Infusion Center Management During the COVID-19 Webinar transcript
JAMIE BACHMAN: Good afternoon, everyone. And thank you, Mohan and. Josephine, for having us today. And welcome to everyone from around the country who is dealing with this situation just as we are. We hope that some of the things that we’ll share with everyone today will be helpful to you and your organizations and look forward to fielding any questions that come from our dialogue. Brian and I are sitting here just six feet apart with masks on. So we’re observing our social distancing from that perspective and glad that everybody could join remotely. So as we thought about the first deaths our organization took earlier this month as this coronavirus, COVID-19, in particular became apparent that it was going to be rampant in our community and really put pressure on our health care community, we, as an organization, did a number of things.
We started out of the gate over the weekend as this really hit its stride by canceling all of our elective surgeries. And as we define elective, both in and outside of cancer, you think about things that were not life-saving measures at that exact time we’re essentially put on hold for the foreseeable future. So orthopedic procedures,. GI procedures, et cetera, went by the wayside and have continued to hold during this early time of the pandemic. And the primary reason for doing so was to prepare ourselves to accommodate a surge whenever that happens and prepare the hospital for emptying the beds, which in our case is, I’m sure many of you experience are relatively full if not over capacity a lot of the time.
The next thing we did, and this is primarily in the outpatient setting, both for cancer and non-cancer specialties, was to defer or convert to virtual visits all of the routine follow-up care with providers. We first did this for the high-risk population outside of cancer– so if it was a primary care or non-cancer specialty and you had an appointment and you were considered high-risk by some of the CDC definitions, like being immunocompromised, like having received a solid organ transplant, being pregnant, being of certain age, et cetera, immediately screened out and deferred, unless it was essential visit. And then we moved on actually into the cancer community and had our providers look very carefully at the people they had on their schedules to see and determine who could either be seen virtually or not be seen for some period of time starting with 3, 6, 9, month follow-ups like you might imagine and it becoming increasingly aggressive as the pandemic picked up speed.
We have over the course of several days done what we would consider about a four year project to implement a virtual health. It’s been choppy, but it’s actually working. And we’re doing several hundred visits per day now via virtual health sending patients to community labs for their testing. And then they’re interacting with providers without having to enter the building. It’s offered us two opportunities, one to continue care for people who desire it and to interact with people who actually need it, but don’t need to be in the building. And it’s been a tremendous benefit as we try to figure out how to match the need of our patients with the size of our workforce in the face of all that’s going on. At the same time, we first encouraged and then we mandated a work from home policy for our appropriate staff and providers.
And so, as you might expect, those who don’t provide direct patient care and have the ability to do things outside of the walls of the hospital were immediately dispatched to their couch. We set them up to the best of our ability with technology from the health care organization. But in many cases people had their own, which was tremendously helpful, because mobilizing a workforce to work from home that quickly is tremendously challenging. So we’ve been lucky to have a lot of people who could provide their own things for themselves. That’s actually worked well in two ways.
One, it’s kept us functional and distant from one another. It’s also created a bench in that we have people who are working from home, who are not being exposed to health care environment on a daily basis, such that if people who are here do get sick, we have people who are ready to come in. And then finally, we evaluated social distancing options in our high risk and high volume area. So places like cancer clinics and infusion centers and radiotherapy delivery treatment areas and determined that there are a number of things that we can do to help create social distancing in those areas.
BRIAN SHIELDS: Hey, this is Brian Shields, a couple a couple extra comments on that. It’s funny. It’s been almost a month ago now, but even thinking back about the very initial first days of our response, one of the first things we did out of the gate was to implement travel screenings and best practice advisories in Epic in our EMR to try to identify patients that had a been– that had traveled overseas to China and then eventually to Italy, et cetera. And obviously, the list of places that we were screening for has evolved quite rapidly as the pandemic has spread. So we continue to have tools like that in place, but as our responses evolved over the weeks and days, those things kind of seem like– they’re hardly going to remember all the little different things that we’ve done.
JAMIE BACHMAN: So beyond those, what are you doing to protect the safety of your patients and staff? Well, this has evolved quickly. If we’d been doing this webinar a week ago, the answer would actually would be quite different. And so we’ll give both an initial response as well as talk about how that’s evolved over time. We started limiting visitors early on. And it was really through a discouragement policy and asking people to leave their loved ones at home as much as possible, both in an inpatient and outpatient setting.
So that quickly progressed to limiting the number of people who could visit an inpatient unit on a given day to actually as of a couple of days ago completely prohibiting our inpatient visitors period– so even the most dire of circumstances, and it’s very sad. And I’m sure you all are encountering things like this. We’re just not allowing any visitors on our inpatient units at this time. We’re limiting our outpatient visits to visitors, two to one caregiver. We’re giving our practices a bit of flexibility to deal with this, because we know that it’s necessary in some cases.
But again, we’re really leaning into the discouragement of bringing people with them, except for those circumstances where the patients require some sort of really intense support. And intense support from our perspective falls into three categories, physical– so thinking about things like getting them from the car to the door to the practice and a wheelchair– cognitive– places where people would have a difficulty understanding what’s happening and need someone to work with them through that. And then, of course, the emotional support provided.
