HOAF Covid-19 Update: Task Force, Response, and Safety

Dr. Vaughn: Welcome to Cancer Shop Talk, Behind the Diagnosis.  I am your host, Dr. Christopher Vaughn, Physician and Owner at Hematology Oncology Associates of Fredericksburg in Virginia.  We are redefining the conversations about cancer through the lens of an independent oncology practice.  Thank you for joining us.

Today we are recording a follow-up podcast episode focused on the Coronavirus, COVID-19, and how we have supported our patients and community during this time.  This podcast was recorded on October 12 of 2020.  Please check our website, hoafredericksburg.com for the most recent information. 

Dr. Vaughn: Well I would like to thank everyone for coming out tonight, our special task force team here.  This is really – I almost think this is six months from when I think the pandemic started.  I remember about to watch the Duke basketball game on March 13th, and it stopped because of the pandemic.  And I think that was like to me the beginning of the pandemic.  And so, we’re about six months from the beginning, or at least what I think is the first day of the pandemic, around that time.  

And we are here to discuss tonight to discuss – I’d like to focus on our approach as a practice to the pandemic, review, kind of what we did initially, our implementations and guidelines and protocols.  We can talk about how effective they’ve been and where we’re going to go from here.  There is definitely, I get a sense, some growing concern from our patients.  There’s some more anxiety about, you know, the future with the winter months coming, temperatures cooling down, about the concern of co-infections and the impact on their immune system.  

And so, I think it’s a good time to kind of come together and tell our community, you know, what we’ve done and what we plan to do going forward to protect our patients.  So, I’m thankful here for everyone, and I’ll let you all introduce yourselves, if you wouldn’t mind.

Candace: I’m Candace.  I’m one of the Nurse Practitioners in the surveillance clinic and part of the COVID task force. 

Jen: I am Jen, and I’m Exam and Lab Manager, and I am part of the COVID task force.

Dr. Maurer: Dr. Charles Maurer.  And I’m one of the Oncologists here, part of the COVID task force that was created, as Dr. Vaughn said.  Essentially as this pandemic was starting, we hit the ground as fast as we could with it.

Dr. Vaughn: And that was one of the initial things I think as a practice we did was forming this cohesive unit to meet initially on a daily basis I think, guys, and then maybe it became more of once a week.  But it really showed how cohesive I think our group was and how we’re going to adapt as things were constantly changing, especially in March and April, with the virus.  So, I just want to get an idea and open up here to all of you your initial impressions of our response to the pandemic and how we made some changes and adapted along the way and what the future may look like.

Jen: I think that we were really quick in sort of getting things rolling.  I think the first time we heard about it being, even before it came into Virginia, just when we were hearing, you know, rumblings in New York and things like that, we started right away planning, you know, what we were going to do, came up with sort of an approach, kind of green, yellow, red.  

So, we were considering green, just a little bit stricter policies on, you know, monitoring people and travel and things like that, and that was going to be before any cases were in Virginia.  Yellow was once we had the first case in Virginia, we had, you know, ramped up a few things in that area.  And then red was going to be the first time we had a case in our area, which actually happened – yellow and red happened at the same time.  And so that was where we really started with, you know, the screening at the door.  

And one thing I was really proud of was I think we were probably one of the first places healthcare wise or otherwise that started universal masking.  I think even before the hospitals did, we were requiring masks for our patients and our staff.  We had some outpouring of volunteers making masks and things like that for the office, so we were able to provide masks for patients which I thought was really, really great.  But that was one of the, you know, one of the first things that – we were one of the first areas I guess that did that, and I was really proud of that.  And I think most of our processes were ahead of even the hospitals in the area to protect our patients and our staff.

Candace: Yeah, we were very proactive on making sure we were able to test our staff and our patients, that supplies were limited so we made sure that we got in contact with our reps and with the VDH so we could test anybody that we had any concerns about.  We also increased our usage of, you know, hand sanitization and made sure we were stocked up with gloves so that all of our staff felt safe as well.

Dr. Maurer: I think one of the most important things that we were able to do was not shut down.  We were able to continue care, we were able to continue care for all of our oncology and hematology patients throughout this entire pandemic, and I was thinking about it was really initially protecting our staff and our patients; diagnosing, how we do that, and then treating whether if they have COVID what do we do and how do we manage it, and then also continuing the treatments that are ongoing. Those are the three main areas that we have worked on and continue to work on as it evolves.  

You know, six months ago, seven months ago, would I have thought we would be here right now in this kind of situation; you know, I think everyone was hopeful that this would potentially pass.  It really hasn’t, and we’re really trying to figure out the best way to safety continue to do what we do every day and live through it until eventually we start to see a clearing which I am hopefully we’ll eventually see over time, but we still have to continue to manage our patients and keep our staff safe, all the measures that we’ve been working on, many, many, and they continue to evolve.  Sometimes every day we’re making adjustments, as we have new information.

Dr. Vaughn: Yeah, I think that actually is a great point.  I am very proud of sort of the resiliency of our office to not shut down.  I think there have been, not only in Virginia, but nationwide some other oncology practices did kind of shut down for a brief period, and that puts a lot of angst in our patients’ heart and minds when they’re going through treatment for cancer.  So, you know, maintaining some sort of protocol to keep patients actively on treatment in a safe fashion was instrumental.  

