Corona Virus, COVID-19 HOAF Response & Task Force

Dr. Vaughn: Today, we are recording a special podcast episode, focused on the Corona Virus, COVID-19, and how we are supporting our patients and community during this time. This podcast was recorded on March 17th, 2020. Please check our website, HOAFredericksburg.com for the most recent information. I’m very comforted to be here today with our task force team who have been working non-stop to develop appropriate procedures and policies to help our patients through this unpredictable and anxious time. I’m going to let them introduce themselves.

Candice: I’m Candice, a nurse practitioner in the surveillance clinic. 

Jen: I’m Jen, and I am the Exam and Lab Manager.

Danielle: I’m Danielle. I’m a Nurse Practitioner and the Clinical Director. 

Dr. Vaughn: So, I’d like to start, just with a general question. Because there’s been, maybe initially, a misconception on this being just a normal virus. Please, enlighten us, if we could, about what COVID-19 is, and why we need to take this very seriously.

Candice: So, I think most people know that COVID-19 is a virus that first started – or, first was reported in a province of China, in December of 2019. So, the – COVID-19 is actually an acronym for Corona Virus Disease, 19 being 2019 when it was discovered. The Corona Virus, itself, has been around for a long time. Many years, but over the years has been responsible for certain outbreaks. For instance, the SARS outbreak was a version of Corona Virus. The Corona Virus-19 is sort of the newest strain of this virus, and to-date seems to be the most devastating. It’s highly virulent. So, it lives on surfaces. It’s easy to transmit. The biggest concern is that patients don’t develop symptoms, at the time of exposure, that there is an incubation period anywhere from two to fourteen days. So, an average patient, they’re finding now, is developing symptoms within five to seven days. That being said, all of this information is new, and it’s – these numbers could change too. But the idea is that it lives on surfaces. It’s in a droplet form. So, respiratory exhalation, coughing, these types of things can spread the virus. Those droplets from a normal cough can travel 10 feet. And so, anything it lands on, it lives on. If it lands anywhere near the respiratory tract of another person, that person inhales it and they become infected with the virus as well. A lot of people think that it’s similar to a cold, or similar to the flu. It’s very different in all aspects to both of those things. The probably, most concerning thing is that incubation period where people do not have symptoms but potentially can spread the virus for several days before they even have symptoms. And they’re finding that a lot of people in the population are, essentially, carriers. Meaning, they are completely asymptomatic or have very little symptoms, but also can be spreading the virus to people at that time. And then, the most affected or the population that’s the most vulnerable to the devastating effects are obviously, immune-compromised patient or patients that have other coexisting illnesses. Elderly patients as well. So, obviously, that makes up the entirety of our patient population. Which is why we’re trying to be so vigilant about protecting our patients. 

Danielle: And I think it’s important to mention with the COVID-19, the three major symptoms are; fever that we see at 100.4 or above, cough, and it’s a dry cough, and shortness of breath.

Dr. Vaughn: So, I would like to just start, and open it up to the beginning, in its genesis of this taskforce and how you guys started to think about this, and come up with, what I think was ahead of the curve for a policy in place to help our patients. 

Candice: Well, I think as responsible healthcare providers, we always have to be cognizant of what’s going in the world, healthcare-wise. And we all sort of noticed the developing pandemic in China. And then as it was touching other areas of the globe, we started to become more concerned. Americans are avid travelers, international and otherwise. So, we sort of knew that at some point it’s going to hit our country as well. So, we started thinking about this way in advance. And I think Jen was very proactive on getting the testing. I think we had the ability to test probably way before most places in our area, or even in our country. I think she started ordering those things as soon as they released it for ordering, Probably upwards of like, a month ago, or more. And then we just were kind of really paying attention to the news and what’s going on and started to see cases hitting the United States. And we thought, okay, it’s coming this way. So, I think probably three weeks ago is when we started really getting pro-active on developing plans and how we were going to – if this hit us, how we were going to handle it. So, we all kind of got together, first very informally, just texting and emailing and things, so that everybody was sort of thinking about things. And as we started to see more and more cases developing, we decided we needed to nail down something concrete. We got together, I think, maybe, two Thursdays ago or something. And before we ever had the first case in Virginia, we sat down and we had a plan in place. We had a sort of working, you know, yellow – or, green, yellow, red, system. Green was going to for us be; no cases in Virginia but we’re already taking precautions because we know it’s coming this way. Yellow, is going to be; we have a first case in Virginia. And then red protocol was going to be; we’ve got a case in our general regional area. What we got was, we rapidly went from –

Danielle: Green to red.

Candice: Green to red. 

Dr. Vaughn: Yeah.

Candice: Yeah. So, we all kind of – it was a lot of people with just a lot of thinking and researching to try to figure out what our best processes would be. And we definitely relied heavily on the guidelines that were put out by the CDC and the Virginia Health Department. And those guidelines were rapidly changing. So, we had to make sure we were staying on top of what they were recommending from one moment to the next. 

