Going beyond the curve: Restarting our eye practices following the COVID-19 pandemic

Social distancing, reducing our clinical volume, and canceling elective surgery has led nationally and in Ohio to a significant flattening of the curve anticipated of COVID-19 cases. Locally we are currently trending at a model of social distancing between 60-80% and have blunted the expected incidence such that our healthcare organization can now get back to elective patients while not being overwhelmed with COVID-19 inpatients. In particular, ophthalmologists were the hardest hit surgical specialty experiencing a drop in 79% of clinic visits according to a recent evaluation. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits.

And we are about to embark on probably the greatest national experiment – what happens to the pandemic as we open our doors to our patients again? How do we start our practice knowing that potential flares of COVID-19 might exist in the future? With no vaccine in the near term, how do we best protect patients and caregivers? Here are some ways in which we will strategically open our doors and stay safe.

Virtual visits are here to stay. We will continue seeing patients virtually whenever possible reducing their exposure to our healthcare organizations. We covered in a recent article how we re-tooled our providers and practice to accommodate telehealth appointments (https://consultqd.clevelandclinic.org/how-to-use-telehealth-for-ophthalmology-patients-during-covid-19-crisis/). We are experimenting now with hybrid visit types – involving limited contact expedited appointments within the office with a diagnostic device and then performing a virtual visit afterward. This has already shown promise in glaucoma, general ophthalmology, and retina clinics and now we see almost 30% of our eye patients virtually.

We will promote current remote eye options and encourage innovation for future devices. Many forget that we do have a remote device approved already for monitoring dry age-related macular degeneration. The Foresee Home monitoring system can be fully integrated into EMR with the ability to order the test and see the results. The findings were supported by a randomized clinical trial that showed significant benefit. And we have many companies working on home OCTs devices to detect activity in those with age-related macular degeneration, diabetic retinopathy, and retinal vein occlusion. An additional benefit of these home OCT devices will be in how they streamline office workflow. For example, our practice on average has a patient wait 45 mins to get an OCT due to the sheer volume of patients using the device. Imagine that we had patients doing these tests at home and coming in with their results for interpretation and treatment to our offices.

Our waiting rooms and exam rooms will have to evolve. The average ophthalmologist sees between 40-60 patients per day. Social distancing in offices can be difficult given the footprint. We will have to check the temperature of a patient entering our offices, offer masks if they are not wearing them, reduce patient movement between rooms, omit diagnostic testing unless absolutely necessary for clinical decision making, and opt for skipping seats between patients in the waiting. We are currently performing a pre-visit interview for patients to capture their history prior to their arrival to clinic so their work up time is shorter. Lastly, providers will be seeing patients at a slower rate to properly space them apart on a schedule with longer office hours and thus this could lead initially to a lower overall clinical volume than we saw before this pandemic.

My temperature being checked on entry to Cleveland Clinic

Our ambulatory surgery centers will have to adapt.  We will see changes in how our buildings are structured improved filters and ventilation if needed. Physical barriers such as clear plastic guards will reduce transmission. The centers will have to incorporate COVID-19 testing before any surgical procedure. And this is complicated since even if the patient has a negative test, between the time of their test and the time of surgery there is a risk they could be exposed.  And what about cases of bilateral surgery like cataracts separated by two weeks?  Patients would have to undergo COVID-19 testing twice to ensure they are negative for both surgeries.  This will be complicated by the backlog of cases that 2 months of no surgery has created.  Any interruption in the supply chain from adequate testing, surgical supplies, PPE materials will delay cases further.  

We will establish the New Normal.  Americans will continue to contract COVID without a vaccine. The measures we have established in our personal lives at places like the grocery store will become part of our work lives.  This will include patients and providers wearing masks in the clinic, reducing social gatherings and likely medical education meetings, and using hand hygiene as routinely as we possibly can.  Ultimately the New Normal will never make us feel like we did 6 months ago, and we will adapt and understand that there are many decisions, big and small, that will need to take place at all levels of society for us to overcome this pandemic. 

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