Do you feel like there – have there been some adjustments, or you mentioned kind of constantly having to evolve and make changes, what has – what’s happened recent in the last few months?  Are we kind of anticipating some change, again because we’re entering maybe into the flu season?  Are we becoming more restrictive again or what’s happening here at HOAF?

Candace: Those discussions are ongoing.  We’re trying really hard to follow the guidelines that the Virginia Department of Health has put out, that the Governor has put out.  We’re definitely complying with those and then obviously some of our policies here are a little bit stricter just because of the patient population that we have.  So, you know, right now we have loosened a little bit on some of the items like visitor policy.  You know, in the beginning I think we were not allowing any visitors.  As we sort of started to see things level out a little bit, we started to allow one visitor.  Patients for office visits, still no one is allowed in the infusion center as a visitor because that’s a less controlled environment.  It’s a little bit more open without, you know, barriers.  

So, as time goes on I guess we kind of had to see how things are going to evolve, and what the numbers are doing in our area as far as new cases, and that will kind of determine whether we continue on allowing a visitor with patients or whether we scale that back again.  We are kind of encouraging people to not come if there’s not a definite need to come, that meaning comprehension issue with a patient or a physical need for someone to be there or even an emotional need.  But otherwise, if it’s not a necessary visitor requirement that we would still ask patients to not bring a visitor.  But as we go through the season, I think things may even change with that.

Dr. Maurer: I think we’ve seen our oncology patients, in particular those who are on therapy, have done an outstanding job with trying to be as quarantined and as safe as possible during the entire pandemic, and I think that’s really helped us throughout this whole last six and a half months to keep the vast majority of them free of Coronavirus and the secondary effects.  We have had patients of ours who have developed Coronavirus.  I mean some of them don’t even know where they got the virus; some of them may have had an exposure from a family member, and we’ve been able to effectively, you know, work with them.

And it’s interesting, we’ve seen varying degrees of illness where some patients have had high-risk factors but they haven’t gotten – become sick, and others may have needs to be in the hospital as we work trying to get them healthier and taking the extra precautions with them, trying to be a little bit safer if they are on therapy.  But there have been some significant changes.  Early on in the pandemic, you know, when there was in Florida there was the mandate if anyone was coming from Florida that we wanted them to quarantine.  Now Florida is an open state.  And so, we have not required that.  So, that has been a change.  

And sometimes that leads to some confusion from day-to-day, but as the pandemic changes we’ve had to adjust to that.  And then also, exactly like you brought up, Dr. Vaughn, in terms of where are we going this fall, so one of the things that we’ve been trying to do is really first off make sure all of our patients have gotten the influenza vaccine because many of those symptoms and people who get influenza can be very [inaudible 10:28] Coronavirus, or if God forbid, they were to get both viruses at the same time no one really knows what that would be like.  

But that’s some of the measures we’re actively working on right now.  I now all of our staff have been getting the influenza vaccine and then we’ve been – most of our patients really, I’ve seen this year I’m highly encouraged by the rate of vaccinations that people have been getting.  I think we have a higher amount of patients who are willing to take the influenza vaccine.  

Jen: We know how important the caregiver role is with, you know, in cancer care and how they want to be here to support them, and so we are meeting every day to reevaluate the situation, and kind of like Candace said, if you absolutely need to be involved in that visit, then you know, we certainly encourage them to come, but if you can stay home, you know, Facetime or somehow virtually attend, then we do ask that you do that as well.  Because our number one goal is patient safety and staff safety, and so if we can eliminate any potential exposures then that’s what we would like to do.  

Dr. Maurer: Especially if both people coming in, let’s say they’re both seniors, do they necessarily need to have two exposures there, so if one patient comes in, and then often what I’ll do in the room, I’ll just call the patient’s family member right there and say, you know, I’ve got mom here, this is what we were talking about, what questions do you have, always, always willing and it’s actually really great to keep that communication open.

Dr. Vaughn: I want to bring up, also the question comes up a lot with some of our patients about testing for COVID-19.  I know initially I think we had 100 tests I think here in our office in early to mid-March.  We were one of the few medical offices that actually had tests.  How has that changed as far as testing a patient?  It seems like now we may be hearing of them having a positive test from outside, correct?  We’re not – are we seeing a lot of testing being done, acute tests, at our office for patients or the ones that have maybe contracted the virus from outside testing now that it’s much more common to have a test maybe done.

Candace: Yeah, I think definitely our frequency of testing has declined some, and I’m not sure exactly what’s prompting that.  I do think part of it is that patients are actually becoming more savvy and they’re calling ahead of time and saying, “I had a potential exposure.  I’m going to go get tested here with the rapid testing that’s become available in the area.”  Patients have preferred that a little bit because you get a more – a rapid answer.  I think that has also contributed.  

I think the uptick in the availability of testing has helped.  In the beginning there weren’t many places that were providing the tests, and now I think most of the urgent cares in the area, both of the hospitals are having some sort of drive-thru testing, so I think that’s definitely ramped up and made it more available for patients to get tested.  So, that probably contributes to why we haven’t seen as many.  And I also think patients are staying home.  If they’re feeling sick, they’re calling and they’re saying, “I’m not feeling well, I’m not coming in today.”  