Jen: We initially wanted to get out preventions. So, how could you prevent getting the COVID-19? So, good hand hygiene, checking your temperatures, staying away from sick people or people that have traveled. And then, as it  got into our community, we’re like, okay, now, how do we treat these patients, if they do get it? And that’s when we all got together, we built this task force and decided, we are going to do this kind of, drive-thru triage to prevent the patients from coming in here, to protect other patients. And kind of keep them in an area where we could assess them and then, decide the level of severity. 

Danielle: Yes. We really didn’t want anybody coming into this building with infection because we – as an oncology practice, our patients are very immune compromised. So, we really worried about that. And I think that was our thought from day one, a month ago when this whole thing started. And when we went to code red, it was literally, every day, okay, we actually met a couple times a day in the beginning just to sort of make sure that we have every process in place to avoid any contamination of staff and patient. And to keep them out of this building at all cost to protect our patients that do need item treatment and that do need to come in here. 

Dr. Vaughn: And, where were we finding the guidelines for these decision-making? Were you using CDC recommendations? 

Danielle: Mm-hm.

Dr. Vaughn: WHO recommendations?

Danielle: CDC, Virginia Department of Health.

Dr. Vaughn: Where did we pull-

Danielle: WHO, to some extent. But mainly, Center’s for Disease Control, just keeping on top of what Dr. Fauci has been saying in public, and also the website. And then the Virginia Department of Health where – we’re checking that every day, as well as CDC.

Jen: And within the community, we have been sharing information between Mary Washington Hospital, Stafford Regional Medical Centers, Stafford and Mary Washington. And we’ve all been sharing our protocols and processes. So, we’ve kind of had consistency and continuity of care within these patients. 

Danielle: And I’m really proud of our practice because we actually started these protocols way before some of the other community resources did. I think we were – we had our protocol in place before Mary Washington’s ER did. So, it’s still a work in process unfortunately. 

Dr. Vaughn: It’s – yeah. It’s constantly changing every day

Danielle: Yes.

Dr. Vaughn: But that’s what I do kind of want to highlight. One of the special things about our practice being a provider, having the comfort and knowing, these policies were being standardized early. We were ahead of the game. And of course, our patients are at-risk and immunocompromised. We had to have this in place and it shows our commitment, I think to the patients here in the community. And it shows, I think, the benefit of a strong community practice, where we were able to kind of pull together quite easily, and make big decisions. 

Candice: And really think outside the box, too. Because the things we’re doing are really thinking outside the box. It’s sort of, assessing the patient outside, which I think a lot of community medical centers are doing now. That’s what CDC recommends. But we’re also going to have to look at, okay, we want patients with cancer to see their doctor. But right now, we really don’t want you to come see your doctor if you are feeling okay and if you’re stable and you’re not on active treatment. People that are on chemotherapy, you’re still going to get your chemotherapy. You’re still going to get your treatment. We still want you to be seen. But we’re going to do it in a very safe way so that our staff is not contaminated, and you’re not contaminated. And we’ve established some of these guidelines where we stopped getting visitors from coming in. We know that when you have a cancer diagnosis, having a loved one there is really important. So, we had to decide also, what constitutes a visit that is okay to have a visitor there. And we decided that if you’re a new oncology patient and hadn’t been seen here, bring a loved one with you. I think if you are starting your first day of chemotherapy, you want a loved one there because that’s a very scary time for our patients. And any time you have a scan review to figure out how your cancer is doing, that’s also another visit of where you could have a visitor. But we really decided that, in order to keep everyone safe, especially in the infusion center where you have a lot of other patients that don’t have white blood cells to fight infection, that it was just best to not have visitors at all. And sort of thing outside the box. How do we keep the family members involved when they’re not here with the loved ones? Therefore, the phone calls in the room and that sort of thing. So, …

Dr. Vaughn: Yeah. That is – I was just going to comment on that. That is a barrier that is a little bit hard in the world of oncology.

Candice: Yeah. 

Dr. Vaughn: We do love to keep the support system in place for our patients. Because sometimes that is a positive reinforcement that you need. But we’re doing this to help our patients. And I think the family members and visitors hopefully understand that. 

Jen: I think they do because of the way –

Dr. Vaughn: By removing themselves, they’re helping the patient. That’s our job to make sure we don’t lose the communication. It may be different forms of communication. But we don’t want to lose that with our patients and family members. 

Jen: And we remind them that this is temporary. This is not going to be forever. Hopefully, if we do the social distancing appropriately and everybody does their part, I mean, three to four weeks and we can start reevaluation of the visitors coming back in. But it’s not a forever.

Dr. Vaughn: So, just a quick question. Just maybe, you can kind of role play a little bit. A patient comes in the door. Jen I’ll start with you. Comes in. What is the process of, let’s say they – we may be worried they do have COVID-19.? How does HOAF handle a family member or a patient coming through the door?