That last one’s a bit of a catch-all blanket. And we’re starting to re-evaluate that because of the way that people define emotional support in this context kind of like they do with animals. As they walk into our infusion center each day, we want to be careful that we are really, really cautious about how many people we have in the building, why they’re there, and really sensitive to the needs that they provide the care and support to the patients we’re treating, but also trying to keep as many of those folks out as possible. Part of this evolution was to actually implement front door screenings. Again, this has been something that’s progressed over time.
First it was just checking to make sure people didn’t have more than the visitors that they were supposed to have. Then it evolved into screening for symptomatic patients. People who are symptomatic are given a mask. People who have more than the number of visitors that they’re supposed to have are politely turned away. And those who are able to have one visitor with them in the outpatient setting, those patients– those caregivers rather are also screened for symptoms. These masks, albeit, in short supply, we felt were important to control and mitigate exposure to patients between themselves and to the staff as much as possible.
So we’ve been distributing masks to any of those patients who are showing signs. We continue to redeploy the staff that are not working from home to places throughout our campus that would be consider off-stage and the duties that are, perhaps, different than what they would normally do. And so examples of those would be taking clinicians and administrative staff that might be working at front desks or in team rooms in close proximity to one another, spreading them out into spaces that were vacated by people who are now working from home and having them post-up and spend their time there. And in some cases actually using consultation in exam rooms as workspaces for our clinicians, such that they’re not sitting together in small crowded spaces, like they have been in the past.
In our common waiting spaces for our practices we’ve removed a certain portion of those seats so that people can’t sit next to each other, moving them out into corridors and exterior walls of those practices so that there still are places for people to sit, just distance from one another as much as possible. In our infusion setting, we move very quickly to determine which of our spaces we needed to block so that we wouldn’t have people sitting close to one another throughout the day receiving short or long treatments. And Brian will talk in a minute about how we came about with our plan and executed on that, not only here on our academic campus, but throughout some of our other sites.
And then finally, we’re in the process currently of cohorting our suspected, pending, and positive COVID patients into an area, where we’ll be providing all the care that they need under their regular clinicians oversight in a place where they won’t be exposing other patients who are not suspected pending or positive to anything that they have while still being able to receive their cancer care. So the next question we got was if you’re doing front door screenings, do we still need to try and create social distancing within the infusion center? The short answer is yes. We found that people will enter the building no matter what with or without a mask with symptoms. And so it’s very, very important to keep the people who are treating apart from one another.
Not to mention, some of the literature that we’ve studied suggests that people can be asymptomatic for quite some time. And so to the extent that we can prevent people who are actually not feeling ill, but are perhaps carrying the virus from being close to one another, we certainly want to do that. We’ve done that by limiting the number of patients who are in shared spaces. We’ve leveraged all of our private spaces as much as possible. Those are filled every day in places where there are group settings– so more than one treatment going on in a small confined area. We’ve taken some number of those out of service as to achieve a distance between that. Some cases is every other chair. And some cases, it’s more than that. It’s really dependent on the size of the area and the actual geographic layout that we’re seeing there.
BRIAN SHIELDS: One comment on that. To foster that, the work that. Jamie that was just describing, after we went through and evaluated the physical layout of all our different infusion centers and determined what chairs we would need to take out of service, we worked very quickly with the Lean TaaS team to develop optimized templates to accommodate that reduction in shares. So that as we were scheduling appointments into each of the different infusion centers that it would still be level-loaded and create a good environment for our patients and our staff. So we were able to do that at five different infusion centers across UCHealth.
Not all of our centers actually required revised templates, but for the ones that did, we were able to develop and implement those right away. Some of the ones that didn’t basically was driven by the physical layout of the infusion center and/or the current volumes in level at which we were filling our available capacity, where our current volumes were such that we were able to use every other chair in an environment where that’s appropriate without necessarily even limiting our templates to accommodate that.
JAMIE BACHMAN: So as you might imagine, as you start changing constraints, like the number of pharmacists, the number of nurses, the hours of operation, and the number of the chairs, that influences your max capacity throughout the day. So it was really helpful to apply some sophisticated logic to decisions that we were making and doing it in pretty quick order. So the next question is, my center normally runs at near-maximum capacity and reducing our capacity will mean turning away patients. Is there a way we can avoid this? While some of the things we started to talk about already, including extending the operating hours in the days– so if you’ve not considered already being open on the weekends, we would suggest doing so.
If the constraint of chairs to allow for social distancing limits the number of people who could come through and what you would consider your normal operating hours, certainly starting earlier and ending later would be a consideration. Using the tails, the early mornings, and the late afternoons in particular so that you can control the flow and regulate the number of patients in the area could become important. We’ve also staggered our nursing shifts to go along with that obviously. As you care for patients across a longer day, you need to understand how that impacts how your staff come and go. And we’ve adjusted that accordingly as well.
