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The Effect of the COVID-19 Pandemic on Clinic Operations

Educational Objective
Review how COVID-19 has affected clinical operations in Seattle, WA
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Ed Livingston: As of today, March 12, 2020, COVID-19 continues to rapidly spread throughout the world.  Seattle was one of the first major cities in the United States to be affected by COVID-19, and has had to rapidly accommodate the changes in the city as the disease spread through it.  Dr Doug Paauw, professor of medicine at the University of Washington, spoke with us about his experience in having to respond to the COVID-19 pandemic.  In this special edition of JAMA Clinical Reviews, we will discuss how primary care clinic operations are affected when an epidemic hits the city.

From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice.  Here's your host, Ed Livingston.

EL: Could we start by having you tell us your name and title?

Doug Paauw: My name is Doug Paauw.  I'm a professor of medicine at the University of Washington School of Medicine.  I'm a practicing general internist, and I run our medical student teaching program at the University of Washington.

EL: We are very interested in the situation on the ground in Seattle.  So, we'd like to know what's happening there, what you're facing, what you've learned from this, what you've learned that should be communicated to other cities, other institutions.  So, if you could just tell us what you think is important.

DP: A lot of different things have come together here with this pandemic and the impact it has on our population, and as a practicing internist, the first thing that I just kind of want to alert all our physicians out there and medical professionals that are involved in patient care is that the overwhelming thing we've seen has been the need for information from patients.  And so, our electronic portals, our messaging direct from patients, our calls into the office of people that are very worried have really escalated, I mean probably 10-fold more than normal.  And so, trying to think of structures that will help address those, because usually those things are added onto the physician's day or they're added onto the nurses’ or MA's day, and that has been quite overwhelming.  The other things that are unforeseen impacts is communities change, and for school closures is suddenly support staff may not be able to come in because they have young children at home and they don't have childcare.

And so, they're very real, and we have faced this, the shortage of workforce, including especially support staff, medical assistants, people to answer the phones, nurses, and in some cases physicians because there is nowhere for their children to be doing things during the day when there are school closures.

The other major thing that has really impacted, and I think this has gotten a lot of national attention, has been the shortage of personal protection equipment.  And this is really a big issue in our own clinic and in our own hospital that they are having to ration it, and so, instead of having multiple people rooming a patient, just this morning we got a decree from our clinic that this would be a physician-only activity as far as taking care of the patient in the room.  There would not be able to be medical assistant help in getting vital signs, as far as checking oxygen saturations.  Everything that needs to be done for the patient has to be done by the physician because there is not enough personal protection equipment to go around, so it's being rationed, physician only.

So, those are a few of the things that surprised me.  They weren't the things I would have first thought about when I would be facing this.  I thought it would all be about how sick the patients would be, triaging, who gets seen, and all those things, very, very important things, but some of these practical things are definitely going to affect our physicians.

EL: A lot of communities across the country or around the world are going to face this exact situation if they're not dealing with it now.  So, given what you've learned or you're learning, do you have any advice for others running clinics or other physicians about how to react to this Coronavirus concern and what they should or shouldn't do differently?  Is closing schools the right thing?  Kids don't get particularly severe disease.  This is the first time I've heard someone say closure of schools effects our staffing, and that's a major problem.  So, those sort of broad ideas, what do you take away from all this?

DP: Well, I think it's a challenge because I do think the school closures, as a public health issue, is a good thing.  The kids don't get sick, but they definitely transmit the virus, and they are very, very social and potential sources of spread to the wider community.  So, from a public health standpoint, I think that's a very reasonable thing.  From a practical standpoint, it has implications.  And so I think that school closures, I'm certainly not opposed to them, but the ramifications are very real.

