May 2020

NEWS

Covid-19 News You Can Use
How different practices responded to COVID-19


by Liz Hillman Editorial Co-Director

No medical practice was spared from taking some action in response to the COVID-19 pandemic, but responses varied depending on the type of practice and location.

James C. Tsai, MD
President, New York Eye and Ear Infirmary
of Mount Sinai (NYEE)
System chair of ophthalmology, Icahn School
of Medicine at Mount Sinai
New York, New York

As of April 23, according to the New York State Department of Health, New York was considered the epicenter of the COVID-19 pandemic in the U.S., with more than 15,700 deaths and 263,460 positive cases. Dr. Tsai described the atmosphere at New York Eye and Ear Infirmary. “I think the atmosphere has gone from one of fear and trepidation to ‘what can we do to meet the needs of the community,’” he said in early April.
“We are the oldest specialty hospital in America, and we were founded in 1820 to meet the needs of the community, which at that time were untreated eye and ENT disease. Now, in 2020, we think we are meeting the needs of the community in terms of the COVID crisis.”
Many NYEE physicians and staff members have been redeployed across the Mount Sinai Health System hospitals. NYEE is still serving as a specialty hospital and clinic for emergency and urgent eyecare needs of not only Mount Sinai patients but referrals from other practices and health systems in the New York metropolitan area, including New Jersey and Connecticut.
Dr. Tsai said they have an extensive screening process for patients, conducting a virtual visit before patients even come to the walk-in eye clinic. Prior to the pandemic, Dr. Tsai said the hospital talked about telemedicine offerings, but the focus was still on in-person visits. Since COVID-19 hit, teleophthalmology at NYEE took off.
The symptoms of patients are monitored, with surgical patients having COVID-19 testing 48 hours before operations and close monitoring the day of the procedure. NYEE ophthalmologists, like many around the country, have full personal protective equipment (PPE), including fitted plastic shields on slit lamps, and visits are now designed for minimal exposure.
Dr. Tsai said NYEE has been in communication with state and local health officials from the outset, with the potential for NYEE to increase its bed capacity to serve COVID-19 patients, if needed.
“This has really been something that has turned our world upside down, and I think we as ophthalmologists recognize that we can switch gears as physicians, and we have to be able to help out with this crisis,” he said.
Dr. Tsai said he can’t predict when things will get back to “normal,” but he believes the pandemic will change healthcare delivery going forward into the future. At present, he said the pandemic is raising questions about how to provide care to patients who are not able to seek medical care and guidance with in-person visits. In the future, he thinks it will change how telemedicine and teleophthalmology is viewed and how eye emergencies are handled.
“I think it’s a higher level question of whether medicine will go back to what it’s been, a fee-for-service, volume-driven in-person type of practice vs. a greater focus on protecting patients with a more comprehensive, telemedicine-assisted in-person service.”

Stephen McLeod, MD
Chair, Department of Ophthalmology
University of California, San Francisco (UCSF)
San Francisco, California

Dr. McLeod detailed the protocols at UCSF to prevent further spread of SARS-CoV-2. In a pre-clinic call, the patient is interviewed by a staff member for various symptoms. As much of the visit as possible is performed over the phone and the physician explains that the eye examination in the clinic will be targeted and performed thoroughly but quickly. It’s explained that patients and physicians will keep talking to a minimum while in person, and some testing methods have shifted to reduce exposure.
When the patients arrive, they are communicated with from their car, then taken directly to the exam room. If arriving on foot, they speak with staff from the waiting room with reminders to keep a 6-foot distance. Patients are also reminded not to talk at the slit lamp, Dr. McLeod said. Only essential personnel and the patient are in the exam room.
After the exam, Dr. McLeod said a few summary statements and directions are given to the patient from a distance. If more discussion is needed, the patient and the physician communicate remotely once the patient is in their car or schedule a time to speak on the phone.
Dr. McLeod said UCSF has established a “drive-through” IOP testing protocol as well. A tech is stationed outside the building with a tonometer. Patients are given a mask to wear and are asked to roll down their window for IOP to be checked with a portable tonometer. Based on the data, the physician follows up with the patient with phone or video.
For urgent surgical cases, Dr. McLeod said requests are made to department leadership and, if approved, placed on the surgical block. All UCSF ASCs are closed, so surgeries are being performed at Mission Bay Hospital inpatient operating rooms.
As for redeployment potential, Dr. McLeod said UCSF has a redeployment plan for all departments and all physicians.
“The current plan proposes ophthalmology physicians be redeployed to outpatient medicine services, if necessary,” he said.

Michael Patterson, DO
Captain, United States Army Reserves
Eye Centers of Tennessee
Crossville, Tennessee

Dr. Patterson’s practice serves Tennessee’s Upper Cumberland region, which comprises 10 rural counties. As of April 23, there were just over 200 positive COVID-19 cases within this whole region. “We’re a very different area than the average practice,” Dr. Patterson said.
Despite the low numbers compared to more populated areas of the country, Dr. Patterson said his practice shut down for the safety of employees, their families, and patients. Dr. Patterson said in early April that he and his father, Larry Patterson, MD, are taking on urgent cases, and he was taking call for the month.
“Eleven doctors are not working currently, and 120-plus staff are not seeing patients right now,” he said.
The eight-location practice is still seeing “walk-in” emergency cases (which might be up to 10 a day) and performing retina injections. Dr. Patterson said the practice is not offering telemedicine right now, in part because his patients don’t want it.
Before coming to the clinic, patients are screened with a call for symptoms and travel history. The patient is told there will be minimal conversation with the doctor during the exam. Once they arrive, a nurse conducts further screening outside the clinic. Patients are admitted one at a time without family members, with few exceptions. There are no chairs in the waiting room, patients are led straight to the exam room, and everyone wears a mask, Dr. Patterson said. If a patient does need urgent surgery, Dr. Patterson said they have a one-room ASC that is only used for ophthalmology.
Dr. Patterson, serving 7 years in the military, has offered his services as a physician to the local hospital but said they don’t currently need him.
“Our hospitals are laying off employees right now. Hospitals are going under because they’ve canceled elective surgery,” he said.
As for the economics of his practice, which is also not doing elective surgery, Dr. Patterson said the executive team has taken out lines of credit personally to pay the payroll, rent, etc. They hope to apply for and receive government stimulus loans to help with this.
The current state of things can’t continue at this pace for too long, Dr. Patterson said. For example, even the cleaning supplies being used in his practice to make sure patients and staff stay safe are hard to come by. If they can’t be replenished, he said they might need to shut down further.
For now, he said “we take a deep breath, do the best we can.”
“Our job as doctors is to be calm; our staff is looking to us,” Dr. Patterson said.

How different practices responded to COVID-19 How different practices responded to COVID-19
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