with the kids and fed them Cheerios to keep them distracted.

It seemed like the end of the world and I wanted to be almost anywhere other than where we were.

But by afternoon, the wind died down, the clouds cleared, and the sun came out. All of a sudden, it was just another beautiful day on the Outer Banks. Over the next 3 days, the power returned, the flood waters subsided, and the sand was cleared from the roads. The bridge re-opened and the people staying in Salvo came out and cheered when one of the first vehicles that crossed the bridge to the island was a Budweiser truck.

COVID-19 is a lot like Hurricane Alex. The patient surge is coming and we can’t just wish it away. Just as the news announcer said on TV in the morning of August 4, 2004, we should hope for the best but prepare for the worst. But also like Hurricane Alex, the COVID-19 surge is going to pass; the clouds and pandemic storm is going to eventually subside; and life will be back to normal once more.

April 1, 2020

Categories
Inpatient Practice Intensive Care Unit

Reducing Hospital Employee Exposures To COVID-19 Patients

Having patients with COVID-19 in the hospital can be disturbing to the doctors, nurses, and respiratory therapists who take care of them. The good news is that isolation procedures work and proper use of personal protective equipment can dramatically reduce the chance of getting healthcare workers infected. Even though that risk is low, there are certain simple steps you can take that will reduce the risk even further. By taking these steps, you not only reduce healthcare worker exposures but you can also conserve personal protective equipment (masks, gowns, gloves). Here are a few:

  1. Use the right personal protective equipment (PPE) and be sure that it is used correctly.
  2. Minimize blood draws. If you don’t need daily labs, don’t send the nurses in to draw them. When you do get labs, try to cluster all of the lab tests that you need in a single phlebotomy.
  3. To anticoagulant a patient, use oral apixaban, oral rivaroxaban, or subcutaneous enoxaparin instead of a heparin drip. The problem with heparin drips is that you have to do frequent PTT blood tests. Other anticoagulants do not require testing.
  4. Use a sliding scale of subcutaneous insulin rather than an insulin drip. Insulin drips require the nurse to check the patient’s blood glucose every 1-2 hours whereas the SQ insulin sliding scale may only need to be done every 6 hours.
  5. Synchronize medications. Ordering a Q6 hour medication plus a Q8 hour medication means that a nurse has to go into a patient room 7 times a day. If that Q6 hour medication can be stretched out to be given Q8 hours, then a nurse only has to enter a patient’s room 3 times a day. Even better, use medications that only have to be given once a day whenever possible. This is particularly true of empiric antibiotics where there may be multiple equally appropriate antibiotic choices – some that have to be given 3 or 4 times a day and some that only have to be administered once a day.
  6. Use meter dose inhalers instead of nebulizer treatments. Nebulizers can result in aerolsolization of viral particles, at least in theory. Meter dose inhalers for bronchodilator treatments reduce the amount of time that a respiratory therapist has to be in a room to deliver a bronchodilator treatment.
  7. Have patients self-administer meter dose inhalers (or nebulizer treatments). The respiratory therapist can often observe the patient from a door window or a video monitor to ensure that the patient uses proper technique.
  8. Minimize the rounding team. If bedside rounds normally consist of the attending physician, a nurse, a resident, and a physician assistant, then reduce that to just the attending physician and just once a day.
  9. Don’t use physical and occupational therapy if you don’t need it. Frequently, admission order sets will include PT and OT for nearly every admission. Only order it if you really need it.
  10. Don’t order tests that you don’t need. “Routine” daily chest x-rays are usually unnecessary.
  11. Don’t order tests that can be done later. If a chest x-ray shows a suspicious pulmonary nodule and a chest CT is recommended for confirmation, that CT can wait a few weeks.
  12. Empiric treatment is OK. If a patient has epigastric pain, rather than ordering an endoscopy right away, give the patient some empiric omeprazole to minimize procedures.
  13. Utilize inpatient telemedicine for consults. There are two ways to do this, by a regular telemedicine visit or by an eVisit.
    1. CPT 99451 is for an eVisit and reimburses at 1.04 RVUs. There has to be an order for the consult and the consultant has to put a note in the medical record. The consultant must document his/her time and it must be > 5 minutes. This is a way to get reimbursed for the so-called “curbside consult”. An example would be “What follow up should occur for the incidental 5 mm pulmonary nodule that was seen on my patient’s CT scan?”
    2. CPT G0425 (30 minutes ), G0426 (50 minutes), and G0427 (70 minutes) are for initial inpatient telemedicine consults. For follow up inpatient consult visits, use CPT G0406 (15 minutes ), Go407 (25 minutes), and G0408 (35 minutes). These codes are based on the amount of time communicating with the patient
  14. Can you run your pumps outside of the patient’s door? continuous infusion pumps are forever alarming or needing infusion rates to be frequently adjusted. If the infusion pumps can be placed outside of a door with the tubing running under the door then the pumps can be adjusted without the nurse having to enter the room.
  15. Eliminate visitors. Visitors can bring COVID with them and many visitors have often had close contact with COVID patients before they were admitted, making them especially high risk. By eliminating visitors, there are fewer members of the public in patient care areas who can infect hospital staff. Furthermore, there are fewer times that the patient’s door is opened and no additional personal protective equipment consumed by the visitors.
  16. Be sure that the healthcare personnel are getting enough rest. When a nurse, RT, or physician works too long of a shift or too many shifts, fatigue can set in and with fatigue brings mistakes. Mistakes with isolation procedures can create infection risks.