We have gotten difficult conversations with our providers. And they’ve been really helpful in guiding our teams to select those patients that would be appropriate for holding treatment, in particular, in our non-cancer population for other medical specialties, but also starting to look at some of the cancer population of people who could push out their next treatment a week or two weeks or more just to prevent them from being exposed, prevent them from being in an area that we don’t want them to be in given their immunocompromised state and also to help create some capacity by having them come at another time. Our clinical pharmacist and our doctors have worked very aggressively to convert patients who are on IV therapy currently to oral therapy that they could take at home.
This is, of course, not possible with all diagnoses and all treatment regimens, but where it is they’ve been very quick to push that. It’s been tremendously helpful in keeping people home and safe in their living room and keeping people out of a hospital where we prefer them not to be for all the reasons we’ve been talking about. We’re considering transferring some of our cases into home care. It’s been complicated with such a surge of sick and in particular elderly patients to find home care agencies who are willing and able to deliver therapy at home, but in other markets that may not be the same as it is here in Denver. And so I would encourage people to explore that as we are as well.
And finally, we are looking– and this will be version two of what Brian was describing before– redistributing our care to other locations within our system and actually outside of our system as well. And so our first pass at this was looking at each of our infusion centers with fewer chairs than normal. Our next version will be operating at a similar capacity, but with fewer infusion centers than normal and figuring out how we might move patients around within our system. And because this is just an unknown endpoint for us, we’ve partnered with our community medical oncology providers that have infusion centers around Denver and around the state of Colorado talk about jeopardy plans, where if providers became sick, staff became sick, or locations became compromised, how we work together outside of our organizations to really care for patients for some period of time until we achieve some version of normalcy again.
So next question, if it becomes necessary to limit patient access, how do I prioritize which patients to treat? What services could I shift to the community setting? This is a tough one, but it does come back to what I was just describing. As prioritization is very much a provider led activity and it’s going to be unique in each organization, we have some providers and some of our teams who are very quick to defer treatment, very quick to push it into community settings, and others not so much. So some of it’s provider preference. Some of its patient condition. Some of it is the community settings that are available to push these into, but we are sending things like port flushes and disconnecting of pumps in two places outside of our academic setting just to make more room.
When we can, we’ll continue to do that. And I expect that it will include things like urgent care centers and freestanding. EDs, but we’re also balancing that with the possibility of exposing people to germs. And so it’s a bit of a slippery slope. It’s something we’ve not moved on yet, but are considering other alternatives, like primary care offices, other specialty care offices, those places that don’t have much activity now, because their patients are not coming to see the physicians and looking for new locations in the community to send people.
So the next question is, we anticipate or are already short-staffed due to staff calling in sick. They’re needing to tend to the family obligations, the school closures. How can I maximize the team we have, and how can we help not to burn out the ones who are coming in? At UCHealth, we’ve developed a jeopardy plan for both our staff and providers. As I mentioned before, we’re using an aggressive work-from-home strategy complemented by an aggressive work behind the scenes strategy. But most importantly, the jeopardy plan includes having people at home who are staying away from the hospital setting, presumably not being exposed to the virus, who will be ready to come in and work when those who are here have been and can no longer work for the next two weeks. We’ve done this at a team-based level.
So in our organization, we’re aggregated by disease specific teams by diagnosis. So breast, GI, GU, et cetera. Each of those teams has developed their independent plans for jeopardy coverage. They have that for both the inpatient and the outpatient setting. It applies to both their staff and their providers. It’s played out now for two weeks. And they have two weeks planned into the future. And our next level of detail of this is actually to treat the teams in a more general fashion. And they’re developing plans across the teams, such that if the breast team achieved jeopardy and needed support, the GU team would be their coverage, et cetera, et cetera. And so we’re putting these plans into place so that if we have mass outages of either staff or providers, they’re ready to leap into action first within their teams and then across their teams.
As I mentioned before, we started to create these cohorts of people who are both on and off campus. This is happening across all our teams of surgeons, radiation, oncologist, and medical oncologist. They’re actually having specific people in groups of people who are rotating and are staying home very intentionally so that they are not exposed. And they’ll rotate on when it’s they’re turn in about a week or so. Not only is this important, because it keeps them fresh and it keeps them safe, it also keeps them fresh, the people who are working in the health care setting. I’m sure you all are experiencing are in a very stressful situation.
We want and insist actually that they rotate off so that they do have time off and days off. And we’re doing that in times– depending on the team of between off three and off seven days after having been on a rotation of a week. We’re attempting to stagger our shifts even more than usual, and so making sure that we’re prepared for days to run long when things don’t go as planned, making sure that we have enough people at all times of the day so that they’re ready to support our patients and support one another. And throughout this, one of the things that’s been really important is to communicate this throughout our team very, very broadly.
On a daily basis, oftentimes our organizations have got updated information about the COVID-19 pandemic. We’ve taken all this information so that it’s consistent between a university, a health system, and a hospital, and we’ve repackaged it and distilled it down to the information that would be important for those caring for cancer patients. So people have just what they need, understand the important details and how it applies to them and the patients they’re caring for, and aren’t overwhelmed by the information but always have what they need right in front of them.