Jen: Anybody that comes through the door, whether it’s a patient, family member, UPS guy, whoever, They’re automatically getting screened by a medical assistant. And they’re being asked the major questions. Shortness of breath, fever, cough, have you traveled? Have you been exposed to somebody that has COVID-19? If those are negative, you’re going to go ahead and go in. If you should have any of those symptoms, on the patient level, we will then assess you. We’ll check your temperature. Even if you have a fever or not but you do have complaints of an acute onset within the past two weeks of a cough, or shortness of breath, we’re going to ask you to go to the side of our building. And then our nurse practitioner, Candice, and one of our nurses, Nicki, will go outside and do a full assessment. And then determining what Candice sees and thinks, she may do testing. She may do bloodwork. For the family members, if they are experiencing those symptoms, we do ask them to return to their vehicle. 

Dr. Vaughn: And so, Candice, you test them. Or, I guess you decide if they need to be tested based on further questioning and symptoms.

Candice: So, we’ve actually had the ability for the MA and myself to go out. We do have the proper protective equipment and we’ve done labs right there in the car. We can do vital signs. Obviously, we can assess the patient, listen to their lungs. And mostly a lot of it is questions for the patient about symptoms. Exactly – trying to pinpoint exactly what is going on, to determine, is it something that we feel is high-risk or concerning for COVID-19. Or, is this something that’s more related to their treatment or their disease process. Because oncology patients are a little tricky in that because you are automatically immune-compromised if you’re on chemotherapy. So, you are at risk for other things that maybe aren’t this particular animal. So, we have to kind of use our best judgement to determine, does this look like what we’re seeing? Or, is this just something that we can say is probably something else and you’re safe to go back in the building? Putting you around the side of the building is really to protect everybody inside the building, obviously. But now necessarily to say that you’re not going to come in the building. It’s to just kind of give you that once-over at a provider level to determine, okay, this is probably fine. Let’s bring you in and do what we were here to do today. Or, look. This is concerning. We’re going to go ahead and test for this COVID-19. At that point, what we would ask is, be prepared to go home and quarantine, essentially. Yourself and your family members. Whoever’s in the home with you should stay home as well. Generally, our testing is taking anywhere from two to four days. When the testing centers are inundated with a lot of tests, I’m thinking it’s taking closer to the four-day mark. So, we have been quarantining patients and family members in the home for that entire time. That means not going anywhere., work, or otherwise, until we have that testing back. And that’s kind of the process that we’ve been doing. We obviously have assessed more patients than we’ve tested for. Which is a good thing. But we do have the capability to test, if we need to. 

Dr. Vaughn: It’s a great model, I think that we’ve designed. Because you’re at least removing them from the office space or triaging outside. Kind of, I guess, created out own little environment with the parking lot. 

Candice: Yes.

Dr. Vaughn: We have our own little drive-thru tent. And that’s actually – maybe you guys picked up on this, I think looking at and reading some stuff with what the Chinese did. But this is sort of how they handled – or, how it initially was. this sort of, outside triage. And they would check blood work, assess for fever and other stuff. And then they sometimes had some imaging on-site they could do. But I think that’s great that we’re removing them from coming through the door immediately, which I think is ahead of the game from what some of the emergency rooms and urgent cares are doing. 

Jen: Some of the urgent cares and prime cares, they just don’t have the ability to do the testing. So, you know, they’re sending them home to self-quarantine without knowing, and just hoping that they’re without the COVID-19. Or, they’re sending them to the emergency room. Which is what is causing such difficulty in the testing is because, some of these patients really aren’t appropriate. But there’s no testing elsewhere. And so, we are lucky to be able to have it be able to provide it for our patients. 

Candice: Criteria for testing is pretty strict. The health department has outlined guidelines on who should be tested and when patients should be tested. So, we are being very diligent on screening patients and really just testing appropriate patients. 

Dr. Vaughn: Can you review that again, though, real quick? What are the…?

Candice: Right now, and there is a little bit of leniency in some ways. We do, if we’re going to test through the health department, we do have to call and get permission to test through the health department. So, their guidelines, their criteria, are pretty specific. Usually they’re using a ruling-out test, such as the flu. Sometimes they’re doing RSV testing. So, if those are both negative, and a patient has a pneumonia or shortness of breath, cough, fever, those patients should be tested. Other patients are the high-risk patients from nursing homes that have those symptoms as well and also rule out for other viral testing. And then, of course, there’s another side for exposed healthcare workers that they are testing for. But for the most part, it’s fever, cough, shortness of breath. Those are the primary symptoms. Typically, they’re not seeing patients having runny nose or sinus symptoms. So, that’s another kind of tool we’re using when we’re ruling patients out. There’s some bloodwork abnormalities that they’re seeing pretty regularly in patients with COVID-19. So, we’re also using that as a tool to help us rule in or rule out whether there’s testing requirements. So, it’s kind of developing. The guidelines that we just kind of went over here are the ones that were released just today from Virginia Health Department. But in three days from now, we may have different guidelines or, when this podcast comes out, there may be different guidelines. So, it’s kind of a work in progress. Something we have to follow every day to see what they’re recommending as far as testing.

