June-July 2020


COVID-19 News You Can Use
Reopening practices in the COVID-19 pandemic

by Liz Hillman Editorial Co-Director

The lobby at Vance Thompson Vision, now devoid of the usual coffee, snacks, and beverages, as well as accent tables free of reading material and chairs spaced out
Source: Brandon Baartman, MD

Vance Thompson Vision has placed barriers/breath shields on anything with oculars, including slit lamps and diagnostic and treatment devices.
Source: Brandon Baartman, MD

Reopening ophthalmic practices for routine clinic visits and elective surgeries upon easing of mandates in the COVID-19 pandemic depended on various factors: how much the practice “shut down,” practice location, availability of PPE, etc.
EyeWorld spoke with a few ophthalmologists before they reopened their practices, gaining insight on actions to safely expand services and perspectives on how the pandemic could permanently change their practice.

Brandon Baartman, MD
Vance Thompson Vision
Omaha, Nebraska

Dr. Baartman said his practice worked hard to predict when the right time to reopen for elective care would be.
“While we can never be 100% certain in anything but hindsight, we have targeted resuming elective cases in the first and second weeks of May and have already started opening up clinics in limited capacity to see routine medical evaluations,” he told EyeWorld on April 28.
The number of patients seen per hour is reduced to enhance patient and staff safety.
“We will plan to slowly ramp up volumes as we work through our new-look clinic schedules, learning as we go about what works and what doesn’t. We’ve also significantly altered our patient experience cycle, with almost all information exchange (such as obtaining medical history or providing surgical counseling) occurring over the phone before and after appointments. Our hope is that as we proceed through the reopening phase, we will optimize these processes to create a sustainable program that benefits us even after the immediate threat of the pandemic eases,” he said.
Upon arrival to the parking lot, patients are asked to call staff for admittance, and guests who accompany patients are asked to wait in the car. Staff and patients are screened with questions and a temperature check upon entry to the clinic, and the practice has a reusable cloth mask program for all individuals onsite with “meticulous disinfection protocols to make sure we are minimizing risks with each patient interaction.”
“All sites have placed slit lamp shields to add a layer of protection and have advised patients that examinations will be performed with only necessary conversation taking place. With most of the history being obtained prior to the visit and much of the counseling taking place afterward, we are able to then limit how much face-to-face time is spent talking with patients,” Dr. Baartman said.
Dr. Baartman said the thinking of “before and after COVID” should be more “before and with COVID.” Many changes as a result of the pandemic will be in place for as long as it takes for new cases to significantly diminish, which might occur with vaccine development.
“We should be prepared by making sure our changes are sustainable solutions that are both effective and not onerous to implement,” he said.