The next question is many of our patients are canceling their appointments with a very short lead time, making it difficult to plan staffing needs the next day. What can I do to ensure we’re making the best use of our available staff? We have used the time when patients cancel actually to do different work and plan for the next day. In some cases, that means using outbound telephone calls to engage each and every patient we expect to come. Sometimes that means communicating through the context of our electronic health record. And what we’re doing in those ways is we’re confirming they’ll be here, managing their expectations for what they’re going to encounter at the door as it relates to our visitor policy, confirming they’re feeling well enough to come in and that they should wait until their appointment the next day to actually have their medical care delivered and don’t require some sort of other intervention before that, but also it allows our staff to really have a handle on who will be there that day.
And as we’re doing it typically within 12 hours of the visit, it’s very helpful to plan for the next day. We’ve also proactively identified and moved a lot of these non-urgent patients off the schedule. We talked about this before, but we’ll do that each and every week working with our providers to make sure that we get the right people in the door, the right people into the virtual visit, and the right people staying home waiting for a rescheduled visit two weeks out, four weeks out, or perhaps longer depending on how everything progresses around us. With the situation constantly evolving, how long should we implement these temporary measures to start?
Our approach, at this point, honestly is as long as necessary. We are expecting that this will last for no longer or no shorter than one month from now in Denver, Colorado. Each geographic region is probably going to experience a different onset, a different duration, different apex. And I would guide you to follow the data that’s coming out of the CDC. Watch the information that we’re seeing published from our colleagues at Harvard and John Hopkins as it relates the incident, as it relates to death rates, diagnoses, and work with your organization to understand how that impacts you. We’re planning, quite frankly, to experience an incredible surge in diagnoses, which will lead to an incredible surge in patients presenting to the emergency department requiring inpatient care and for many of these people to require intensive care which will stress the system in unimaginable ways.
And so in preparation for that, we’re doing all the things we’ve described so far today, but also going into other planning activities to determine what it is that our staff who are working from home or currently caring for cancer patients may have to do to care for the COVID-19 population as it evolves and grows in front of our eyes. We don’t know what the future holds. We’re planning for the worst. We’re hoping for the best. And we’re trying to put everything we can in play as early as possible to give us time to react to what actually happens to be able to quickly adjust.
Finally, how are you communicating with patients about the virus? Can you help suggest any specific messaging we could use for patients starting with new treatments versus ongoing? I’d say that we’ve had very direct conversations with our patients. And these conversations have been led by both our physicians as well as our scheduling staff. We’ve talked to them about the seriousness of this pandemic and the seriousness with which our organization takes it. We want to have all of the people in our cancer center receive the care that they need. We also don’t want to expose them to things that they don’t need to be exposed to.
We found is actually quite fascinating compared to some of our other non-cancer specialty patients who said, thank you very much for not making me come in. I’ll see you when everything settles down. Our immunocompromised patient population, to some extent, almost seem unfazed by this. They know that their cancer journey is something that is very challenging for them. That’s what they’re focused on. And while they know and appreciate there’s a lot of noise in the community around what’s happening in the world, it’s very, very serious, we’ve found that many of them are really just leaning into their cancer journey, coming along with us, taking our guidance, and just ready to get through this and move on to the next phase.
It’s been humbling to see the courage with which they’re approaching this. And we’re just glad that we could be here to support them. And we’re doing everything we can to make it a setting that can accommodate them while keeping them safe.
MOHAN GIRDHARADAS: Terrific. We’ve got a whole bunch of questions. And, Jamie and Brian, that was great to go through the initial set of questions. But we’ve got like 10 or 15 questions or more coming in live. So let me quickly click through them. Nursing staff wearing masks, they currently do not. The infusion center does chemo and regular as well. Would we benefit from masks if they are not N95 masks?
JAMIE BACHMAN: One of our approaches, as an organization, was about a week ago was to outfit all staff members and providers who were working in a patient care area, who interact with patients in any way clinical or non-clinical for longer than five minutes with a mask. And the primary purpose of that actually was probably less to protect the staff and providers from the patients. Although, it certainly does that, but really to protect them from us. We’ve potentially had exposure to patients and want to make sure that we’re– whether it’s going COVID-19 or other contagious diseases, when we’re caring for our patients, we want to protect them.
And so all of our patients, all of our staff, all our providers are wearing face masks– regular surgical masks, not N95. N95 masks are in play, although in short supply in many areas of the country, for those staff and providers who are performing procedures or activities that would generate an aerosolized situation. And so in conjunction with typical PPE, including goggles, gloves, gowns, anyone performing anything like that, would also be offered a N95 or higher.
MOHAN GIRDHARADAS: Great. Next question sort of related. How are you handling conservation of PPE materials? Can the same gowns and masks be utilized for an entire shift if they’re not soiled?
BRIAN SHIELDS: Yeah. So the surgical mask that. Jamie was describing, the guidance that we’re following is to wear– wear that and after the entire shift. And on top of that in an effort to try to conserve PPE, we’ve shifted to a centralized distribution model. So that at the start of each shift, the charge nurse or the administrative leader will go and be given their allocation of PPE for that entire shift.
