Moderators Bruce Maller, CEO of BSM Consulting, and Eric Donnenfeld, MD, of Ophthalmic Consultants of Long Island and Connecticut, led a group of industry professionals who offered their expertise to aid attendees in getting practices back up and running as shelter-in-place orders come down across the country. The symposium took place at the virtual meeting on May 16.
Here, we’ll recap a few of those pointers provided by the experts.
COVID-19 Fact and Fiction
Matthew McCarthy, MD, COVID-19 attending physician at NewYork-Presbyterian, New York City, began by explaining some facts of COVID-19, the disease that leads to coronavirus in humans.
He cautioned against relying on some of the testing procedures currently available. One area of testing, to hunt for the virus, is RTPCR testing or nasal swab, which has netted false negatives due to the swab not being deep enough into the nasal cavity. The second is a serology, or antibody, test, a blood test that shows whether someone has been exposed to the virus. He explained that, in light of the pandemic, the FDA allowed companies making diagnostic testing for COVID-19 to do internal tests before selling them to the public. Now the FDA is asking these companies to show their work and prove the antibody test effective.
“One of the messages is that there are all kinds of fraudulent tests on the market as of now,” Dr. McCarthy said.
He also discussed some of the ongoing therapies, including hydroxychloroquine. “I can tell you from personal experience, I saw some people get better with it, some people get worse with it, but I didn’t really think it was having any effect on patients, and that’s the general consensus,” Dr. McCarthy said.
He also discussed the therapy remdesivir, initially created for the treatment of ebola. The National Institute of Health ran a study that has shown the drug to decrease the presence of symptoms from 15 to 11 days, Dr. McCarthy quoted Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. It is only available through clinical trials right now.
As the medical community works to find therapies to slow (and eventually cure) the coronavirus, he urged the audience to take precautions in the following ways:
Consider how to modify the waiting room (for example, do away with it altogether)
Post a sign on the front of the building with instructions, indicating you are taking it seriously
Consider screening, including with temperature checks
Make sure employees wear masks and eye shields
Take universal precautions and assume every patient has the virus for the time being to protect yourself and your staff
Patients will have very strong opinions about what is safe and not safe, he said. His advice is to take an abundance of caution and forward-thinking steps.
What Ophthalmologists Should Do to Prevent Infections
The challenge with preventing infections in the operating room and office is to create a safe environment while also providing exceptional eye care, outlined Francis Mah, MD, chair of ASCRS cornea clinical committee, La Jolla, Calif.
Dr. Mah first pointed to the Centers for Disease Control and Centers for Medicare and Medicaid as sources for global guidelines. But he also advised considering specific needs and concerns for ophthalmology specifically.
For example, Dr. Mah advised eye care personnel to wear surgical masks in the clinic and operating room and cloth masks otherwise. (He also mentioned that this advice should be weighed against the incidence rate in your area.) Dr. Mah also stressed that, to be effective, people should not only wear them but also consider factors can affect the usefulness of the mask, like the fit, not touching it once it is placed and facial hair.
In addition to personal protective equipment, including eye shields and gloves, he recommends triage questions ahead of visits, blocking out seats for social distancing or urging patients to wait in cars to receive a call, text or escort into the clinic, taking out all communal, high-risk physical objects, such as brochures, magazines and toys, limiting visitors to the office, separating work stations for technicians and using protective screens at each, and placing signage from the CDC in the office.
In terms of staff scheduling, Dr. Mah recommends a team approach to limit exposure, as in the same individuals are scheduled together consistently. Disinfection practices are also of the utmost importance, for which Dr. Mah offered some pointers:
Tonometers can be disinfected with 70% alcohol solution.
Bottles may be contaminated internally or externally. As such, keep out of sight to not be infected.
In addition to a 70% alcohol solution, diluted bleach, Clorox, Lysol and Purell brand products will suffice.
Leading in a Time of Crisis
Mr. Maller spoke about three principles that became a touchstone for his decision making throughout the pandemic:
Protect the integrity of the business, such as managing the financial strategies.
