“What are the best practices in providing safe dermatologic care during this pandemic?”Dr. Francisca Kartono, discusses safety protocols that are implemented across our 6 clinic locations in South East Michigan with fellow dermatologists in the practice.
Currently, more than 9.8 million confirmed cases of the novel coronavirus have been identified in the United States, resulting in 237,000 deaths. Acute care medical facilities risk being overwhelmed in epicenters of disease, and outpatient care declined drastically across the country since March of 2020. This COVID-19 pandemic has dramatically altered the delivery of outpatient care. Clinics had to defer not urgent, elective visits, modify their practices to safely accommodate emergency in-person visits only, and increase the use of telemedicine.
In the beginning of the pandemic in April 2020, reports by the Commonwealth Fund showed a 60% overall decrease in clinic visits. But since then a gradual rebound of visits has been observed, almost back to baseline by October for several specialties, and recently exceeding pre-COVID -19 levels. Practicing dermatology in this pandemic is challenging but possible to do safely. As offices remain open, new protocols and careful monitoring are necessary to keep patients and staff safe.
Dr. Kartono : How has COVID-19 affected Hamzavi Dermatology and Dermatology clinic operations?
Dr. Iltefat Hamzavi: Our offices followed statewide health department orders and closed our clinic doors except for providing urgent post-operative visits as well as cysts and/or cutaneous infections requiring intervention in March through May. During that time many of our providers also volunteered to help support hospitals during the initial surge. We initially had most of our staff working from home, and had to furlough some staff. Since reopening our clinic doors in early June, we have rehired close to 100% of our original staff and hired new staff members. There are several of our employees who are at home still due to family needs and concerns. We saw a much-reduced patient volume initially as we implemented new safety and social distancing protocols. Gradually we have increased our patient volume to almost full capacity across all clinic locations. We converted a portion of clinic visits to teledermatology/virtual encounters to reduce in-person clinic presence, created early morning slots for those at-risk or immunosuppressed, and extended clinic hours when possible to allow for adequate time for cleaning and social distancing to happen.
Dr. Kartono : What has Hamzavi Dermatology/ Dermatology Specialists done to ensure patient safety, office cleaning as per COVID-19 standards, while continuing to operate during this pandemic?
Dr. Marsha Henderson: All of our clinics have made several changes to ensure the safety of our patients and staff. These include:
- Required daily temperature checks and COVID-19 symptom screening
- Wearing face masks (N95 or KN95 and surgical masks)— oftentimes 2 masks, as well as eye protection (goggles or face shields)
- Consistent hand washing or sanitizing before and after each visit
- Additional air purifiers and upgraded air filtration systems in all facilities
Other measures include continued social/physical distancing, which requires patient patients. We appreciate all patients that have been very accepting of the following changes:
- Minimizing non-patient visitors
- Decreasing the number of visit slots— while this may decrease appointment availability, it is important to make sure the clinics are not crowded
- Minimizing waiting room time and keeping a 6ft distance in the waiting rooms when possible.
- Some of our clinics are using the parking lot as an additional area for patients to wait before being called for their appointment.
- All patients are screened for symptoms and temperature prior to entering the clinic.
We also have multiple visible signs throughout clinic reminding us on the need for appropriate masking. Patient rooms and are disinfected after each visit while common areas such as the waiting room seats are disinfected multiple times throughout the day.
Our clinics only use EPA approved disinfectants for COVID-19 as listed by the CDC. Pre-surgery COVID-19 testing can be required for prolonged encounters or surgeries where adequate masking is not possible.
Our front office and check out areas have newly installed acrylic shields that double as sneezeguards and reduce the likelihood of transmission of viral particles to protect staff and patients.
Dr. Kartono : What evidence is there regarding the efficacy of masking, eye protection, and air circulation in preventing the spread of COVID-19 and how is it used in the Hamzavi Dermatology/ Dermatology Specialists clinics?