That allows us to basically have more control over where the PPE is going and better visibility to our current run rates on a daily basis, both here on this campus and across the entire health system. Just as you saw in a grocery store with toilet paper as scarcity crept into our lives, we noticed that patients, caregivers, staff, and providers were finding their way into the normal storage areas where all of this PPE and helping themselves to it. And so to control that, we’ve gone to an allocation system so that everyone gets what they need, but not more.
MOHAN GIRDHARADAS: Great. Next question. This is a concern that they’re putting themselves and their patients at risk. They do access ports and set up lines, et cetera, which does not allow for social distancing. What are you doing in terms of helping out in this way? BRIAN SHIELDS: Yes. Some care can’t be provided without actually touching patients. It’s the reality of what we do. And so because of that, we are using the PPE that is necessary to protect both the patients and the staff from one another. And in cases like that, accessing lines and whatnot, we would use the typical PPE setup. So in this case, it would be gloves, gown, mask. And if the patient was symptomatic or tested or suspected to be called positive, we would also include goggles.
MOHAN GIRDHARADAS: Got it. What guidelines are you following when you have a rule– when you ruled out a COVID patient, but then they’re due for their chemotherapy? Are you holding until the negative test result? Are you deferring until the symptoms have been resolved? Are you dependent on the attending for making that decision?
BRIAN SHIELDS: Yes. We’re depending on the attending to make that decision. And it has been an individual clinical decision in each case. But we’re relying on two important pieces of guidance to do that. And the clinicians are taking both of them very seriously. So the first that came from ASCO was essentially to weigh the benefits of the therapy against the risks of being exposed or having side effects from being COVID positive and use your best clinical judgment. And that could either be really helpful or not particularly helpful, depending on who you ask. The second which is probably a little bit more helpful from the CDC is that– and we’ve actually been in this situation already is that once a patient’s fever has broken for I believe it’s three days, or the onset of the symptoms from COVID-19 are greater than seven days, it’s been recommended that it would be OK to continue with therapy. And so a little more specific, and so with those two things in mind, each clinician is making an individual decision for an individual patient taking those two things into consideration.
MOHAN GIRDHARADAS: Are you allowing virtue pre-chemo clearance visits? And have you unlinked the pre-treatment clearance from the actual chemotherapy infusion?
BRIAN SHIELDS: Yes, and yes. In fact, we’ve had some virtual visits when the patients have been in the building and the provider is in the building, but not in front of them, again, social distancing, using virtual visits between a clinic and an infusion setting, a clinic and a patient in their car, a clinic and the patient before they come to see us from their home. And so in all of those ways, decoupling the infusion visit from the provider visit, and finding ways to interact with them virtually so that they don’t necessarily have to be face-to-face with the provider before receiving their treatment.
MOHAN GIRDHARADAS:. Next question. Have you created a list of traditionally inpatient services that you can now move into an outpatient infusion center? And could you give us some examples of this?
BRIAN SHIELDS: We have, but it wasn’t specific to this current COVID-19 crisis. We are a member organization of the NCCN and have worked with an infusion efficiency group there. That group has identified a number of chemotherapy regimens that have classically been delivered in an inpatient setting and have actually just put out some materials on quick start kits to help organizations move that forward. And our particular organization, the one that we’ve worked to move forward is transitioning EPOCH from inpatient to outpatient. It’s going relatively well. It will help us to free up the rough order of magnitude of 400 plus bed days per year. And as we get more and more comfortable with doing things like that, we’ll apply to some of those other chemotherapy regimens. that others are starting to transition as well.
MOHAN GIRDHARADAS:. Next question, Jamie. Are you checking temperature at patient entry? If not, why not?
JAMIE BACHMAN:. We’re not, but we’re hearing that a lot of our colleagues are. The reason we’ve not so far is because we haven’t been able to operationalize it. Quite frankly, it’s been complicated to secure the doors with the questions, with the visitors, and masks in the way that we described before. It would be surprising to me if that’s not the next level of detail that our organization gets into. And I know that there are some active plans for attempting to do that in the coming days, but truly it’s been not because there is a perception that it wouldn’t be helpful, but because it wasn’t the thing that we needed to spend our time on at the time, but we will.
MOHAN GIRDHARADAS: Great. How– how does UCHealth feel about fabric masks?
JAMIE BACHMAN: So far that’s not something that we’re using. We’ve heard a lot of our colleagues around the country talk about potentially putting fabric back masks into play. Our current stance is that we’re not using any homemade PPE. We’re not using any fabric PPE, but, again, as supplies become scarce, our thinking on that may evolve. But at this time, we’ve been very aggressive in our conservation efforts, very aggressive in our preparation to repurpose and reintroduce. PPE, like Brian was describing before and so hopeful that we’ll not get to a place where we’re making our own or using things that would typically not pass muster for the care we provide.
MOHAN GIRDHARADAS:. Next question. How do you respond to people who say that you should not redeploy people?