Jen: And we’re being very judicious with it because of supply, as well. So, we want to make sure that we’re not going to face a situation. I know that if you look at the president’s address to the nation yesterday, that we’re expecting – we’ve been waiting for more and more testing to come out. But we’re being very judicious because, you know, you’ve got to remember, with cancer patients, most cancer patients will develop some sort of respiratory side effect from their treatment. So, a lot of these oral oncolytics cause pneumonitis’s and it gets very – the anxiety level is really high. So, we want to make sure that we’re looking for zebras. We want to make sure that we’re testing appropriately. 

Danielle: And we don’t want to quarantine somebody for up to four days if it’s not necessary. 

Jen: Exactly.

Danielle: Yeah. So, we’re not testing everyone.

Dr. Vaughn: So, that patient that comes through, let’s say we are worried enough to test them. We tell them to go home, self-quarantine. Are we calling – at the practice, are we calling every day? Let’s see how we’re doing? How is the follow-up? One question. And when are the results going to be back.

Candice: So, it’s been taking four days for us so far. The patient’s that we swabbed. And the first patients that we did test were Friday. And so, I actually was on-call over the weekend. So, I did make phone calls to them both days, over the weekend. And then again, Monday and Tuesday we had someone from the office, whether it’s me or Jen, or one of the medical assistants, calling to just check on patients, check on symptoms. We are telling patients that during that quarantine period, obviously, we’re only sending patients home to quarantine if they’re stable. Mild or stable. If they’re unstable, then we would send those patients directly to the emergency department. But stable patients can go home and quarantine. We’re checking on symptoms every day, and then we’re asking patients also, that if they develop worsening shortness of breath or they become unstable, obviously, they’ll go to the emergency room, but we would prefer they call our on-call physician or our dedicated line during the day, so that we can facilitate a call ahead to that emergency department to let them know that they’re coming, so they can be expecting a patient that is, what we call, a person under investigation. Or, person of interest. Whatever they’re calling them. So, that’s kind of the working plan that we’ve been doing with patients so far. 

Jen: We’re pretty, almost psycho about looking up these results. I’m looking them up on the hour. Because I know how anxiety-ridden they can be when waiting for these. And so, I have been – through the whole weekend I was checking for results. Because as soon as I can give that negative, or the positive, it’s an answer, that puts them at a little more ease and we can then go to the next step of determining what to do. And if it’s negative, why are you feeling this way? Let’s rule out some other things, as well.

Dr. Vaughn: And how about, how are the family members handling that? Are they quarantining? Is the patient isolated by themselves? Are they just doing a family quarantine? 

Candice: During the address yesterday by the president, they did recommend whole-house quarantine. So, if someone is sick or diagnosed with COVID-19, it should be anyone in the household is also quarantined. So, that means no one goes out. No one comes in. And you just kind of –

Jen: Shelter in place.

Candice: For lack of a better term. If a patient absolutely has to go out, or a family member, I guess, absolutely has to go out for groceries or necessities, then we would recommend wearing a mask. Obviously, the hand washing and things like that in the public. The main goal here is to prevent rapid spread of the virus. And the way to do that is to contain it where it is. 

Danielle: We’re not even just telling family members and patients that. We’re telling our staff that too. Do not go to public places. Try to avoid restaurants right now. Don’t travel if you don’t need to travel. Stay home. It’s really important to squash this.

Candice: I mean, everybody, that’s the general takeaway is, this whole social distancing. And what that means is not going anywhere that you don’t have to go. So, we’ve seen in other countries, that this has been done too late. And it becomes a mandated issue but then they’re already behind. And they’re already rapid numbers, growing numbers. And that’s what we’re trying to prevent, obviously. This idea of flattening the curve so that we don’t run out of accommodations in the hospital’s for patients, once we hit that critical number of positives. Really, just the principle of staying home if you can, not going out if you don’t need to. Go out, sure, if you need necessities from the grocery store or whatever but be very vigilant about your handwashing, and wiping things down, and keeping things clean, and not gathering in crowds of more than 10 people, and really just trying to stick with those guidelines. Because we’re trying to protect our patients. They’re the most vulnerable patients. Everybody else is responsible for doing that. I think for the most part, our patients are doing it. They’re staying home. But we don’t want so-and-so’s granddaughter to bring it to them because they’ve been out and hanging out for St. Patrick’s Day or whatever. It’s everyone’s responsibility to protect the most vulnerable people in the population. 

Dr. Vaughn: It seems like we’ve been meeting pretty regularly. As staff, I know we’ve had the meetings with the providers for the physician’s and the nurse practitioners and the assistants.

Candice: Yes.

Dr. Vaughn: And upper management. This task force, then. You guys are meeting daily. Changes are being made daily. So, we’re constantly on top of any new events or changes.

Danielle: We meet every morning. I think yesterday, we actually had three meetings, didn’t we, during the day? So, it really depends on what’s going on and what we’re learning. So, every morning we meet to go through anything new and sort of debrief on the day before. Or, if there’s anything that we really need to be worried about that we’re not doing yet. Perfect example today. We have the PPE or the protective gear that we need to take care of our patients. But there’s a national shortage of that as most clinicians and most of the general public know. But today, for example. We were able to get masks for every single one of our employees. And I actually want to point that out. Because I think being an oncology patient and walking into a clinic where everybody is wearing a mask, could be a little bit daunting and a little bit scary. But know that we’re wearing that mask to protect the patient from the staff. Because we get exposed to more than one person. So, when you come in the office, you’ll see everybody wearing a mask if their in patient areas. 