So whereas we may have seen that patient before or may or may not have been a high risk for COVID we may have tested them anyway and now they’re not coming in, they’re feeling better in a couple of days and, you know, we’re not necessarily testing them.  So, I think that maybe has something to do with it.  I don’t know.  Jenn?

Jen: Yeah, we still have the capability, but we’re definitely limited who we test, you know.  The ones that come in with the fever that have significant symptoms, the cough, shortness of breath, Candace and the COVID team are going out there and swabbing them.  But like Candace said, most of the time people are much more proactive.  They feel sick and they’re going to these urgent centers and getting these rapid tests.  Unfortunately, we don’t have that capability yet.  We’re working towards that, but our tests can take three to seven days which is a long time to wait if you are concerned you may have contracted the Coronavirus.  

So, I think what Candace said is correct.  I think people are going out and they’re getting the test done with this rapid test versus the PCR which takes a little bit longer.

Dr. Vaughn: And that’s nice to see I think from our patient standpoint.  It shows you, one, I think we’ve educated them well, but they’re not exposing, if they are concerned, they’re not exposing, you know, unintentional, high risk patients in the office.

Dr. Maurer: I think a good question would be if someone – how do we deal with someone who does have a fever and they come into the office or they do have a cough or if they have been having, you know, muscle aches and pains?  And that patient we’ll triage ahead of time and we still see them outside and can check them for Coronavirus outside.  We have an area set up, designed, so we can assess that person pretty quickly in their car.  So, avoiding that person from coming into the office as much as possible, and yet still taking care of them.

Jen: Unfortunately, going through cancer treatment there’s many other reasons why you may develop a fever, and so we’re certainly not going to rule out, you know, the Coronavirus, but we will have Candace and our nurse go out there and if they feel like this is completely related to, you know, your treatment and maybe the disease then Candace will determine that, and so bring you in for your visit or antibiotic, medication, whatever she feels is necessary.  But of course, that’s virtually; we’ll evaluate you outside.

Candace: Yeah, we set up an area where there is less potential exposure to staff and other patients.  We kind of just bring you in sort of a back-door area.  There’s a room, you know, right as they enter that.  You can kind of just take the patients in.  So that would limit, you know, exposure for staff or other patients and then still be able to take care of the patient sort of in an isolated situation.  

Jen: But do not be alarmed.  If you come in with a fever, we will ask you to go to the side of the building for further evaluation and then we will either determine that swab is necessary, which I did say we are capable of doing and we will ask you to go home and quarantine until we have the results, or we will bring you in for further evaluation.

Dr. Maurer: Have we asked about having rapid tests here?

Jen: Yes.  Oh yes.  So, we were very, very close to having rapid testing here.  The contract was signed and we were ready to go, and unfortunately the same day Trump signed the order for the Human Health Services to release all the same analyzers that we were trying to purchase to every nursing home across the United States, so there was a significant back order.  We are still actively and hoping to get it, hopefully by the end of October, but no promises there.  But yes, we were trying to be ahead of the rush, and we missed it by – 

Dr. Vaughn: An analyzer for a lab is what we need to do the rapid test.

Jen: Yes, we need the analyzer, and we do [inaudible 17:26] swab just like any other site, and we can get results back within 15 minutes.  And now they actually have for the analyzer that we want a COVID and flu swab all at one time, so you swab once and then it tests for both COVID and flu, so we’re hoping to get that, fingers crossed, it was – I was devastated because [inaudible 17:47].

Dr. Vaughn: I’m just thinking forward, I mean and you know, and this may be something that becomes habit, but could this be a part of – you know how we usually get blood work before chemotherapy the day before, I mean is there going to be a point in time where we do a rapid, you know, cause to do a rapid COVID test pre-chemo labs just cause you do worry about the asymptomatic patients that may be carrying it.  So, that’s something, you know, that interesting to think like that, but that could be a part of, you know, our regular workup, just doing it like you would check, you know, kidney function and liver function.

Dr. Maurer: So, an outcome of all these nursing homes that we see these rapid tests very quickly was we got to see first-hand how that worked successfully or sometimes not so much.  You can see why the nursing homes, you know, HHS decided to send those kits to the nursing homes, they are quite problematic.  So, one of the challenges with these rapid tests have been false positives, so as they work that out and we screen people, large numbers of people, then we’ll have a certain rate of false positives that what do we do with those people and then do they then get a follow-up test and you have to wait, could that delay their therapy?  So, all of that will get worked out over time.

Jen: Yeah, I think, you know, we discussed if somebody has, you know, be asymptomatic and be positive, would we then go to a PCR testing which is a little bit more meticulous and they kind of – they’re a little bit more accurate, and so I think we would definitely dot our i’s and cross our t’s to make sure that these patients that are truly Coronavirus positive are, you know, actually infected and they’re treated appropriately.  So, I think we’ll definitely work something out where if we find that there’s an increase in our positive cases that we will, you know, send out for better testing.  

And, on top of that, you know, if you have a positive, we now have the capability of doing the antibody testing in our office.  So, you know, bring them back two weeks later and check them for their antibodies, and that’s another way to determine if they actually did have the virus as well.  So, we do have the capability of that.  

Dr. Vaughn: Of the antibody test, yeah.