JAMIE BACHMAN: Mohan, could you clarify the question, or you talking about redeploying people to other areas outside of the cancer center?
MOHAN GIRDHARADAS: That’s all the questions says. If the person who wrote that wants to submit a fresh question to clarify. All it says is, how do you respond to those that say you should not redeploy people? I’m assuming that that means your staff in terms of what tasks they perform. Let’s move on from it and hope that we get a clarification from it. Are the staff wearing masks all day despite patients with or without symptoms?
JAMIE BACHMAN: They are. Each person is given and asked each day. They wear it all day. They’re encouraged not to take it on and off, in particular, not to take it on and off in a clinical area and in front of patients. As you might imagine, it makes the communication somewhat challenging, but we’ve taken that line that anyone who’s in the building, interacting with patients is in a mask.
MOHAN GIRDHARADAS: Great. Do you have spaces where moving chairs to six feet apart is not an option? I guess that’s when you went to the alternate chairs, because those chairs don’t move that easily in the main infusion center, right?
BRIAN SHIELDS: Right. So in some of the areas, were we weren’t physically moving the chairs, we were just stopping. We’re not utilizing the chairs and just letting them sit empty to create the every other chair scenario and provide for that physical distancing. So those are always available to use if we have to, but obviously we’re trying to completely minimize that as much as possible.
MOHAN GIRDHARADAS: One question on the cohort that tests positive. Are you maintaining the social distancing between them, even though all of them are positive?
JAMIE BACHMAN: In the cohort approach that we’re taking, each patient will be in an individual room. So by virtue of that, they will be distanced. Although, they could encounter one another and perhaps be within six feet in the process of checking in or entering the waiting area, our goal is to keep them apart if not for the distancing for the optics of having people separated.
MOHAN GIRDHARADAS: Very good. We will calling patients the day before to screen. Unfortunately, some of them are getting confused thinking that we were closed. So what we’re doing now is keeping it to screening just at our front door. Is that appropriate, or do you have any guidance?
JAMIE BACHMAN: I think you could actually do– you could do either or both. We found that the combination of pre-screening people on the phone with staff members from our practice has been very helpful in managing their expectations that they’ll also encounter a screening when they enter the building. It’s also helped us to identify people who are symptomatic who may need to be fast tracked once they do arrive and allow us to prepare to get them into a room right away. And so from our experience,. I would encourage a both approach, but if you had to choose one, it’s probably better to have someone at the front entrance than to try to expect that it will be managed easily just over the telephone.
BRIAN SHIELDS: I would agree. I would say that the one advantage to doing the day before would be to prevent trips coming in, especially if you have patients coming from far distances. And we have with patients from Nebraska and Wyoming and all over, New. Mexico, et cetera. So any scenario like that would be helpful to try to do that as early as possible.
MOHAN GIRDHARADAS:. Jamie and Brian, you’ve already answered this, but this might be useful to reinforce. In our outpatient oncology departments, our hospital has deemed them as low risk. This includes not wearing a mask. Our staff are concerned and feel that they should be wearing masks, particularly with our oncology patients. Thoughts.
JAMIE BACHMAN: Yeah. As we as we noted before, we’ve taken a pretty aggressive view of this and put all of our staff and provider in masks to protect them from one another, protecting them from spreading anything that’s contagious that they might have been exposed to, to some extent also protecting them from people who could be contaminated with the virus. And so we’re using surgical masks in those settings for even in the face-to-face interactions with patients who are not symptomatic.
BRIAN SHIELDS: I would just chime in to say that I think every health system is likely in a different place in terms of their stockpile of PPE and their ability to secure more. And depending on what your situation is, you may potentially have to make some hard decisions. UCHealth has been very proactive over the years to be in a really good place or at least a decent place. And what we’re trying to be as proactive as possible to conserve and make power supply last as long as we possibly can. But that said, if your health system is in a different place, your decision– the right decision for you might be different.
MOHAN GIRDHARADAS:. Go ahead, Jamie.
JAMIE BACHMAN: One other thing that we’re doing in that same approach that Brian was describing is actually to be proactive in our conservation of chemotherapy gowns. And so as gowns become more scarce for all sorts of reasons, there are certain medications through a very careful review with our pharmacy, our physicians, and our nurse educators have determined that certain classes of medications could safely be delivered without a gown.
Although, it’s not our normal approach. We’ve gotten comfortable with that and then, of course, some that just can’t be delivered without that type of PPE. And so we’re starting earlier than perhaps we would like to. But we think it’s important so that we don’t get into a crisis situation with gowns and starting to stratify the risk of some of those medications and not use gowns in certain circumstances and reuse gowns in certain circumstances– well, again, to be proactive, to limit the likelihood of us getting into a crisis. And, of course, with more patients testing positive coming into the hospital, those gowns will be at premium very, very soon.
MOHAN GIRDHARADAS: Very good. Are you treating patients that are suspected or tested for COVID-19, are you, or are you deferring them pending results, meaning are you just scheduling them for infusion and treating them as if they were just patients with symptoms?
