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MARCH 22, 2020 -- As the COVID-19 crisis deepens and pressure on the medical system increases, clinicians and facilities are having to prioritize care.
To help, medical societies and hospitals are working with providers to determine what care must go on and what can be delayed, rescheduled, canceled, or performed remotely to protect providers and patients and to make way for a predicted surge of COVID-19 patients.
Some decisions are easier to make than others, experts from a variety of specialties and settings told Medscape Medical News.
Leonard Feldman, MD, a hospitalist and associate professor of medicine at Johns Hopkins Medicine in Baltimore, Maryland, told Medscape Medical News that adult wellness visits should be canceled for the time being.
Likewise, if there's no pressing reason to order lab tests, this is the time to put those off, he said.
"If you have a brittle diabetic, maybe we're going to have them come in to get their hemoglobin A1, but the HbA1c is a reflection of 3 months, and you don't want to get it any earlier than you absolutely need to," he said. "It will be a very small subset of diabetic patients we will be encouraging to get lab testing."
He adds that this is not the time to bring in relatively healthy patients for a routine blood pressure check. A much better solution is to urge patients to get a home monitor and transmit readings, he explained.
Don't Delay Child Vaccines
But vaccines for adults, such as shingles and pneumococcal vaccines, can wait, he said. "We don't need to be prioritizing them in the middle of a pandemic."
A routine pulmonary function test for chronic obstructive pulmonary disease (COPD) or any routine test that puts droplets into the air should not be conducted at this time, he said. Likewise, manometry to check esophageal function should wait, he said, if a patient won't develop significant morbidity if the test is not performed.
"The big take-away from all of this is how quickly can you ramp up telemedicine," he said. That would enable more routine care.
In the current situation, clinicians at Hopkins are treating more patients over the phone. "[W]e are treating strep throat over the phone," Feldman said. "We may not be able to feel their lymph nodes and look into their throat, and we'll have to be more liberal about things."
But not everyone fits a telemedicine model. "The hard stuff is a patient you've never seen before transferring to the clinic who wants to have their medicines refilled and we don't know them at all," he said.
Changing prescription strategies can help minimize clinic visits. Clinicians are beginning to prescribe buprenorphine for opioid use disorder for longer periods than they ideally would, Feldman said.
"We'd like to see [these patients] every week, but we also don't want them to have to come into a clinic," he continued.
Decisions on Endoscopies, Surgeries
Gastrointestinal societies issued a joint statement this week in which they urged physicians to "[s]trongly consider rescheduling elective non-urgent endoscopic procedures." They note that some nonurgent procedures may still need to be performed, such as removals of prostheses and evaluations for patients with cancer or with significant symptoms.
However, Mark Pochapin, MD, president of the American College of Gastroenterology, told Medscape Medical News that for gastroenterologists, priorities are, "Cancel all colon cancer screening and surveillance and Barrett's esophagus surveillance."
US Surgeon General Jerome Adams, MD, MPH, tweeted on March 14: "Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!"
Each elective surgery, he notes, brings possible COVID-19 cases in, reduces personal protective equipment supplies, and pulls away providers who may be needed to respond to exisiting COVID-19 cases.
The American College of Surgeons (ACS) last week directed members to cancel elective surgeries and endoscopies. But the college noted in guidance this week that those decisions come with risk as well.
"[G]iven the uncertainty regarding the impact of COVID-19 over the next many months, delaying some cases risks having them reappear as more severe emergencies at a time when they will be less easily handled," the ACS explained.
The association has provided recommendations on how decisions should be made about surgeries.
"[I]n general, a day-by-day, data-driven assessment of the changing risk-benefit analysis will need to influence clinical care delivery for the foreseeable future," the authors write.
The advice is not just for those in COVID-19 hot zones, they write.
"If you practice in an area that's not a hot zone," the ACS says, "we still recommend that you refer to the Centers for Disease Control and Prevention (CDC) website for guidance." Recommendations are available in the section, Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States.
Mayo Shuts Down Most Elective Care for 8 Weeks
The Mayo Clinic announced Tuesday that starting March 23, all Mayo locations nationwide "will defer all elective care that can be deferred for eight or more weeks. This will include both elective surgeries, procedures and office visits. Semi-urgent, urgent and emergency care will continue in clinic and hospital settings."
Similarly, the American Dental Association recommended on March 16 that dentists postpone all elective procedures for the next 3 weeks.
Making way only for dental emergencies will "alleviate the burden that dental emergencies would place on hospital emergency departments," the ADA writes.
At Confluence Health in Washington state, urgent and emergent surgeries, such as appendectomies and broken bones, will be performed as usual, according to a recent statement.
However, since March 17, in-person routine care visits have been "curtailed" for 6 weeks. Patients who have already scheduled nonurgent appointments and elective procedures are being asked to call ahead and cancel.
The health system says that if patients and providers agree that an appointment or treatment needs to be conducted in person, "we will make sure you are seen.
"We are working to offer telephone-based visits and are working as hard as we can to offer video conferencing options shortly," Confluence Health writes.
Robert McLean, MD, president of the American College of Physicians (ACP), said that the primary overall change for physicians should be in reducing the numbers of patients coming to medical facilities for care.
The ACP on Wednesday issued a statement saying it supports suspending elective medical procedures and is also calling for the Centers for Medicare & Medicaid Services (CMS) to do even more to help enable telehealth.
As Medscape Medical News previously reported, the CMS is expanding telehealth coverage for beneficiaries and is easing restrictions during the COVID-19 crisis.
Easing telehealth restrictions will help, McLean said, but not everyone will be able to use the services. Seniors, for instance, may be less likely to have smartphones and less likely to move quickly to telehealth options during a pandemic.
As medical director of Northeast Medical Group of Yale–New Haven Health System in Connecticut, he has asked his group in the past 2 days to determine which patients can be treated via phone or video.
Amy Mullins, MD, medical director of quality and science at the American Academy of Family Physicians (AAFP), told Medscape Medical News, "We recommend that physicians consider postponing wellness exams and nonurgent care until a later date."
The AAFP also recommends designating an area of practice (a connected building or temporary structure) as a "respiratory virus evaluation center," Mullins said.
Don't Travel, Move Research Masks to the Clinical Side
Eric E. Howell, MD, chief operating officer of the Society of Hospital Medicine (SHM), told Medscape Medical News that the SHM is advising hospitalists not to travel professionally or personally.
"We can't forbid it, but we ask. When we lose a provider, it is a massive hit to the rest of us," he said.
Howell said they are also imploring physicians to reuse face masks, not to hoard them, and to divert to clinical use masks and supplies that had been meant for research.
"I have my own single N95 mask that I carry in a baggie in my lab coat," he said.
Howell says providers can use a mask for patients under investigation or for a COVID-19 patient and then, instead of throwing it away, put it in a paper bag so that it dries and can be reused.
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