Jen: The antibody testing, yeah.

Dr. Vaughn: I hope we do get the rapid test.  I think that would be very helpful in going forward for our patients. 

Jen: For patients and for staff. 

Candace: [inaudible 20:10] limitations part, you know, knowing – I don’t think it would be a hard sell that we need to swab you because we’re doing it to everyone and it’s like for your safety.  And I think if I was a patient and I was coming in knowing that everybody around me has been swabbed I’d feel safer.  

Jen: And that cough you had two days ago, you know, that it kind of cleared up, but you’re concerned about it.

Dr. Vaughn: Yeah, and you wonder, I mean going forward, do we do this as random staff testing, you know, once a week, you know, that would be interesting cause some of our staff are younger and may not be the ones having symptoms all the time.  So, it’s something to implement for the staff.

Dr. Maurer: That’s a really good point you bring up because now in this phase of the pandemic it’s a matter of as people get back into some level of normalcy, so whether it’s kids getting back into sports, hybrid version of schooling, then that demand for quick tests really becomes so important so we can know if someone was potentially positive we can isolate them very quickly.  

Dr. Vaughn: Not to mention how important it is to stay on schedule and keep the practice open, and I think that’s the way to do it is not have a huge outbreak.  That’s where the rapid testing is very helpful for our office.

Jen: Well I am – I’m on it every day.  I am texting and calling every day asking the status, and I was just updated that we’re hoping to have it in the next two weeks as long as nothing else comes up.  But schools are opening up and so that is my concern that they may get, you know, preference which I understand that as well, but we are in line, we’re at the top of the line, and I hope to have it – I hope by our next talk we can talk about how well our rapid testing is going.

Dr. Maurer: Well especially since there’s an incubation period, so I mean that can also lead to some what we call false negative tests initially, but they may return test positive, so the one could be negative, if they had a negative in terms of a test, but they had a potential exposure and they need to keep an eye on their symptoms and then maybe they be tested again, depending on that timing.  

Dr. Vaughn: I wanted to ask this question cause this comes up a lot, and I know we implement this early.  We’ve kind of – I haven’t been doing as much of this, but we may go back to this is the use of telemedicine and technology, and you mentioned earlier about one of the important things is kind of reducing the traffic through the office as providers.  Candace, how have you utilized telemedicine and talking with patients or have you used telemedicine talking with patients or [inaudible 22:45].

Candace: I don’t have a lot of experience with the telemedicine.  Some of [inaudible 22:49] have, but I have – mostly my role has been seeing acute patients.  So, not as big of a role in telemedicine, although my new role will probably allow for some of that while I’m filling in for Liz, so the prior, you know, I hadn’t really done a lot of that because with an acute issue or an urgent need you kind of have to lay eyes on the patient and assess them.  

But I envision that we’ll ramp up some telemedicine visits especially going into the winter, not only to decrease foot traffic in the office, but just – I mean patients feel – I feel like more comfortable if it’s possible to do a virtual visit and they feel comfortable with that, then we should be able to accommodate that.  So, I am kind of excited to dive into that.  I could get some headphones.  You know, I can contain it private in my shared office.

Dr. Vaughn: So yeah, Dr. Maurer, have you – good and bad in telemedicine cause I do like it, but I do get frustrated with it at times so – 

Dr. Maurer: Right.  Well I’m going to give you some good advantages that I would have never foreseen.  Here in Virginia we are a moderate climate as we have our snowbirds heading to Florida and then eventually return.  So, what happened as some of our snowbirds started to return back up and this is sort of in the spring, I actually wound up having a number of telemedicine appointments before, especially when Florida was on lockdown.  So, a number of appointments prior to that patient coming up to Virginia as a setup so did that person need a CT scan, did they need whatever, was their treatment going while they were down in Florida?  

So, suddenly that really opened up things because I have a number of patients who live, as you do too, that might be in Norfolk or North Carolina or live in West Virginia or they are visiting family or somebody in another state and I can do a telemedicine appointment.  And it may not be, you know, 100 percent of what you want, but it can accomplish a lot.  So, I thought that has been a great attribute.  

I have found in terms of the downside of the telemedicine appointment there’s some things where, one where you actually have to examine the patients.  That becomes challenging.  The second is I’m a face to face person, especially if I’m delivering news and sometimes it’s not such good news, and being there right with that person or family, it’s essential.  It’s not impossible to do it over video and audio, but it makes it harder to create that connection, and I have done some of those.  I’m not a fan of that.  

But it does allow, you know, the telemedicine does allow, at least to do – and the good thing is you can share a screen, so if someone had a CT scan and we’re doing a comparison [inaudible 25:37] you can actually show that person what’s going on.  I think that’s been a great attribute.  Or you can review the laboratory data and they can see the numbers.  So, you can really – there are ways that you can try to incorporate as much as possible, but sometimes the depth of conversation is not as good as what could be otherwise.

Dr. Vaughn: I agree with that.  It’s that human connection that is challenging with telemedicine and another issue is, you know, and one we sometimes have older patients who may not be as savvy with the tech trying to share the screens and then also the – we are a little dependent on maybe the high speed internet.  You know, there seems to be sometimes a delay in communication with some patients and it’s hard when you’re trying to make a point and it’s just delayed and their talk back is delayed, so having that kind of conversation and the flow of conversation sometimes can be a little challenging.  

