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Strategies to Mitigate the Impact of COVID-19

 

April 2, 2020

Strategies to Mitigate the Impact of COVID-19: From the APSHO President

 

By Sandra E. Kurtin, PhD, ANP-C, AOCN®, The University of Arizona Cancer Center

 

For any of our advanced practice colleagues who have lost loved ones to the COVID-19 pandemic, we send you our love and our heartfelt condolences. These are extraordinary times fraught with daily challenges that we are managing minute by minute and day by day on both a professional level and in our personal lives. Over the next few weeks, we would like to share stories from oncology advanced practitioners about their COVID-19 experiences, strategies for managing this crisis, and ways we can take care of ourselves, our families, and our colleagues.

I will start with my personal and professional experience with this crisis. First, I spent a magical time in Italy in October with my daughter who was there for the fall semester and got married in the small village of Orvieto, just before our JADPRO Live meeting at the end of October. She and her husband left there at the end of December, just before Christmas. We are so grateful they are home safe, but very sad to see the devastation the beautiful people we met and places we visited have suffered.

Similarly, our amazing colleagues who so graciously hosted us in Seattle for JADPRO Live have been at the center of COVID-19 experience and have created critical processes to limit the impact this has on all of us. We are so grateful to them! To my international colleagues that have continued to share their experiences, strategies, and limitations in mitigating the impact of COVID-19, I thank you.

Strategic Directives at the Arizona Cancer Center
 About 3 weeks ago, we began to have serious conversations about how we could lessen the impact of COVID-19 by limiting exposure of our patients, providers, and staff. We initiated our own processes ahead of any system, state, federal, or city directives as a result of the input we received from our colleagues in Seattle, New York, Singapore, Italy, and Spain. We are forever indebted to them.

We have also looked to our professional organizations, the CDC, ASCO, ASH, ASTRO, and APSHO for guidance and recommendations. I would like to share with you some of what I learned from them in the form of a list of strategic directives that we developed and have deployed within a 3-week period. This list is updated daily at our practice.

  1. Development of a limited exposure provider staffing model to cover inpatient and outpatient services.
    1. Team A and Team B rotate every 14 days (the time recommended for quarantine after potential COVID-19 exposure).
      1. One team is in-field and covers inpatient and outpatient services and the other team is home-based.
      2. Each Team includes MDs and APs representing liquid and solid tumor expertise, cellular therapies, surgical specialties, etc.
      3. Assignment of vulnerable providers to a permanent home-based rotation.
      4. Definition of expectations while in-field or at home.
      5. A daily roll call to identify any illness, testing, and clearance to return to work.
      6. Process for aggressive debulking of clinic visits and infusions for non-essential visits that can be either postponed or shifted to a telemedicine visit.
    2. Establishment of a COVID-19 Team Captain for Inpatient, Outpatient, and Home-based Teams with the following charges:
      1. Oversee daily huddles for the providers (MDs and APs)
      2. Provide updates from the core-leadership team: system, city, and state
      3. Oversee day-to-day clinical processes with a shifting resource as needed to meet the needs of the team regardless of setting.
      4. Hold the line! The temptation to shift members in and out of the field, to effectively maintain a provider workforce that is unexposed and can meet the challenge of a surge, the teams must be maintained.
    3. Establishment of a COVID-19 Clinical Leadership Team to serve as a decision-making body across the Oncology Service Line representing Medical, Surgical, Radiation, Interventional, Integrative, and Palliative Care and Supportive Care Services.
      1. Final decision for who can be treated in the event we have limited capacity
      2. Development and approval of criteria for inpatient admission for treatment
      3. Development and approval for prioritization of diagnostic and procedural processes
      4. Identification of a surge capacity plan across provider and clinical staff based on skill sets
      5. Daily communication with and across teams to provide updates and manage any needed adjustments in staffing or processes.
    4. Development of a telemedicine visit process and platform including billing criteria.
  2. Development of a limited exposure staffing model for all personnel and patients in the building:
    1. Development of a core-leadership team with representation for every staff from intake, to discharge, hospitality, and service.
      1. Twice daily huddles
      2. Ad-hoc meetings as needed
      3. Daily COVID-19 email blast
      4. Virtual Town Halls to provide broader updates, dispel myths, and answer questions
    2. Deploy “Distance and Disinfect” processes and procedures:
      1. Daily counts for PPE, cleaning supplies.
      2. Daily updates for appropriate use of PPE.
      3. Provide expectations for disinfecting workstations, patient areas, equipment, etc. upon arrival after 4 hours and at end of shift with processes logged each day by individual areas.
      4. Development of criteria for testing, quarantine, and return to work specific to work with immunocompromised patients.
      5. Shifting vulnerable staff and providers to the home-based team.
    3. Standing up a screening and triage process for all patient and staff entering our center BEFORE they enter the building.
      1. Limiting building access to one entrance for patients and one entrance for staff.
      2. Development and daily updating of screening, triage and COVID-19 testing processes for staff, providers and patients.
        1. Daily counts for PPE and testing kits
        2. Daily updates for results reporting
        3. Process and daily updates for managing persons under investigation (have been tested but no results or exposure to a person testing positive).
        4. Development of a triage and testing site on site but separated from the entrance; this is in our garage on the first floor and uses a drive up–only process to limit exposures.
      3. No caregiver policy:
        1. Options to conduct virtual visits with caregivers waiting in the parking lot or at home while the patient is in the visit.
        2. Virtual discharge teaching and post-infusion teaching processes.
        3. Follow-up phone calls to patients and caregivers.
        4. Criteria for exceptions (we have allowed only three in the outpatient setting: traumatic brain injury patient with expressive aphasia and cognitive deficits requiring wound care; a patient with severe disability with a tendency toward violent behavior requiring life-saving treatment, a patient who is deaf and blind requiring a post-surgical visit to remove staples). Exceptions are not being made in the inpatient setting, including in the event of patient death.
      4. Process for admitting patients under investigation or testing positive for COVID-19 that require essential visits.
        1. Outpatient process:
          1. Must be escorted in a wheelchair to limit any contact with surfaces.
          2. Escorted through the back entrance and into a designated isolation room. Labs, any procedures, and treatment to be done in that room. Then escorted back out through the designated entrance.
          3. Inpatient process: Patients are dropped off at the emergency entrance and are escorted by transport staff. No visitors allowed passed the drop off site.

You can see so much has happened in just 3 weeks. We are anticipating a surge in the next 2 to 3 weeks based on projection models and will face a time when we need to decide who we can treat based on capacity and how to shift staff to areas of high impact. We are hopeful these mitigation measures will reduce the impact. There is fear, of course, but an amazing resilience and unrelenting courage. I am the In-Field Team Captain and a member of the Core Clinical Leadership Team. I appreciate the leadership, tireless efforts and willingness to find solutions among our team members.

We do try to find humor where we can: a daily COVID-19 handwashing song is one of my favorites. My data usage curve on my phone looks very much like the COVID-19 curve. Our patients our so grateful that we have enacted these processes on their behalf and in support of each other. We are happy to share anything we have developed.

We here at APSHO, JADPRO, and Harborside wish you and your families well-being and safety. We would love to hear about your experiences, personal or professional, and any strategies you have deployed in your practices to limit COVID-19 exposure and to support your colleagues, patients, and your families.

 

 

 

Read more from the APSHO Advance: Special COVID-19 Series

 

Related: 

The JADPRO Podcast: How Cancer Practices Are Adapting to COVID-19