Jen: I think that’s one of the scariest things about this virus is that healthy people with good immune systems may not have any symptoms and they could essentially be carriers to infect other people. So, that was one extra step that we decided to take to protect our patients from our staff. Because obviously, we’re all trying our best to practice social distancing. But we all have to go to the grocery store. We all have to do some of these things. So, in order to take one further step to protect our patients from our staff, essentially, we’ve decided to have all medical personnel wearing a mask. 

Dr. Vaughn: Yeah. It’s been a hard thing for me. Just because that kind of goes against the norm of our practice. We have this beautiful sort of lodge-looking building. Sort of centered on wellness and you don’t want to have this sort of sterility look like other medical buildings. But I think, Danielle, you’re right. It’s – we’re really – this is the norm for now. Hopefully, it’s going to change. But we have to protect everyone. And that distance is important. How have you guys been keeping yourself cleaned and safe?

Candice: A lot hand washing and a lot hand lotion.

Dr. Vaughn: Yeah?

Candice: A lot of – yeah.

Jen: Well, Candice and our LPN, obviously gown-up to the entirety when they go out to these patients. But we’re doing all the same PPE that we’re expecting our clinical staff to do. I know we’re gloving-up obviously, with almost every patient with anything. Not just when you’re trying to do a blood draw. But obviously, when – unfortunately, like you said, we’re a very close and personal practice. But we’re distancing ourselves for – unfortunately, not doing the handshakes and the hugs that we normally do. And again, that’s temporary. And we’re just like, Danielle said, we meet every day. And sometimes multiple times a day whenever there’s a press conference. We regroup after that so we can stay up to the latest and greatest of their recommendations.

Candice: Yeah. I think a couple of other things that we kind of did to prevent, or hopefully prevent, any spread of anything is, we’ve actually advised staff members to consider wearing scrubs. Even professional people that don’t normally wear scrubs. We’ve extended that ability so that people could potentially come in, change here, change back out to their regular clothes and leave, and then just lauder the clothes their wearing here so you don’t transport things in and out from home. We’ve created what we call a dirty area, essentially. We have a decon room. So, we’re keeping all of our –

Dr. Vaughn: Is that my desk?

Candice: We’re keeping all of our personal protective equipment in there. The door is closed all the time. So, we’ve shut off entry through that entry and exit door. It’s only in and out for the staff that’s going in and out to check those patients. So, all the rest of our staff is rounding through another area so that they’re not potentially contaminating themselves or anything else coming in and out of that particular entrance. 

Danielle: I mean, we’re constantly going through the rooms and the computers and the phones and cleaning, disinfecting. It’s around the clock. We try to do it on the hour. If not, with every patient in every room. I think the screener in the front is huge. And it’s not going to go away until this virus goes away. I think nursing is very aware of how to triage these patients as well. So, if they get the calls, they’re getting the same answers if they were to call my phone. Which I don’t know if we discussed. But we have a dedicated Corona Virus phone. So, if you do have any concerns, or any questions, or potentially think you should be seen, you would call our office and then hit extension, 8, I believe.

Candice: 8 or 9. I can’t remember. But it’s the first –

Danielle: It’s on the recording. It gives all the information a patient might need if they are concerned about the virus or think they have symptoms of it. And that goes directly to a live person. So, it’s not a voicemail. It’s going to go directly to a live person that’s going to answer that call and route that patient in the right direction. 

Candice: It’s extension 181.

Jen: I think the other thing we’ve done, actually, is really try to debulk the amount of people coming into this building. So, we’ve cancelled a lot of non-essential medical appointments, if you will. So, people coming in for their yearly breast cancer follow-up or for their iron levels, we’ve told them all, stay home unless you really need to come in. Unless you’re sick. And I think that’s going to continue to develop. I know that today, Medicare actually just released a notice saying that they were really debulking, or unrestricting a lot of their policies on telehealth and telemedicine. So, I think that’s huge for us. And we’re actually, right now, I’m in the process of trying to come up with some sort of protocol, so that we can make sure our patients can reach us. And that we can manage them by telephone or even by video if we have to, to try to keep them from staying away from public places and being able to be safely managed medically, in their home. So, we’re in the process of doing that. 

Dr. Vaughn: That’s a very comforting thing, I would think, as a patient. Knowing that we’re not neglecting them. Finding alternative kind of, new methods –

Jen: Yes.

Dr. Vaughn: – of communication. 

Jen: Yeah. I’m so glad that – because we were really worried about that. And we’ve been actually trying to figure this out for about a week or two. How can we make sure that we can still take care of our patients from home, and still be able to do that so that it’s legal, if you will, and it’s the right thing to do? And so, I’m so glad that Medicare came up with that today. And I think there’s going to be some other changes with insurance companies, too, to make sure that we can take care of our patients. And they need to feel like they can reach us, if they need us. 