But it is that human element you kind of miss a little bit with telemedicine, but it has allowed us to still provide care to patients and not have them in the office all the time and expose them to potential risks.  

Dr. Maurer: To me it’s another tool and it’s one of those things that now we’re in a new phase and I hope that, you know, when all this clears out that we always have that option because it does have a clear role in certain circumstances.  So, it’s like one of these things that are coming out of the pandemic.  There are some positives, believe it or not, that have come out, and that is in certain situations it is a positive.  I hope it stays and that Congress decides to allow it particularly for our seniors and other commercial insurers as a way to continue care even beyond what we’re living through now.

Dr. Vaughn: Is that up for a vote in 2021 to continue funding telemedicine?

Dr. Maurer: I believe so.  

Dr. Vaughn: Okay.

Dr. Maurer: They have to extend it.

Dr. Vaughn: Extend it.

Dr. Maurer: Right.  If people are listening – 

Dr. Vaughn: We’re going to send this to our politicians, this podcast, because as Dr. Maurer was saying, it is a tool, and it can be very valuable.  So, I want to bring up this question to our esteemed task force.  Have we communicated with some other oncology practices either in Virginia or even nationally about maybe some of the sort of protocols they’ve implemented or guidelines they have done?  

I know, for instance, there was a recent summit of community oncologists and they kind of had some bullet point items, a lot of them we touched on, you know, utilizing telemedicine, maybe finding ways to kind of focus maybe high risk patients and maybe treat in a different area, using, which I think we do a great job, using disinfectants all the time, you know, how you utilize maybe virtual education on websites and things like this to get more information out.  But have we talked to any other, and that’s not even oncologists, maybe any other healthcare clinics or offices about what they’ve been doing?

Candace: In the very beginning I don’t – I didn’t reach out personally to other offices, but in the very beginning I did actually do some sort of searches online primarily about oncology practices.  A couple of different ones came up from Washington state, so when they had their sort of outbreak up there, there was some oncologists that were coming on and kind of providing some guidelines as to almost like hindsight, like what they would have done if they knew it was coming and how they would have, you know, either prepared for it or tried to slow I guess the spread.  

And so, I think that actually did help me.  In the very beginning we sort of came up with the task force as to some like line items and bullet points of things that we should implement or things that we should look at doing like right away.  And I knew that was two different practices, community practices, both of them in Washington state, and I feel like that was very helpful as like a guideline.  

And then, of course, we also used the CDC guidelines and the Virginia Department of Health guidelines really to guide how were we going to change our practice from the beginning.  And then we followed that along.  And of course with the hospitals and things like that we have definitely kept abreast of what they’ve been doing, primarily with the hospitals that, you know, we work with, we’ve kind of tried to change things in the office like as far as visitor policy and things like that as they were changing.  As long as we felt those changes were safe, we were doing that so that patients coming from one facility to another there was kind of a cohesive practice.  

But as far as reaching out specifically to other practices, I don’t – I didn’t do any of that.  I don’t know if you did any, Jenn.

Jen: I personally spoke with our regional Virginia Department of Health.  I talked to them whenever there is a certain question.  I have their cell phone number so if there’s any concern the nature that we are doing things correctly I do reach out to them.  And then periodically, not a specific practice, but I do reach out to who we refer to, so the surgeons, the rad ops [phonetic], make sure that we’re all doing the same thing as far as visitors go and making sure that if they’re not allowing visitors we’re going to try not to allow visitors either cause we don’t want to negate what they’re doing.  So, we do touch base with them, make sure that we’re all following the same practices, yes.

Dr. Maurer: Right.  That’s what we did at the Cancer Committee.  I have raised that specific question at one of the Cancer Committee meetings early on that to maintain consistency throughout.  So, if a patient was going to the Radiation Center or if they were seeing a surgical oncologist or if they were going to the Infusion Center at the hospital or the Infusion Center here that they – the patient was expected to wear a mask, that visitors either were or were not allowed.  So, that consistency helped because it continued like a solid theme.  

And with that I think the community and the patients and their families really got the message and holding the line with that, and I think it’s really helped.  You don’t know, right because this is a prevention, but I think it potentially could have been much worse had we not done that and at the very least is showing we’re trying to do everything we can to keep them safe, the patients and their families safe.  And so, they can continue to get their care and they can get better.

Dr. Vaughn: No, that’s perfect.  I think you want to develop these sort of habits, right, and then you want to make sure they’re consistent, so it helps knowing that the entire sort of cancer community, whether it’s the surgeons or the radiation oncologists, are all practicing the same, you know, the same protocols.  And the patients don’t like having things different, you know, one practice versus the other, so that’s great that we have come together, you know, as a cancer community here in Fredericksburg.  That’s wonderful.  

I wanted to come up – well talk about this question again because it does come up often, and it’s one of the more difficult things I have to experience as a provider with my patients.  But it’s that constant balance of delivering sort of patient care and thinking about the safety of the patient when we try to incorporate, you know, the patient support system and their caregiver, whether it’s a spouse or children, because we do have to limit their visitation, you know, at the times of treatments.  And sometimes they may not get all the information, you know, back to them when you’re talking to the patient.  