JAMIE BACHMAN: For pending, yes, we’re treating them as just with symptoms and watching them closely. For positive patients, we’re using those two combination of two factors that. I described before from ASCO and the CDC guidance.
MOHAN GIRDHARADAS: Great. Process check, we’ve got about 13 minutes. We’ve got six or seven questions. I’m confident we can work our way through all of them. If you’ve got some questions that have not yet been asked or answered, please post them on the Q&A panel. I’ll be able to see them. And we should be able to get through them. OK, moving on to the next question. Have you worked with your peers to loosen the payment rules with things like covering. Onpro to keep patients for returning in 24 hours for a growth factor injection, for example?
JAMIE BACHMAN: We have not actively done that yet, but that’s actually a very good idea. And we’ll take that as one of our notes to connect with our managed care team to engage with our payers, because it’s another way of keeping people out of the house. Very good question, very good suggestion.
MOHAN GIRDHARADAS:. With the masks that we’ve talked about, do staff get an allotment per day, like one or two, or how does that work?
JAMIE BACHMAN: Currently, it’s one per staff per day, unless it becomes visibly soiled or broken in some way. That is the limit. If they are ineffective for any of those reasons, then they’re getting another.
MOHAN GIRDHARADAS: Are you doing anything special for pre-infusion lab visits?
JAMIE BACHMAN: As much as possible, we’re encouraging people to have their labs done outside before they come, one, so that they can get in and out more quickly, two, to decrease the volume in our lab and the number of touch points in the organization. But I think that’s the only thing that would be a little bit different. Brian.
BRIAN SHIELDS: Yeah. I mean, generally just trying to decentralize it. So we, for our infusion center, our main infusion center, we have a centralized lab draw area. And so the less people we can funnel through that one room, the better. So if we’re able to draw labs in clinic or in the community, the better.
JAMIE BACHMAN: That’s one of our areas we’ve struggled with social distancing because of the size.
MOHAN GIRDHARADAS: Got it. Next question. How are you temperature checking your employees?
JAMIE BACHMAN: We are not currently. As we described before and for the patient visitors, we’ve not gotten to that point. Again, we’re actually hearing from some colleagues around the country, they’ve started to check all of their employees as they enter the building. We have not gone down that road yet, but I suspect as our experience evolves, we will get to that point. The places that we’re hearing are on the coasts, which are several days ahead of us in their experience. And we expect that, at some point, we’ll follow suit.
MOHAN GIRDHARADAS: Great. Thank you, Jamie. We’ve got the clarification on that the redeploy question. So he has this modified version of it. People say that you should not redeploy people, because they are then potential vectors.
JAMIE BACHMAN: It’s interesting. I suppose that’s– I suppose that’s a reasonable point from an epidemiology standpoint. From a workforce perspective, the people who are being deployed would only be those who are symptomatic or asymptomatic rather. They would typically be people who had been in isolation, oftentimes working from home for some period of time presumably without contact. And while I think there certainly is some risk in any person entering any setting to be a vector, the reality is that we’re trying to match a workforce that’s shrinking, because of infection with a patient population that’s growing because of infection. And those two don’t align particularly well. And so I’d say, not just in our organization, but in most others are having to live in some of those gray areas for this time.
MOHAN GIRDHARADAS:. Looks like the person in Baton Rouge, Louisiana clarified about temperature checking that we are doing this in Baton Rouge. So if you could elaborate a little bit more, I’ll be able to share that with the group. Moving on to the next question. Have you actually had. COVID-19 patients, or are you planning for it at the moment?
JAMIE BACHMAN: We have. We have had a positive tests, many in our organization, many in our health system, many in our state, and a handful in our cancer center. So if we were to have this call in a week, we’d have more experience than we do today, but we are actively engaged in caring for those folks.
MOHAN GIRDHARADAS:. A related question. Are you planning to have one or two days where you will treat cancer patients that are COVID-19 positive with one provider and a few nursing staff? The idea is to keep the patient and the staff separated so that the room can be cleaned appropriately after.
JAMIE BACHMAN: Yeah. We’re actually going to take this is into our cohort unit, where the suspect, pending, and positive will all be cared for by a very small number of staff. They’ll be cared for in private rooms with doors closed with appropriate PPE. Each of which will be cleaned appropriately afterwards. We’ll do those visits on each day, because the reality is is that especially with the pending and the suspected population, it’s hard to know as they enter the building. So it’s a place to take them. And so we’ll use this space as a way to cohort those patients with a small number of providers and staff each day, but not cohort them into one day.
MOHAN GIRDHARADAS: Fantastic. The Baton Rouge clarification is clear. We are now temp screening in Baton Rouge all employees at the entrance and all patients. Happy to share it if anyone would like to know more. So I’ve got the name and contact number. So we can follow-up if anyone’s interested on how to do the temperature screening. Next question. If a patient tested positive and their quarantine is complete, what is the process for getting them returning to the infusion sites? We treat both chemo and non-chemo patients.
JAMIE BACHMAN: Excuse me. The post-seven day symptom onset and post-three day fever breaking has been the guidepost for us. We’ve not encountered this yet, but we will soon. They’ll be reintroduced to the general population.