Dr. Meredith Price: A meta-analysis article in the Lancet in June 2020 ( embed hyperlink: https://doi.org/10.1016/ S0140-6736(20)31142-9) and a CDC Morbidity and mortality Weekly Report in October of 2020 (link: https://www.cdc.gov/mmwr/volumes/69/wr/mm6943e1.htm?s_cid=mm6943e1_w) have shown some useful evidence-based guidelines. Physical distancing of at least one meter (approximately 3 feet) reduced transmission risk from 12.8% to 2.6%. Further reductions are likely if greater distances are used such as 6 feet. Face masks reduced transmission risk from 17.4% to 3.1%. Data on the effect of eye protection on COVID-19 transmission is very limited, but data in this article suggested a risk reduction from 16.0% to 5.5%. Limiting encounters to 15 minutes or less also has shown to help in limiting risk of exposure. Our clinic uses all protective strategies (social distancing, masks, eye protection, time efficient visits), which is even more effective than any strategy alone. Air circulations in our buildings have been upgraded to a very efficient MERV 13 filtration level when possible, and additional ceiling or floor air filtration units that can filter out particles down to 0.1 microns have been installed to produce room air exchanges every 15 minutes or less in the exam rooms and common areas. We accomplish this using cutting edge HEPA filters and UVC light based technologies.
Dr. Kartono : Describe what occurred after you learned that one staff member or patient tested positive for COVID-19 at the clinic?
Dr. Judy Fontana : In late May prior to reopening our doors, COVID-19 PCR tests were performed on all clinic staff prior to returning to work. All active employees are screened for temperature and signs/symptoms on a daily basis and when appropriate, re-tested with a COVID-19 PCR test.
One of our patients tested positive for COVID-19 prior to their surgical appointment, which entails close contact with our Mohs surgeon. It is our practice that all patients who will be undergoing this procedure are tested 2-3 days prior to their surgery. The patient was asymptomatic and immediately notified of his positive test result. The physician who saw him on 2 separate occasions prior to this positive test was re-tested as per local health department guidelines and tested negative. All staff that had interacted with him also tested negative, including the staff that administered his nasal swab for PCR testing. This is one way in which we can feel more reassured that our strict PPE is protecting us and our patients.
We also had a staff member who suddenly developed symptoms and later the same day, tested positive for COVID-19 via PCR. We are fortunate to have a same-day turnaround time for PCR testing via a local lab. All fellow staff who worked with this staff member in the preceding 48 hours were tested, again per local health department guidelines. One patient with whom there was a close encounter just prior to development of symptoms was also offered testing to which they agreed. All employees and the patient tested negative and have all remained healthy. Again, this underscores the meticulous PPE that all staff and providers wear and strict safety guidelines to which we adhere.
Dr. Kartono: What other challenges are there in regard to safely practicing dermatology during COVID-19?
Dr. Andrea Schrieber : Challenges in practicing dermatology during this COVID-19 pandemic occurs as testing for this disease is still met with logistical challenges. We have the capacity to send our patients and staff members for testing, but results often take days to a week to arrive. The false negative rate of the RT-PCR test for COVID -19 ranges 2-37 %depending on how common COVID-19 is in the communities we serve(https://www.bmj.com/content/bmj/369/bmj.m1808.full.pdf) making high risk encounters such as Mohs surgeries moderately risky even with a negative test result. When prolonged surgical visits and cosmetic visits are performed, current algorithms and local testing logistics do not recommend pre-testing for COVID-19 for various reasons, and this creates another moderate risk for exposure for staff and patient. As of October, the local incidence of positive test results in our communities keeps rising, which creates a need for us to adapt day-by-day in clinic and modify our safety protocols based on the frequently changing recommendations of the local health authorities.
By implementing mask-wearing and social/physical distancing protocols and adopting the rigorous containment measures of rapid identification, isolation, and contact tracing, our dermatology practice can maintain optimal safety for both patients and staff during this COVID-19 pandemic. To date, we have identified 4 cases that we know of in the past 6 months across 200 employees and over 45,000 patient encounters. We continue to provide responsible dermatology care for our communities while helping our local health departments detect, trace and contain COVID-19 infections.