Dr. Vaughn: Yeah, I’m just – I can think of a patient who’s on an oral oncolytic and they don’t need to be in for an IV infusion. But yet, we can maybe manage – maybe it goes induction, but it goes through the phone. Telemedicine. For instance, if the have a rash, we can see it and it’s a great avenue of helping that they don’t need to come into the office but still manage appropriately. 

Candice: Yes. And I think even, I think about the patient with a rash, right? And I think if we were – again, we were actually just trying to figure out our patient population. A lot of our patient population is elderly. And I don’t know that they really could manage a video, if you will. But the ability to be able to say, hey, can you Facetime me and show me your rash. Or, Skype me and show me your rash. I mean, we can do that. And I think that’s what we’re working towards. And hopefully we’ll have that in place by the end of this week.

Jen: And if you are one of the elderly patients and you do have a rash and you feel like it’s something that needs to be seen acutely, again, Candice is our surveillance clinic nurse. And we have her solely dedicated to that. So, if we feel like it is appropriate to bring you in, we will still bring you in. 

Dr. Vaughn: Yes.

Jen: We’re not turning patients away when it’s something that’s severe and significant to their diagnosis.

Dr. Vaughn: That’s important for out patients. Because really, they need to stay on-schedule for their cancer diagnosis and treatment. And that’s kind of a message. We’re doing this in a way to keep people on a schedule, keep their treatment going. But yet protecting them against this disease right now. 

Candice: Trying to keep people on track. Just because [inaudible] – the cancer is not going to got away because Corona Virus is around. So, we’re going to take care of their cancer, take care of them.

Dr. Vaughn: Well, it sounds like, within two weeks, you guys have developed an amazing policy here. And it’s still changing and it’s fluid, obviously.  What – would there be any recommendations or any kind of, just points? Let’s say a community practice elsewhere in Virginia. Just kind of maybe a little step behind. What were some things you say, this is what we’ve done, and this is working?

Jen: I think having a dedicated team allowing you to have a nurse practitioner or a nurse MA be off the floor and be able to focus on these patients directly. I think that’s huge. Candice had, at times, even though there’s only a couple of patients that have this concern, it’s still, it’s a big process to roll it out or to determine whether they should be tested. And so, allowing her to be able to dedicate her time just to those patients is huge. And making sure that she’s making the right treatments and being able to call the physician and be able to say, this is what I have and discuss the case. I think having a nurse that, that way you have the continuity of care between patients. Every patient is being swabbed exactly the same way. Every patient is being tested exactly the same way. So, we are getting accurate results and making sure that these patients are being taken care of appropriately. 

Danielle: Communication with patients is huge. So, that’s something we’ve really tried to focus on. We’ve sent out emails to patients to let them know, put it on our website. We’ve got signage all over the building. We’re having nursing and medical assistants and provider’s like, telling patients our protocols. Putting their minds at ease. And I think that helps a lot because – especially when we’re assessing patients in the car. They’re waiting for a while. So, they’re going out and we’re doing some bloodwork and then we’re going back out again and we’re saying, okay, now we’re going to do this, or, we’re ruling out for flu. We have to wait for certain steps to happen before we arrive at the point where we say, okay, now we’re going to test. So, I think, just communicating that openly with the patients has really helped a lot. I mean, our patients obviously, have been really great with this. And they have not minded one second of waiting in the car. They understand that we’re doing this for them. So, – and then they’re comforted by the fact that when they are okay and they come back into the building, then we’re doing this for the next person that comes in. So, – to keep them safe. So, I think, really, educating everyone. I mean, every time we had new and different changes to our sort of, working plan, or our policy, we’ve had open communication with patients and then staff as well. So, we’ve tried to not have staff meetings where all of our staff is in one place at the same time. But we’ve sent out a lot of emails to staff to just really try to update them and keep them abreast of what the changes are each time we adjust something within the policy. 

Candice: And I think I would recommend any practice out there really, really put a screener at the front door. Really screen well before that patient walks in the door before a stranger or family member or a deliveryman walks in the door with possible contamination. Just stop it before it walks in the building.

Dr. Vaughn: Right. Remove that – 

Candice: That’s the best first step.

Dr. Vaughn: – patient or family member from the infusion area. What I’ve seen is commitment, the whole staff from the scheduler to our building administration to the doctors. It’s really a uniform movement. And that’s critical. 

Danielle: I think flexibility is key. I really do. And I think our staff has been amazing with their flexibility. And our patients. The visitors. I really expected a lot more kickback with patients not being able to – especially when you’re a cancer patient, right? You want your family member there. But everybody’s been so understanding and so gracious. And for those that really don’t understand why we’re doing this, it’s – really, we’ve had very few kickback with visitors that don’t understand and want to come in. But again, it’s truly for the safety of every other cancer patient. And the community, in general. Because we want to keep everybody safe. So, there’s a reason. It’s temporary.

Candice: I think commitment is the word of the day. Because we are texting each other 24 hours.

Danielle: Yes.