How do we – how do you guys approach this, you know?  I still struggle with it.  I’ve tried to come up with some changes in how I discuss things with a patient, maybe stay after hours to call family members.  But how has it changed you, Dr. Maurer, during this time?  Because I find this is one of the more challenging things with COVID-19.

Dr. Maurer: Right, especially because problems can sometimes happen suddenly and acutely and you have to deal with them, and getting that family member involved pretty quickly, so by phone, or if they have to come into the office, you bring your mom to the exam and you have a conversation and you go over the steps of what needs to be done so they have an understanding so they are not felt in the dark cause they’re as much a part of that patient’s care as the patient themselves.  And so that’s critical.  And if that’s not happening, we definitely want to know cause we are doing everything we can to keep our patients’ families involved.  

And I think one of the things that we’re seeing, one of – as we look at all sorts of metrics that are triage or just general phone calls have gone up.  Initially back in March I think there was a lot of fear about Coronavirus, but now I think it’s a lot of logistics management and making sure we’re communicating effectively, you know, we do see those phone calls coming into the office and our teams have been managing them.  But there’s other ways to do it.  So, we have the portal with the See Your Charts, a nice secure way to message the staff with questions, and they get back to you, whether it’s the refill line or other ways that we can communicate.

Dr. Vaughn: Yeah, I have used, you know, I have used facetime in the room, you know, if the spouse if outside in the parking lot or at home, so I’ve even had – I’ve done a lot more of this is even have sort of our nursing team, at least my nurses, kind of update, you know, constantly how the patient is doing, so it’s put a lot more work on them.  But I think having the caregiver just constantly aware has really helped out cause they’re so used to being there at the chairside, and that detachment can be an issue.  

And so, we just try our best to constantly communicate with them via, you know, facetime, phone, nurses messaging.  I feel like we’re constantly calling them on off days just to make sure they’re okay.  But I just wanted too make sure we’re aware we’re thinking about them at all times because they may not physically be here, you know, the caregiver may not be here.

Dr. Maurer: Right.  I just had this situation just a little while ago where an acute lab came up and we had to deal with it, and the nurses took it upon themselves to call the wife up and we organized some imaging, we organized some follow-up and we were able to talk with the wife, we asked if she had questions.  She wanted to know what the plan was, what to do if there were symptoms.  And by the end of it she felt more comfortable with that.  So that was great that the nurses called her directly.  Even before I had even known she was right there.

Jen: We’ve seen a lot of patients that come in and the caregiver, the family member, they don’t feel like it’s absolutely appropriate for them to come back, but what they’ll do is they’ll write their cell phone number on a piece of paper and send it back with the patient, whether it’s a mother or the dad, that they may not know the number, and so they write it down, hand it to the patient and then I’ve had all of our providers, you know, happily call them after the visit to just kind of go through what was discussed, and that has worked our really well.  

And then again, like you said, facetiming has been a key role.  I’ve offered up my cell phone many a time to accommodate that.  And then just calling in in the visit, you know, we have phones, mobile phones, that they can be in the room as well.  So, if you want to give the doctor or the [inaudible 36:40] a cell phone number of your loved one then that’s also a good idea. 

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Dr. Vaughn: Before recording this episode, we opened our Facebook page to questions from the community and we’ll go through some of these questions now.

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Dr. Vaughn: I do want to start with the first question which is a very good question.  Hopefully, it can kind of bring about some discussion in some of our protocols.  But this question was, “As a patient what can I do to help create a comfortable and secure environment at HOAF?”

Jen: Well first and foremost I would say wear your mask and wear it all the time while you’re in the building.  Don’t pull it down in the room.  Make sure that it stays over your nose and covers your mouth for the duration of your visit.  And you know, I know some of these patients, they have breathing issues and difficulties, and I highly recommend they consider virtual visits if they don’t feel comfortable wearing the mask for the entirety of their appointment.  

Also, you can monitor your symptoms.  If you do develop cough, shortness of breath or a fever, please do not come to your visit.  Call us.  We will triage you appropriately.  We will decide if we feel an outdoor triaging with our COVID team is appropriate or we may ask you to monitor your symptoms for a couple of days and bring you in at a later date. We can move your treatment out a week.  There’s all sorts of other options, but we ask if you do not feel well, please call us before you come.  Do not come directly to the office.

Dr. Maurer: One other is that if there’s been an exposure at home.  So, if a family member is COVID positive we really need to know, or someone that they’ve been in close contact with.  And that’s technically someone who you’ve been within six feet without a mask for more than at least 15 minutes or at least 15 minutes.  It doesn’t take much there to get that contact.

Dr. Vaughn: What is that again?  It’s within six feet without a mask for 15 minutes with someone who is known positive.

Jen: Known positive, it’s considered a high risk for exposure.  And honestly, per the Virginia Department of Health it’s anybody that’s not wearing an N-95 mask, so a paper mask or a fabric mask, they’re still considering that high exposure if you’re less than six feet and you’ve been within direct contact for great than 15 minutes.  And the recommendation is 14 days quarantine.  

So, if you have had that exposure, please do give us a call.  We may suggest go getting a test and, you know, five to seven days or we may have another suggestion.  But yeah, keep in mind that if you are exposed, then there will be other things that you’ll have to follow up before we can see you.