Responsibly manage every member of the team to the other side.
Stay connected with patients, colleagues and strategic partners, for example the landlord and professional advisors.
Certain qualities are indicative of good leadership during a time of crisis, Mr. Maller said: remain calm, get educated, act the part, be decisive, be selfless, be hopeful, be clear and concise and demonstrate empathy.
He closed with this thought: Leadership is the secret ingredient that will allow organizations to survive and thrive the crisis.
An Administrator’s Perspective
Dan Chambers, MBA, COE, FASOA, CEO of Key Whitman, Dallas, provided an administrator’s perspective on opening practice procedures.
Communication, not only with the staff but also with your patients, is important. He advises a calm, firm and positive approach. As policies and procedures take place frequently, ensure that these are distributed. Patient notices include text messages, emails, social posts, websites updated with new protocols and recall messages and reminders asking, “How are you?”
Additionally, opening procedures need to address concerns of staff and patients alike, such as extra housekeeping provided and that the practice is following disinfection guidelines from governing bodies.
Key Whitman, Mr. Chambers said, opted for a tiered approach to opening with the following steps for percentages of patient flow and volume allowed in the practice: 33%, 50%, 66%, 80%. In the ASC, the practice opened with non-overlapping surgeons on block scheduling.
Key Whitman also turned the parking lot into the waiting area. Once there, patients would get their temperatures checked and answer triage questions. Mr. Chambers also said that chronic glaucoma patients were offered the option of an IOP check in the car. This was followed up with a telemedicine call.
Speaking of telemedicine, Mr. Chambers said patients utilized the platform happily and protocols were ironed out as the process unfolded. The practice has also implemented a hybrid approach, in which diagnostic visits are administered by staff members without seeing a doctor, OCT or visual field was acquired, for example, and then the patients leave. The images were examined and followed up with a telemedicine or call with the patient. Looking forward, Mr. Chambers says, patients will drive how that office visit ideally takes place.
In terms of the financials of reopening the office, Mr. Chambers said they held off production pay for providers until the practice felt more comfortable with its position. The practice continued to pay employees and wanted them to feel comfortable with their employment status. Once the practice began operating more continuously, and following the Payment Protection Program, it extended the following offer to its staff members:
100% of salary if they are ready, able and willing to work, from office or home
110% of salary if they were able to work and would come in contact with patients
90% of salary if they were not willing to come into the office
Mr. Chambers says it was a combination of all of these efforts, thus creating a stable group of employees, that allowed them to ramp up quickly. “Without good employees feeling comfortable and secure, we don’t have much of a business,” he said.
How to Restart an ASC
Regina Boore, MS, BSN, RN, CASC, senior vice president at BSM Consulting, began by covering the legalities of restarting an ASC. As of the time of the conference, 25 states issued orders to resume elective procedures. However, she noted, state and federal guidelines are not coordinated.
To restart, the ASC needs a supply of PPE and disinfectant. N95 masks are required for anesthesia providers and disinfectant procedures are approved by government bodies. Additionally, ASCs will need to check with their state department of health for testing requirements.
Policies and procedures need to be reviewed and amended (including much of what was already discussed, such as mask protocol) with the addition of:
Post-exposure plan for COVID-19
Respiratory protection program and polices in intubation and extubation for COVID-19 (if anesthesia-providing ASC)
In addition to updating the written documentation, in-service staff training is necessary for things like COVID-19 trends, review of revised polices, infection control, PPE management and scheduling procedures.
Her final pieces of the to-do list for re-opening an ASC:
Governance oversight and approval should not be skipped
Hazard and vulnerability analysis should be updated
Infection control assessment should be approved
ASCRS Efforts to Provide Long-Term Financial Relief
Finally, Nancey McCann, ASCRS director of government relations, discussed the actions of the group to try facilitate long-term financial relief for physicians. They include: advocating with like organizations for the inclusion of physicians in future legislation, QPP hardship exemption extension and additional direct financial support (specifically, grants). OM