March 31, 2020

Categories
Epidemiology

Droplets, Fomites, and COVID-19

The disease COVID-19 is caused by the virus SARS-CoV-2. This is a member of the coronavirus family. These are viruses that can infect humans, other mammals, and birds. Most coronaviruses are rather benign respiratory viruses that account for about 5-10% of annual colds and flu-like illnesses. But occasionally, a coronavirus will successfully jump from one species of mammal to humans. When this happens, humans have never encountered that particular strain of coronavirus and so we have no immunity against it. Recent examples of coronaviruses making this zoonotic jump include SARS (from bats) and MERS (from camels). Although we do not know for sure, it is believed that SARS-CoV-2 originated in bats.

Coronavirus are transmitted the same way as other respiratory viruses are transmitted, by droplets of respiratory secretions. There are two ways that droplets can spread the virus. Either an infected person can cough or sneeze in another person’s face with the result that those respiratory droplets land on the second person’s nose, lips, or face. Or, the the infected person can get those respiratory droplets on their hands by coughing into their hand or touching their nose or mouth with their hand; when the infected person’s hand then touches a surface such as a door knob, light switch, keyboard, or television remote control, then those droplets get passed to those surfaces.

Those surfaces now become fomites. A fomite is any surface that that can serve as a intermediary conduit to get a virus or bacteria from an infected person into another person so that the infection spreads. Fomites are coronaviruses best friends. Certain types of surfaces make better fomites than others. For example, copper surfaces kill viruses whereas stainless steel surfaces do not kill viruses. Smooth surfaces, such as metal of glass, make better fomites than porous surfaces, such as upholstery or fabric, because viruses and bacteria tend to get wedged in between the fibers of fabrics making them harder to be picked up by another person’s hands.

Face masks can help prevent spread of viral-laden droplets from an infected person to an non-infected person, both in the hospital and in public. In the hospital, doctors, nurses, and respiratory therapists wear masks when caring for patients with respiratory viruses such as coronaviruses because they often have to get close to infected patients who can cough or sneeze in their faces. So in the hospital, it is the uninfected people who should wear masks.

In public, it is just the opposite; the infected person should wear the mask and not the average uninfected person. As long as you are maintaining social distancing by standing 6 feet from someone who is infected, even if that person coughs, those droplets are going to fall to the ground by gravity before they reach you. By having the infected person wear the mask, when they cough, they cough into the mask, thus substantially reducing the ability of those respiratory droplets to reach someone else. In fact, when healthy people wear masks when they are out in public, those masks get moist from the humidity of breath and most masks tend to get colonized with bacteria and fungus that can then make that previously healthy person sick.