Dr. Vaughn: So, I’m a patient, I’ve been exposed, I call – do we still have the triage line?  

Jen: Yeah, uh-huh.

Dr. Vaughn: Because I know we talked about it before, the COVID triage line.

Jen: Yeah, call our office and it’s extension 181, and you’ll get me personally, and I’ll walk through it.  I’ll ask you all the questions and I’ll determine what we feel is a high-risk for  exposure, a low risk for exposure and how we want to proceed with your visit and/or treatment.

Dr. Maurer: And that number is really for weekday business hours.  On weekends, after hours, we need our patients to call the answering service.  There’s always a doctor available 24/7, 365.

Jen: But we really feel our best line of defense is masking, masking appropriately, and really good hand hygiene, you know, we ask that you come in, you sanitize your hands, wear your mask over your face and really just ensure that you’re being safe and that will make everybody else safe.

Dr. Vaughn: So, we’re going to move on to the next question, and I think this also brings up some confusion.  I don’t know if we have a solid answer as this may be evolving.  “If I need to travel out of state do I need to reschedule my next infusion?”

Dr. Maurer: At this point if you’re traveling out of state, I think one of the questions you should be asking yourself, are you going into a high-risk region?  And regardless of whether it’s a high-risk region or low risk, there’s nothing to say that’s just as important as following those precautions no matter where you’re at.  You really need to be doing that, high risk, or a low risk area, so that’s just like Jenn was saying, wearing your mask, following social distancing, washing your hands if you’re going out of state.  If you’ve had an exposure, absolutely you need to call us, but I don’t think there’s a specific guideline that says you need to necessarily notify us if you’re going out of state.

Dr. Vaughn: Are we going to be looking at sort of high-risk states in the future?  Is it – I know that was an issue in the early spring.

Jen: Yeah, when the Coronavirus first came about, we were certainly looking at which areas were higher risk based on how many tests were positive, and we were asking that question to the patients, where are you traveling to and from.  But now with Virginia being completely open, you know, it’s hard to say you can go to anywhere in Virginia that’s as highly populated as say the next state over, but we are constantly re-evaluating it.  If we start seeing an uptick in these numbers, we’ll figure out which ones are hotspots, and which places we need to start questioning.

Dr. Vaughn: Because I know I’ve been asked this multiple times this past few weeks, one of the hotspots are on college campuses, and we do have – some of my patients have children, you know, in their first year in college, so they want to go visit them.  And I think as Dr. Maurer was saying, my answer is just continuing the practices that you’re doing now, and that’s the best way to protect yourself.  That’s I think all we can do right now.

Dr. Maurer: I was just talking to one of the ICU doctors in the hospital and we were talking about our college kids and his daughter is at a college here in Virginia and their rate of known infection is pretty low, and that’s because the school has been very strict on maintaining policy and guidelines, and if not then there’s significant repercussions for that student.  Whereas as compared to when some schools started very early on there were a number of activities that went on with the students that led to significant spreading of the illness very quickly over many, many students which then led to some of the campuses closing down.

Dr. Vaughn: Okay, moving on to the next question.  I think this may actually tie into the first question.  “Do we need to wear our mask out in the open?”

Jen: I think general rule of thumb here is if you’re not appropriately socially distanced from the next person, so if you can’t be six feet away from the next person, I think wherever you are, you should still maintain those practices.  So, if you are going to an outdoor sporting event or something, you know, where you’re watching your child play football or something, if you’re on the sidelines standing next to the person next to you and you can’t be far enough away from them, then yeah, you should still be maintaining the practice of wearing the mask.  

Ideally, outside, the idea is that we can kind of get away from everyone, and that’s why there’s been some confusion on whether or not you need to continue to wear a mask outside.  But it doesn’t change the ability to transmit the virus just being outdoors, so I think if you can’t appropriately distance yourself from the next person, then yes, you should be wearing a mask.

Dr. Vaughn: Yeah, it is nice to have some time away from the mask.  So, for instance, if you’re just walking your dog with your spouse, it’s okay not to have the mask on, maybe?

Jen: Yeah, certainly here – 

Dr. Vaughn: Versus outside – 

Jen: If you’re with the person that you share your, you know, immediate home with, those folks are, you know, you’re exposed to them all the time.  So yeah, if you’re outside with your significant other or your kids or whatever and they’re playing, no need for the mask.  It’s really just for people outside of your household that you can’t appropriately distance from.  

Also, you know, one of the things to keep in mind that we’ve really been reeling, you know, and being really, really adamant about with our staff that we also want to impart onto the patients is that, you know, the Virginia decree by the Governor actually requires us to wear masks indoors, and I think that’s something that it might be and the very least we can do for people around us to really try to limit the exposure, the risk, for everyone in the community.  And we really, really hit that hard with our staff in trying to, you know, be advocates for our patients and trying to be, you know, upstanding citizens and really setting an example when we go out. 

And I think our patients already do a great job of that, but I just kind of wanted to reiterate, you know, that that is an order by the Governor that we are required to wear masks indoors, grocery store, doctor’s office, any of those places.  So, what we’re asking here is not anything above what’s already an order that we are just trying to comply with as well.