As far as advice I give, for places that are ramping up and getting ready to take care, making sure that there are ways to do virtual support.  It may be that if somebody is at home, because their kid's at home, can they help do triage from home?  The phone calls, the messages, being able to do those things.  They may not have to be on site.  They could do both.  And having policies ready for that so that it's not a blindside thing when five people call in and say they can't be there the first day there's a school closure, having a backup plan and saying, okay, we already got you set up at home from your home computer.  We're going to be able to have phone calls forwarded on to you so that you can do some of the triage from home.  I think that's a big part of what we're doing, and I could see that being something that can be done distant.

EL: That's really a very important piece of advice.  What about the physician workload issue that you mentioned that you now have a very large number of queries coming in, either by phone or the electronic medical record, that is sort of overwhelming for any given physician.  Do you have any advice on how to manage that?

DP: Yeah.  This is an interesting one.  So, we're seeing a huge uptick in our virtual stuff.  The patients don't want to come in.  They're self-quarantining, or they're terrified.  Many of them are terrified of the clinic environment.  They believe that's where they would get sick.  So, we're seeing kind of an odd situation where our most vulnerable patients who need disease management, close evaluation and treatment are choosing not to come in to regularly-scheduled clinic visits because they are worried that they are going to get COVID-19.  And then you have a surge in the worried well that are worried that they may have been exposed, and they want to talk to their doctor about it, or they want to see their doctor.  So, we've kind of seen this very interesting thing of the people that probably need the medical care the most are avoiding clinic, and the people who might need it the least want to be reassured.  So, I think this is, again, a very good opportunity for us to ramp up our ability for virtual support, where if we can do things through the phone, do things through the electronic record.

On Monday, this past Monday, for example, one of my colleagues who was working with a couple of medical students, their entire schedule, every patient cancelled because they were already prescheduled appointments.  And we have been really trying to do a good job on triaging people that have URI symptoms, and certainly our public health and the CDC have really pushed towards getting in contact and seeing who really needs to come in, who are the people who need to be tested and not filling the emergency rooms, urgent care centers, and doctors' offices with people who have very, very mild symptoms.

EL: So, the confounding feature of all this is that we're in the midst of a very bad flu season, and I guess flu and Coronavirus, COVID-19, are somewhat different.  So, what are those characteristics of patients that are at risk for becoming very ill that would prompt you to want to have them come in?

DP: Yeah, there are a couple things.  So, first, we look at the actual patient.  We look at the patient risk factors, and then we look at the disease presentation.  In our triage, the patient risk factors that we know from the early study that came out of China was individuals who are older, and the mortality rate for this disease goes up after the age of 60.  I believe it's three and a half percent or more around of people over 60 and it goes up per decade of life.  Then, in addition to that, individuals who have heart failure, cardiovascular disease, diabetes, and hypertension are really the groups that were sorted out there.  We have also projected onto that, the assumption that people that are immunosuppressed and people who are very, very sick at baseline are going to have a higher complication rate.  So, that's kind of the group that we triage as high-risk patients.

As far as symptoms, the one symptom that has really played out as being a symptom that may lead to hospitalization for this disease is the symptom of dyspnea, that people with URI symptoms and dyspnea we triage to immediate evaluation because we know that COVID-19 has a reasonable percent of these patients get significant lung involvement.

And even in some of the studies from China, in asymptomatic patients, some of those patients on scan had some actual evidence of ground glass appearance in their lung.  So, anybody with dyspnea who has fever and cough, we want them to be seen, either come into our clinic for evaluation and diagnosis or going through the emergency department because we know that their chances of getting hospitalized is much higher.  As opposed to the people who are febrile, maybe a little bit of cough, but doing okay, we are not encouraging them to come in just to get a diagnosis.  Our systems aren't well-supported right now for that.  At the UW, we're very fortunate.  We actually have widespread testing.  Our patients who come in and need a test, we can get it, and we can get a 12-hour turnaround, which is fabulous.  But in talking to other physicians in the Seattle area and other situations where people have needed a diagnosis, they are still in the process of seeing if their system can get a kit and guarantee that they can get a COVID testing.