Candice: We’re having phone conferences on Sunday’s. I mean, we are staying on top of this off working house. I mean, we’re 100% behind our patients, in making sure that they are getting the best care during this epidemic. And we want to make sure that if we can keep them healthy, we’re going to keep them healthy. 

Interviewee: Before recording this episode, we opened our Facebook page to questions from the community, which we’ll go through now. The first question I’d like to ask; how will upcoming appointments be handled for patients receiving chemotherapy?

Jen: Patients receiving chemotherapy will remain on their schedule. We don’t want any delays of treatment. So, as long as you’re not ill, and you’re feeling well, you will continue with your chemotherapy treatments as scheduled. We’re not planning on any deviation from that because of this pandemic.

Dr. Vaughn: How about bloodwork days? Coming in like, I’m on a three-week cycle and I’m coming for day 10 bloodwork. Is that going to be the same? Are we going to limit that?

Jen: I think we’re – right now, we’re keeping steady counts. 

Candice: Yeah. Pre-chemo labs, anything that is essential to your treatment regimen disease, we are keeping our active treatment patients on schedule.

Dr. Vaughn: So, no real change to a chemotherapy treatment plan?

Jen: No.

Candice: If there’s a significant concern from the patient – so, for instance, if you’re scheduled to come in to see a provider and have your bloodwork done and then the next day is your chemo treatment, and you personally want to limit your time in the building, we can sort of, on a case-by-case, modify some of that if we need to. Maybe adding the labs onto the day of, and a visit onto the day of, and there’s room in that provider’s schedule, we can try to facilitate that if needed, if it’s a concern for the patient. But at this point, we’ve just decided to keep chemo patients on schedule with their schedules, if we can, as much as we can. 

Dr. Vaughn: And that answer may be to this question. The question was asked, my husband comes in for monthly labs to track his leukemia markers. And he also has a heart condition. Is the safe to come into HOAF for labs next week?

Danielle: We have done so many things to make sure that coming into this building is safe for patients when they need to come into this building. So, yes, it is safe for them to come into the building to have their labs for their leukemia. I think they will see all the efforts we’ve made. From the screening at the door, to the no visitors. There’s just so much in place to protect out patients. So, there is no problem with them coming in here to get their lab work done or their treatments. 

Dr. Vaughn: And it may be a case-by-case basis.

Danielle: Yeah.

Dr. Vaughn: Depending on the leukemia markers, maybe pushed off six weeks. So, I think they can be individual. But in general, that’s why we’re doing these things and have these procedures in place. So, it is safe for every patient to come in.

Jen: That’s what I was going to say. Kind of back to what Candice said. If you – the patient, themselves, don’t feel comfortable, just please give us a call. We’ll have the physician or the provider evaluate it and see if they’re necessary. And we can push them out as long as we get the okay. But as long as you feel well, then those appointments do stay on-schedule as well.

Candice: I just wanted to add one more thing too. I think it’s really important for our patients to understand that their lab values are so important to their treatment. And some labs we can push out and not worry about. But some labs are crucial to their treatment and they need to come in for those. Because, you know, they run the same risk of going to a Quest of LabCorp, as they do coming in here. And I think we have done so much to keep our facility as infection-free as possible, that we feel better having them come here. Because I think we feel like it’s safer for our cancer patients to get their labs here. 

Dr. Vaughn: And we’ve invested so much in our lab. And it is – the turnaround time is so quick. So, we can get the information out to them so much faster. Great answer. This is question number three. Is there any concern for patients that recently had follicular and diffused large B-cell non-Hodgkin’s Lymphoma but still have respiratory issues? So, I think this is someone who may have been treated and these are – for the audience, these are to hematology malignancies. Of course, they can create some immunosuppression. But it sounds like these may have already been treated but still had some respiratory issues. Are there concerns?

Candice: Yes. And I will reiterate what was actually discussed nationally. Patients that have a cancer diagnosis of a year or less, have respiratory issues, have cardiac issues, and have a other co-morbidities, are at higher risk for critical disease from this Covid infection, should they become infected. So, yes, there is definitely concern for that. And they – all I would suggest is that they take all the precautions that the national taskforce and local governments have asked people to do. Social distancing, washing your hands, and pretty much staying in place. 

Dr. Vaughn: So, if this patient or a similar situation does have respiration issues, do they come here?

Jen: So, what we’ve been asking patients to do is call first, if you have a concern. And that’s why we have the live sort of, triage person to kind of go through those concerns with you. Either, A, alleviate your fears, or, B, determine that yes, we do want to see you. So, I think that’s the start. Just call us and we can guide you in the right direction.

Candice: If you’re having a cough and you’ve had this cough for, you know, six months, it’s probably not going to be as concerning as if you have a cough that developed a week ago. And so, that’s why we want a call first and make that determination. You’ve had this issue. Otherwise, you’re feeling fine. You can go ahead and stay home. And then, monitor for fever and shortness of breath. And if they worsen, you can give us a call. This is an acute onset of a symptom, then we want to make sure that we assess you properly. 

Dr. Vaughn: And again, this call goes to the hotline? 

Candice: To the hotline.