MOHAN GIRDHARADAS: One more comment on the temperature. We are self-monitoring temperatures morning and evening with a question to answer. If positive temp or questionnaire, we have to contact management. This is the process we are following. I don’t think there’s a question to be answered there. What about radiation oncology? Are you treating positive, or do you have any positive or PUIs– Patients Under. Investigation– in that area?
JAMIE BACHMAN:. Exact same approach as what I described before. And, yes, we do have people in those circumstances as we speak and waiting for the fever to break, waiting for the symptom onset to past seven days in combination. And then we’ll have them back under beam.
MOHAN GIRDHARADAS:. Can you repeat the size of your facility both in staff and patient hospital beds, infusion charts, et cetera? So this is system wide scheme of UCHealth.
JAMIE BACHMAN: Oh, gosh. Let me test my memory here for a moment. So let’s work from inside out. So Brian and I are both in an academic setting. We’re in the Denver metropolitan area. And we are really speaking mostly about the University of Colorado. Cancer Center in our footprint. We have five different infusion centers with roughly 100 chairs. We have ab;out 400 staff in our cancer center overall with just under 100 providers. If you look at our health system, it’s 12 hospitals. It is about 25,000 employees, 1,500 beds give or take. And let’s see, how many infusion centers across all sites?
BRIAN SHIELD’S: 12.
JAMIE BACHMAN: 12, yes.
BRIAN SHIELDS: Just over 200 total chairs.
JAMIE BACHMAN: 200, yeah, 200 total for all of them.
MOHAN GIRDHARADAS: Great. This question has been sort of answered, but just confirming it. Are you dedicating specific nurses and physicians to take care of those pending or confirmed to have COVID, or are you rotating staff?
JAMIE BACHMAN:. We’re going to have a dedicated staff, dedicated advanced practice providers. And we’ll have a rotation of the physician who routinely cares for that patient. We’ll also interact with them. That may be virtually or it may be in person depending on the clinical circumstances, but they’ll have an interaction with the patient.
MOHAN GIRDHARADAS: Very good. Last question on so far, unless someone quickly takes in another one. Are you actively testing the providers and staff who are in contact with positive or high risk patients?
JAMIE BACHMAN: We are not testing staff who are in contact with high risk patients, until or unless they exhibit symptoms.
BRIAN SHIELDS: At which point, we do have a nationwide hotline that is set up with nurses, mainly like a triage, phone line to help direct [INAUDIBLE] staff to employee health to get her testing, et cetera.
MOHAN GIRDHARADAS: Very good. Thank you, Jamie and Brian. Now just a few logistical housekeeping items. We will send the slides out. If you want them drop an email to Josephine Hederoth. The email is probably on your screen, but it’s Josephine, J-O-S-E-P-H-I-N-E, dot H as in Harry– at leantaas.com L-E-A-N like Nancy, T like Tom, A like Apple, A like. Apple, S like Sam. We’ll also make it available on our website after we have a chance to transcript the freeform Q&A, because that– we spent nearly half the time on that. Meanwhile, there are two more questions that have come in. So let’s quickly get to those as well. Our organization has stopped asking the question about fever and are now asking if they’ve had diarrhea in the last two or three days. What are your screening questions?
JAMIE BACHMAN: It’s very interesting. We’ve not moved to the diarrhea question. We’re using fever, cough, other respiratory systems or symptoms rather. Yeah. Those are our primary.
MOHAN GIRDHARADAS: Are the dedicated staff to treating COVID patients, are they volunteering or are they being selected?
JAMIE BACHMAN: By and large, they’re volunteering. We will have a selection process in place if it comes to that point. Many of the people who will be involved in this care are coming from our infusion center settings. We will protect them appropriately. And we’ll monitor them carefully. And they have great love for their patients and the desire to see their care through and so are really on the front lines of this. And we’re proud of them for jumping in. We may get to a place where we don’t have volunteers if people become infected and ill, and we have to rotate off. And we’re developing a plan for how to do that if it becomes the case.
MOHAN GIRDHARADAS:. The last question. Jamie and Brian is going to create some homework for you. Can you share the list of chemotherapy drugs that do not require a gown to administer? So this may be something that you guys need to create a list for. And we can attach it to the slide deck. Meanwhile, one final question has come in. We also asked patients if they have been tested for COVID and if that’s pending or resulted. OK.
JAMIE BACHMAN: Yes, that’s actually part of the original screen in addition to the symptoms. I apologize I didn’t mention this before. It began with a travel history. It moved on to known or suspected exposure to someone who is suspected or confirmed to have– be COVID positive and then moved on to symptoms.
MOHAN GIRDHARADAS: Great. Jamie, Brian, thank you very much. This was incredibly informative. And we will assemble all of the materials and make sure we disseminate and share it as best as we can. Appreciate everyone. We had at the top of the hour. So we will wrap up this webinar now. Thank you again.
JAMIE BACHMAN: Thanks, everyone take care. BRIAN SHIELDS: Thank you.