EL: You just referred to COVID testing.  So, the University of Washington has the capacity to do that.  What is the test?  Is it a PCR test or…?

DP: It's a PCR.  The UW has developed their own sort of a screening system.  So, they aren't hooked in totally to the test kits from the CDC.  So, that's the first screen, and then it gets a confirmatory test.  So, they've been able to do broader testing.  They also have established, I believe the first in the country, drive-by testing for healthcare workers at our Northwest Hospital facility, where healthcare workers who have symptoms can go and get a swab in their car.  They do an online appointment, and in the first day that that was available, 125 healthcare workers were tested in an attempt to try to make sure that we are keeping the public safe.  You know, if a healthcare worker has symptoms, figuring out their risk.  We all isolate them for 72 hours, until their symptoms are gone.  If they're COVID negative and their symptoms are gone, then they can return back to the workforce.

EL: How long does it take for that test to turn around?

DP: Well, it depends where it goes.  So, again, at the UW, it's a 10- to 12-hour turnaround, which is quite good.  For some of the other places, it's 24 to 48 hours, and then certainly early in the epidemic, when things were getting sent to the CDC, it could be up to a week for getting the information back.

El: One of the most common complaints that we have heard about the response to the COVID-19 now pandemic is the lack of testing and that that's hampered a lot of efforts to identify the disease in the community, to help stop its spread.  How is it that UW came up with a test… one, how long have you had PCR testing available for this disease, and two, how did you implement it whereas others have not been able to?

DP: You're absolutely right, Ed, on the issue of not being able to get testing, and it's still a very big problem around the country, and my opinion is, the reason that our numbers are as low as they are in the United States is 100 percent a testing issue, that even in some cities, when people come in with a pneumonia of unknown cause, which in 2020 should be COVID until proven otherwise, there are places where it takes petitioning to get the test because they're being so rationed in communities.

I don't know the actual reason and the behind-the-scenes on how UW was able to fast-track and get this information and have tests available as quickly.  I mean we certainly, we had frustrations.  We had felt like two weeks ago the Seattle area up a little north of us was the first case in the United States.  Obviously, there was a deep concern that there could be community spread, and it took quite some time to be able to do regular testing.  And we felt that the delay was unreasonable even to that point.

So, I have heard that there are other places that are trying to do the same thing so that we can broaden the testing.  The idea that a million tests will be enough for the whole United States is just not going to work.  I mean what we have heard from the national response, I think is inadequate, so having local testing being available is a very, very positive thing.

EL: One of the things that I heard last week, I believe, is that it's probably not the case that Seattle has more cases than any other place in the U.S, it's just that they have more aggressively tested and found cases that would probably appear elsewhere if testing was available.  Do you think that's true?

DP: I think there's some truth to that.  I think that the number of tests that we have done in Seattle is… I don't know the exact numbers.  I know that in one day there were something like 300 tests done recently, and we had 125 in the first day for the healthcare workers.  So, running lots of tests compared to the total number that the United States has run.  I also think that since the first diagnosed case here that we may have had a few-week head start on community spread with this virus.  But I think it's both.  I think that we do a bit more testing, and we may have gotten a week or two head start on community spread.

EL: Yeah, it's an interesting issue because what I think is going to be the main takeaway from this episode, whenever it eventually goes away and we have an opportunity as a nation to think about it, is that the main lesson is that point-of-care testing should be made immediately available and given PCR technology, that that should not be a problem.  Once you know what the primers are, you should be able to just set it up right away and get people tested and identify cases and isolate them right away.  Do you think that's the case based on your experience?

