COVID-19 and Resuming Clinical Visits: Frequently Asked Questions
(Version 2.0; reviewed May 16, 2020
Input from Drs. Ruben Mesa, John Leonard, Matt Kalaycio, Roy Silverstein, Laura Michaelis, Andre Goy and Chancellor Donald
Note: Please review ASH's disclaimer regarding the use of the following information.
Many have worried that the second wave of health-care problems may occur when clinical operations reopen and providers are faced with patients whose disease or toxicity has been unattended due to patient fears or clinical restrictions. Any recommendations in this constantly evolving situation are, of course, subject to change or alteration as new data accumulates.
How can we ensure new patients still seek consultations for emergent or urgent diagnoses?
- Provide proactive messaging to patients that safe strategies are in place to treat emergent and urgent issues despite COVID.
- There should be reinforcement that treatment of cancer is not elective and that the risks of ignoring symptoms is likely higher than the risk of infection with coronavirus.
- Establish communication with referring physicians regarding your center’s continued care processes, safety strategies and availability to continue therapy under certain conditions. Hematologists should promote education of primary care physicians and patients on how therapies might be adjusted to mitigate risk.
- Rather than cancelling consultative appointments for new patients, conduct initial visit by phone call or video visit instead. Provide information regarding condition urgency and appropriate timing of next steps.
- Ensure rapid access for all new patients.
- Utilize e-visits to communicate urgency to patients who should not wait for the end of crisis to obtain further diagnostic evaluations or treatment.
How can we ensure established patients remain engaged and that non-emergent care is resumed when the pandemic slows?
- Establish clinic-by-clinic lists of (a) which patients have been re-scheduled from face-to-face visits to e-visits and (b) which patients have had visits delayed entirely. Use these lists to prevent “loss-to-follow up” via periodic review.
- Categorize patients by urgency of return. Track any cancer screening or follow up that is missed.
- Assemble routine patient call lists for nurses, APPs or other providers (even those working from home or on quarantine). Providers can review symptoms, update patients on safety strategies, review questions about medications or triage patients for more urgent, in-person visits.
- Engage with patient advocacy groups. These larger organizations can then, via Social Media or online engagement, remind cohorts of individuals, en masse, not to let their cancer and blood disease care slip.
- Develop strategies now for extending hours and days (weekend) for clinics, radiology, labs, infusion centers etc., to help handle post-pandemic care needs.
Should practices actively see stable patients via telemedicine during the pandemic, rather than cancelling them, so that there are enough appointments for urgent patients when clinic operations fully resume?
- We have aimed to avoid cancelling appointments and have intentionally transitioned them to virtual visits to lessen the coming backlog.
Should telemedicine and virtual visit practices persist after the pandemic has passed?
- Telemedicine can and should remain a resource to augment, but not replace, face-to-face visits. It can provide touchpoints, toxicity checks, and results discussions – however toxicity checks may not be fully robust when done on line.
- It may be important to remind patients, upon re-entry, of the limitations of electronic communication and visit – to ensure that they know it will be a tool, but not a replacement for the traditional encounter.
- Not all patients are facile with E-visit technology. More intuitive visual phone calls such as Facetime and Duo may also be used for some patients if allowed after the pandemic.
There may be a second wave of infections unless a vaccine is available, or until the bulk of the general population is immune from exposure. How should clinic operations be run post pandemic to minimize this risk yet see the volumes of patients necessary?
- We likely will need some form of continued screening and infection precautions until a widespread vaccine is available. Routine precautions like checks for fevers, cough and shortness of breath are likely to continue.
- Waiting rooms should be reconfigured to ensure physical distancing.
- Patient-facing providers should have appropriate PPE.
- Practices might consider broad use of antibody testing to develop a cohort of providers with protective immunity.
When can previously infected patients safely return to the cancer center for routine follow-up?
- Recommendations on this are in flux and likely to continue to change significantly as the situation evolves. For previously infected patients, some centers are using PCR viral testing before C1D1 of treatment, those about to undergo radiation or for those who have a predictable difficult course ahead.
- Other centers have not required negative PCR viral testing, given prolonged viral shedding and instead rely on patient’s symptomatology – for example, allowing COVID+ patients back into the cancer center if they are at least 10 days from initial symptoms and at least 3 days from resolution of all symptoms. All patients are masked.
- Antibody testing, in combination with symptom screening may make it possible to avoid some of the concerns associated with prolonged positive PCR testing, but this remains to be determined.