Dr. Vaughn: To the hotline. Covid hotline. Okay. That’s a valid concern. And it’s good that they can actually reach you quickly. 

Candice: Yes.

Dr. Vaughn: I think that’s important too. 

Candice: It’s on my hip, the entire day. 

Dr. Vaughn: Right.

Danielle: I think, that being said, too, what’s really important is that we do answer them quickly and we do want them to call us instead of just going to the ER’s, as well. I mean, if you truly have unstable symptoms of Covid, you need to go to the ER. But truly, call us first. Because if you are a patient on active chemotherapy treatment, we do now want you just to go to the ER if it’s something that is related to your chemo treatment.

Dr. Vaughn: Right.

Danielle: So, that’s important. 

Dr. Vaughn: The next question, when I meet with the doctor, many times, I do not remember questions that need to be asked. And my wife handles that role for me. Why can’t she continue coming to my appointments? How can she help now? Very good question. 

Danielle: We actually had somebody ask that question today. It is very important that limit people coming into this building. Including your loved ones. And yes, the wife is very important. A loved one is very important to have during your visit. But there are going to be other ways that she can help. She can stay in the car while she’s – while the patient’s here. We can get her on the telephone to answer questions. We can Skype her if we need to. We have to be creative. But we also have to make sure – like we said earlier. We’re protecting our patients and the community by keeping anyone out of the building that does not need to be here. 

Dr. Vaughn: Can you review real quick again? We have kind of an – not really a no – well. I guess a strict visitor policy. What are those again?

Danielle: So, we are asking that no visitors come in with patients, unless you are a new oncology patient and you are here for your first visit with the oncologist. We definitely want you to have a loved one with you then. If this is your first visit of chemotherapy, your first cycle of chemotherapy, we want you to have a loved one with you then, because these are anxious times. During your scan reviews to go over images and just to sort of see how your cancer is doing, how you’re responding. We would like you to have a loved one there. And during your patient teach session, where we go over the course of treatment, and the schedule, and the side effects to be expected. We would like you to have a loved one there as well. Because that support system is so important. We are asking for no visitors during regular office visits and for your subsequent chemotherapy cycles, to keep as many people out of the infusion room as possible, to protect every other patient as well. But those are the instances where we do want somebody there. 

Dr. Vaughn: And that’s – as we touched on earlier, that’s a challenge as a provider. Because I think, the more people that are in the rooms sometimes, the more understanding there can be with where we are and where we’re going. 

Candice: Yes.

Dr. Vaughn: The direction. Imperative. And this is imperative on us to continue the communication, even if the loved ones aren’t in the room with a patient. So, hopefully this offers some reassurance that it’s not going to – to break the barrier there that the communication will still be in place. 

Candice: It will. And we’ll – we’re more than happy to reach out to the caregiver, loved one, family member, on the telephone during our office visit or during their chemotherapy infusion. We don’t want to isolate anyone. 

Jen: And again, it’s temporary.

Candice: It’s temporary. That’s right. I think, too, one thing I have seen patients do in the past, or I’ve seen wives that can’t make it to visits, even before we enacted this policy, that have specific questions. And you can feel free to send that list of questions with the patient and we’ll do our best to address them even maybe, writing little notes back to, if it’s really a concern and you can’t join by phone, that would be another option that we could – for communication purposes, as well.

Danielle: We also have our patient portal, Care Space, which people can access and send protected emails. 

Dr. Vaughn: I was going to ask. A good time to use the website.

Danielle: Absolutely.

Dr. Vaughn: For information gathering. To get our messages out. And also, I think the infusion nurses can be a good liaison for communication. 

Candice: Website is really our first kind of, point of contact for patients when we do have new information or things are evolving or changing. That was the first place we were able to put out a message to patients that, we know what’s going on and we are working on it. So, that’s something. Check back on the website regularly. 

Danielle: As well as our Facebook page. We are continuously putting the latest and greatest information on our social media platforms, as well.

Dr. Vaughn: And the last question I’d like to bring to the table here is; will HOAF offer virtual visits for patients that are stable, scheduled for routine appointments? I think Danielle may have touched on that earlier.

Danielle: This is how – we are working on that. Feverishly working on that, to try to make sure that we have something in place very soon so that patients can sill feel their connection and still have a formal office visit with their provider. So, more to come on that. I should hopefully have an answer to that by the time this podcast goes out, or by the end of this week.

Dr. Vaughn: Well, I would like to offer this opportunity to thank you guys for being here. It shows how committed you guys are. But just how committed our practice is to our patients and the quality of care during this disruptive time. I think we’re doing the best we can to keep things kind of moving, still. Seamlessly. I guess we could say that. But obviously, there are some hurdles. But we’re doing the best we can. And it shows you just that you have some great management and leadership, what can happen. And I’d like to thank everyone here. Just the commitment has been amazing. Thanks for listening to Cancer Shop Talk, Behind the Diagnosis. We know this is a difficult time for our patients, staff, and community. And we are here to support you in every way we can. Please visit our website HOAFredericksburg.com for more information and like our Facebook page for regular updates.