DP: Yeah.  I think that some of the mistakes made early on were- it's our desire for the perfect blocked out our ability to have a very good immediate intervention.  You know, the Seattle flu study was going on at the time that this broke out, and those researchers were like, well we should go ahead and test for COVID-19 because we need to know what the numbers are and we can get early alert to the whole country, and we can be on top of this.  And as attempts were made to get that instituted and get approval through all the legalistic channels that there were, there was heavy blockage to that, and as a result, it was extremely delayed.  And that was an opportunity missed.  And I think we have to realize that in times of crisis, we are flying by the seat of our pants a bit, and we do the best we can, and we try to get things going quickly.  We've learned that from our other pandemics.  I mean, you know, with the HIV epidemic, medications were available through expanded access before we were absolutely sure they were really particular safe, but in dire times, dire circumstances are needed.

EL: Let me come back to PPE.  So, you've mentioned that the lack of availability of PPE has adversely affected the way your clinic can function.  Do you have any thoughts about how that should be addressed going forward?

DP: As a nation, we had a remarkably inadequate shortage of stockpiled things like N95 respirator masks.  I'm just stunned by that, because you all remember, back in 2001, we had the anthrax scare.  We have had early warning.  We've had plenty of time to sort this out, and I'm just really surprised that what we have stockpiled and available was so little for this.  We've been knowing we were going to have a pandemic for years, just statistically, and there's been noise.  The 2016 Ebola scare sure was sort of a moment that we could have all rallied around this.  So, I think that now this is going to be something that's going to be heavily addressed, because it's affecting a large amount of the population.  My personal opinion is when things can be isolated to one country, we like to bury our heads in the sand as a world, and we don't think about that these are warnings and notices to all of us that we should be prepared.

EL: I want to come back to the Seattle flu study, because you mentioned that all this came up in the midst of that particular study.  So, could you tell us about the Seattle flu study, what is it, and what's it trying to accomplish?

DP: I don't know a lot of the on-the-ground details, but the idea was to get a better idea of, each year we have major influenza epidemics.  We've had an RSV epidemic [inaudible] and to get an idea of the underlying prevalence of these important respiratory pathogens year to year.  And this was just a situation where when they were doing the testing was right at the time that we got the first case of the COVID-19.  So, it was just a serendipity situation where that was a time that was at high respiratory virus season otherwise and so doing a lot more community surveillance than might normally be done.

EL: Is there anything else you think that you should communicate to the JAMA readership, JAMA listenership?

DP: Yeah, I think that as physicians our job is to help people and help them get through their illnesses, but I think one of the things that's so hard here is the unknown and to reassure our patients that we have plans in place, that the triage that's done over the phone is not without thought, that it's not trying to keep people who are sick and need to be in a hospital away from a hospital, that it's really to try to help people be in a situation where they can recover, which is at home for a vast majority of these people, and then to have open communication lines to get the sickest patients in and get them good care.

This is really a disease of triage.  That's kind of really what my take-home from this couple of weeks has been.  We are really trying to triage the people that intense medical care is what's necessary.  We're trying to help the public by not having more spread of the disease from people that are sick than we would normally face.

EL: Well, I thank you for your time and appreciate this.  I hope others are going to find it useful, because the many things you told me today are things that I certainly hadn't considered, and I think they're certainly important to communicate to other clinicians for them to plan as they go forward in dealing with this pandemic.

DP: Every day you learn new lessons.  You hear what somebody else had to face, and you think, boy, I'm glad I can kind of get ready for that.  And some of things that are hard, like the protective equipment shortage, you know, one of the things that the hand sanitizer issue, there's a huge shortage, as you know, and all our hand sanitizers were all taken away and people walked off with them.  So, you learn different things.

DP: Great.  Thank you very much for the time.

EL: Okay.  Thank you so much.

That wraps up this special edition of JAMA Clinical Reviews.  I'd like to thank Dr. Doug Paauw from the University of Washington for speaking with me today.

Today's episode was produced by Jesse McQuarters.  Our audio team here at JAMA includes Daniel Morrow, Shelly Steffens, and Mike Berkwits, our Deputy Editor for Electronic Media here at the JAMA Network.  Once again, I'm Ed Livingston, Deputy Editor for Clinical Reviews and Education for JAMA.  Thanks for listening.


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