So, it turns out that most respiratory viruses don’t get transmitted through the air, they get transmitted by fomites. And that means that the most important way to prevent spread of those viruses is by washing one’s hands after touching fomites.

If I could only have one thing to reduce the spread of COVID-19, it would not be a surgical mask or a face shield, or an N-95 mask. What I would want instead is soap and water.

March 30, 2020

Categories
Epidemiology Intensive Care Unit

Re-Using N-95 Masks In The Time Of COVID-19

The geniuses at Battelle have done it again. This time, they have invented a process for sterilizing and re-using N-95 masks using vaporized hydrogen peroxide. Battelle Memorial Institute is a non-profit scientific research and development institute here in Columbus, Ohio that is located about 3 blocks from the OSU hospital. Researchers at Battelle were the ones who invented the photocopier (and then launched Xerox Corporation), the cruise control for automobiles, the first nuclear fuel for nuclear-powered submarines, and the reusable insulin pen for injecting insulin for diabetics. In full disclosure, about 25 years ago, I had a grant from Battelle to assist with development of inhaled chemotherapy for lung cancer and that led to my receipt of the endowed Battelle Professorship in Inhalational Therapeutics that I held until assuming my position as the medical director of our hospital.

N-95 refers to a mask that can filter 95% of airborne particles. In medicine, we use N-95 masks when we care for patients with infectious diseases that are transmitted by airborne routes, such as tuberculosis, disseminated varicella, and measles virus. The virus that causes COVID-19 is the SARS-CoV-2 virus and this is believed to be transmitted by droplet spread rather than by airborne spread. Normally, viruses spread by droplets do not require the use of N-95 masks; a simple surgical mask with a plastic face shield will suffice. However, certain medical procedures, such as endotracheal intubation, can result in aerosolization of droplets containing viral particles and that is when the N-95 masks are needed.

For an N-95 mask to work properly, a healthcare worker must be fit tested to determine which specific type of N-95 mask fits tightly against the face. If a type of mask does not pass the fit test, then it will not filter out 95% of airborne particles and is no better than a regular surgical mask. Everyone’s face is shaped a little differently so different people will need different N-95 mask types. All healthcare workers who use these masks are required to get fit tested once a year to ensure that the mask that they are wearing actually does what it is supposed to do. Recently, OSHA declared that men who wear beards should not be fit tested because beards can interfere with a tight fit of the masks. For many years, I always passed my fit test with a specific type of N-95 mask despite my beard but because of OSHA’s rules, I was not able to be fit tested last year. Two weeks ago, our hospital required all men who could be involved in the care of a COVID-19 patient to shave their beards (so that they can be fit tested for N-95 masks) and thus, I shaved for the first time in 37 years!.

N-95 masks have come to the forefront of public consciousness recently because the COVID-19 outbreak is causing many hospitals to run low on N-95 masks. A misconception has arisen that N-95 masks are safer than regular surgical masks plus a face shield. For day-to-day care of patients with COVID-19, this really is not true because unless you are performing a procedure such as endotracheal intubation, an N-95 mask is unnecessary. Overuse of N-95 masks in situations when they are not necessary now will result in inadequate supples of these masks in situations when they are necessary in the future. In addition, the over emphasis on N-95 masks could lead the public to overlook the single most important way to prevent the spread of viruses spread by droplets, namely washing one’s hands after they touch various surfaces that those droplets land on (such as door handles and elevator buttons).

With supplies dwindling, Battelle invented a process for sterilizing N-95 masks so that they can be reused up to 20 times. They built the equipment to process 160,000 masks per day and this would greatly improve the nation’s N-95 mask inventory. However, medical equipment is overseen by the Food and Drug Administration. The FDA would only grant Battelle’s mask sterilization equipment limited approval, meaning that they are only permitted to sterilize 10,000 masks per day and only here in Central Ohio. That’s good news for our hospital because now we can count on a steady supply of masks in the upcoming weeks of the COVID-19 surge. But it is bad news for every other hospital in the United States.

Desperate times call for desperate measures. This may be a time for the FDA to take the desperate measure of cutting through bureaucracy.

March 29, 2020