Nicole Fram, MD
Advanced Vision Care
Los Angeles, California

When Dr. Fram spoke with EyeWorld on April 24, California’s governor had just reinstated allowance of elective surgery in hospitals. Dr. Fram said ASCs would follow.
“The whole question is can we get enough PPE and safely care for patients. That’s the biggest issue,” she said.
After being closed since mid-March to everything but urgent cases, Dr. Fram said her practice planned to open on May 18 to see a maximum of 20–30 patients a day in Phase 1 with one doctor working at a time. Phase 2 will involve 40 patients a day with a reassessment of patient flow in the office. Patients have their temperature checked and are then brought directly to one of the practice’s 10 exam rooms upon arrival, and no one is in the waiting room. All staff and patients wear masks. While family and guest are waiting outside, the practice is in constant communication with them by phone. Face shields are employed while testing, and a no-talking policy at the slit lamp is in place, among other safety protocols for staff and patients. Dr. Fram said they are also obtaining information from patients over the phone 3 days prior and prefilling patient charts before they get into the office, cutting down on the time in the office. “This is an efficiency that we will continue long term as it has dramatically cut workup time to less than 5 minutes per patient,” she said.
Telemedicine is something Dr. Fram said her practice will continue to some degree as things shift toward “normal.” She said they’re going to try to take care of the same amount of patients as before the pandemic through a combination of telemedicine and in-office visits, stratifying each based on need. Prior to the pandemic, Dr. Fram said she was seeing 50 patients a day, doing 20 surgeries a week, contributing to publications, and lecturing at conferences.
“This is a wakeup call, and [we’re] trying to see the silver lining for if we can find a way to see as many patients but in a more efficient way to have a better patient experience, and to have staff that understands the importance of working quickly and efficiently; I don’t see how I would ever go back. The only thing we might do, since we have a big office, is increase the number of patients and doctors working at once. But it has to be in a safe and efficient way for the staff and the patients,” she said.
How else will the pandemic change the way she practices?
“Think about it like this: Viral conjunctivitis is the most contagious syndrome we have. I, in 15 years [of practicing], have never had viral conjunctivitis, and the question is why? I used to shake hands and hug. The reason why is that I wash my hands and I don’t touch my face; I use hand sanitizer before and after I see patients. Basic hygiene and masks are paramount,” Dr. Fram said.
Dr. Fram said she might not be hugging patients in the near future, but she thinks it is important to have a greeting that shows warmth. “As a society, we’re going to have to figure out what that looks like,” she said.
Dr. Fram also said she hopes that the pandemic elevates those in the medical profession from a societal value as well as from a reimbursement standpoint.
“Maybe our government and insurance companies will value what we’re doing for patients and not make continual cuts every year to the work that we do. We won’t be able to practice and afford PPE if they reimburse us $40 to see a patient. … We have to be revalued as a profession,” Dr. Fram said.
Finally, Dr. Fram thinks home testing and diagnostic equipment will become a bigger arena over time.
“It’s going to be fascinating to see what happens to decrease the number of patients who have to come through the office and improve between-visit monitoring,” Dr. Fram said.

Jennifer Loh, MD
Loh Ophthalmology Associates
Miami, Florida

When Dr. Loh spoke with EyeWorld on April 22, monitoring national and local news as well as guidance put out by medical societies, she said she was a couple of weeks from opening her practice beyond the urgent cases and telehealth visits she had been seeing. Elective surgery, per an executive order from Florida’s governor, couldn’t start until at least May 8.
Even though she was ready to start reopening, Dr. Loh didn’t think her practice would be “normal.”
“All of my staff are required to wear masks at all times. We’re working actively to get more PPE, and we’re also going to require that all patients wear masks in the office. We’re going to maintain the protocol where family members or friends have to wait in the car, unless the patient is a minor or incapacitated in some way,” she said.
Dr. Loh said she planned on admitting fewer patients to the clinic at a given time, directing them immediately to an exam room where they remain for the duration of the clinic visit. Patients will be questioned regarding various COVID-19 symptoms and exposure prior to admittance.
Dr. Loh said that while the economy will slowly reopen, she thinks there will be some hesitancy among patients to rush back into surgery.
“Some patients will be very eager for surgery, but I think it’s going to be offset by patients who don’t feel ready yet on a personal level,” she said. “It will go from zero to surgery, so that will be somewhat of a surge, but I don’t think it will be numbers we can’t handle for the next couple of months.”
Dr. Loh plans to maintain the telehealth practice she established in the pandemic for the short-term and perhaps long-term future.
“I don’t think it will be a majority of the practice, but I think there will be some. If someone in the future wants to do it, I’ll be happy to do it,” she said
Will we ever go back to pre-January 2020? Dr. Loh said this generation and the next will likely always have a heightened awareness of infection. She said the importance of infection control and enhanced hygiene won’t go away. She also said she thinks the social stigma of wearing masks in the U.S. will be reduced.
As a physician, Dr. Loh said she had already avoided shaking hands with patients, preferring to greet them warmly with a wave when she entered the room, but she said she’s definitely “going to think twice about handshaking in the future.”
“I don’t know if we’re ever going to feel 100% comfortable like we did in January 2020,” she said.

Relevant disclosures

: None
Fram: None
Loh: None


Baartman: brandon.baartman@vancethompsonvision.com
Fram: nicfram@yahoo.com
Loh: jenniferlohmd@gmail.com

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