Dr. Vaughn: That leads to another question which a patient asked is “Is COVID-19 more of an airborne virus or can it be more contracted hand to mouth, both?  How do we think about COVID and how can you contract the virus?”

Dr. Maurer: Well when you think about the Coronavirus and its transmission, think about its entry into what we call mucus membranes, so whether it’s the eyes or the greatest point of entry is the nose, so and that starts with being – touching your eyes, touching your nose, and when the pandemic first started especially it was a lot of attention about oh, don’t touch your face.  Actually, the good thing about wearing a mask it it’s actually kind of good because either you’re protecting yourself in some ways from yourself or you’re mindful of it. That’s how I felt when I would wear a mask, particularly in the office.

Secondly, in terms of airborne, we know that droplets, heavier droplets, can promote the virus, and there have been a number of studies that looked at how significant of airborne transmission is and it does look like there’s certainly respiratory virus – I’m sorry, that the virus is transmitted in an airborne matter, particularly indoors.  It can stay at and hover within that space.

Dr. Vaughn: Laughing, forceful cough, that’s why coughing is a big symptom to be aware of.  Some suggestion why initially adults seem to and not many kids because maybe the force of maybe a younger child’s cough maybe not as much as an adult, but definitely it seems airborne transmission is the number one modality.  Again, importance of the mask wearing for this purpose.  And last question we got, this one is a good question, how it ties in our practice and how we’re treating our patients.  But the question is, “How is ongoing cancer treatment affected by Coronavirus?  Is it a harder recovery?”

Dr. Maurer: Well one good way to start off with that is what’s the diagnostics like of what we do every day?  We now have often an extra step in our process.  So, when we see our patient there’s often many different – before someone starts treatment there may be different diagnostics and tests that need to be done before they can even get to therapy.  And some of those diagnostics require a Coronavirus test.  So, it does require an extra step in terms of logistics.  

A good example and when we know that ahead of time is can, we consolidate some of those.  I just had a patient on Friday.  They needed a port catheter.  It’s a type or way to administer chemotherapy and they also needed a stomach tube, and we were able to successfully do both of those at the same time as well as a biop.  We had to get a biopsy.  So, we used Interventional Radiology services and they were able to do all three measures in one session to consolidate, and they had a Coronavirus test ahead of time, and they had to quarantine beforehand.  So, that takes some extra steps and time here before they get to therapy.  So, I think that’s just to start off.

Dr. Vaughn: And one question.  If they’re on treatment, you know, actively on chemotherapy, you know, are they at higher risk of having maybe a worse outcome with COVID-19 being hospitalized.  There was recently a study that showed actually patients on chemotherapy – this was done in New York at Sloan Kettering during the big outbreak.  The patients on chemotherapy were not any different than those off chemotherapy as far as bad outcomes being like hospitalization.  So, being on treatment doesn’t really put you at increased risk as long as we still practice the habits we talked about earlier.

Dr. Maurer: Dr. Vaughn, another good point is so if one of our patients tests positive for Coronavirus and another good example is I had a patient of mine who was just about to start therapy and she went to a beach house and her family members came in, one of her family members was positive, transmitted it to most members in the house, including her.  And what we had to do was in terms of those diagnostics and therapy, she had to recover from the illness.  Thankfully, she did quite well with it.  She was at baseline.  She didn’t have those high-risk factors.  She didn’t have any significant what we call comorbid illnesses, other higher risk medical conditions.  

So, she had to test negative before she could proceed on with her therapy, which she was able to do, and she’s undergoing treatment and doing well.

Dr. Vaughn: Is it just one negative test or two negative tests or is it 14 days?  There’s a lot of confusion I think from that standpoint.

Candace: We’ve changed things that just regarding what we required, testing and that kind of thing.  At one point we were requiring two negative tests, and we’ve actually changed that policy a little bit.  Now we’re requiring everyone to have just one negative test to come back to the office for treatment or for office visits, and we’re typically seeing those tests taking anywhere from three to four weeks to turn negative.  But we are starting to test those patients after two weeks.  

So, we initially get a positive test, we do two weeks of quarantine monitoring symptoms.  Typically calling these patients frequently, checking on them and making sure they don’t need additional care or hopefully not hospitalization, but we can hopefully facilitate, step in, move that forward without having to redo testing, just with communicating with the hospitals and things.  And then at the two-week mark we’ve brought patients back, and again, the testing is done outside, so it’s pretty quick for them.  They just come in, we test, and then we wait for the results.  

And we’ve done that sometimes on patients, you know, weekly until we get a negative test.  But it’s worked pretty well.  The other option, I think we’ve had a couple of patients that did not want to retest or that had maybe tested positive, you know, in the summer time or whatever, so we also have adopted the policy that if it’s been three months since your positive test that you can return without retesting.

Dr. Vaughn: I want to thank you, everyone, for being here sharing sort of the protocols and insights of HOAF right now.  It’s been as we mentioned, six months into this, we’re still going strong, we’re really taking great care of our patients, we’re staying on schedule, keeping them on treatment in this crazy time.  So, we’re doing a great job, and thank you all.

Thanks for listening to Cancer Shop Talk: Behind the Diagnosis.  If you enjoy our show and want to know more, check out HOAFredericksburg.com; or leave us a review on iTunes.