Epidemiologists and disaster preparedness officials who have contemplated what could spark a public health crisis that overwhelms the nation’s healthcare system and causes widespread social disruption and economic upheaval now have at least one answer: a coronavirus that spreads easily and quickly and can cause severe respiratory distress and death.
The United States and much of the world have been in the grip of a pandemic caused by a novel coronavirus called SARS-CoV-2. Hallmark symptoms of the disease caused by the virus—coronavirus disease 2019 (COVID-19)—are fever, cough, and shortness of breath. COVID-19 has resulted in a nationwide public health emergency the likes of which have not been seen since the influenza pandemic of 1918. As of April 6, the nation has had 330,891 confirmed or presumptive cases of COVID-19 and 8910 related deaths since January 21, according to the Centers for Disease Control and Prevention.
In the United States, the pandemic, which has hit New York City particularly hard, has overwhelmed hospitals, exposed a critical shortage of ventilators and personal protective equipment, resulted in deferral of all but urgent surgeries, forced most of the US population to stay at home, put millions of people out of work, made commonplace the sight of individuals wearing protective face masks, instilled fear among front line healthcare providers, prompted retired clinicians to come forward to help, and led to deployment of the USNS Comfort, a 1000-bed Navy hospital ship that sailed up the Hudson River and docked on the West Side of Manhattan.
New York City has emerged as the nation’s COVID-19 epicenter, with the city’s health department reporting 68,776 cases and 15,333 hospitalizations and 2738 deaths attributable to the disease as of April 6.
Urologists usually are not called upon to contain infectious disease epidemics, but the unprecedented events unfolding since January have prompted them to do their part to contain the spread of the virus. Urology practices across the country have devised strategies for providing care while keeping themselves and their patients safe. They have implemented measures such as social distancing, increased use of telemedicine, minimizing contact time with patients during in-office encounters, and disinfecting surfaces that could transmit the virus.
Some urology practices alert patients to infection control efforts on their websites. The Urology of Virginia website, for example, told patients, “In response to the COVID-19 crisis, Urology of Virginia will convert in-person visits to telemedicine visits in all possible situations beginning March 23rd.” The New Jersey Urology website had this message: “We are asking our patients to arrive for their appointment either alone or with no more than one individual, over the age of 18. Additionally, you may choose to wait in the car or outside the waiting room after registering with us. To facilitate this, we will ask for your mobile number at the time of check in and call you when the doctor is ready to see you.”
Minnesota Urology, which has more than 24 locations in the state, according to the group’s website, has adopted a COVID-19 rotating schedule for urologists. As CEO Dave Carpenter explained in an April 2 COVID-19 webinar produced by the Large Urology Group Practice Association (LUGPA), the schedule involves 3 groups of 4 physicians, each on a 3-week rotating schedule. With this schedule, a “full duty” group provides 1 week of covering in-clinic visits, hospital/OR, call, and some video/phone visits while 2 isolation groups spend 2 weeks in self-quarantine performing video/phone visits. The groups rotate in and out of full duty for an entire week separated by 2 weeks of isolation, Carpenter said.
Hospitals under siege
“For us, it is really about making sure that we’re able to safely keep our doors open and develop strategies to manage the surge [in COVID-19 patients] because the hospitals here are just simply overwhelmed,” Deepak A. Kapoor, MD, chairman and CEO of Integrated Medical Professionals, told Renal & Urology News. The independent group—which has its headquarters in Farmingdale, New York—has more than 100 providers and is a clinical affiliate of The Mount Sinai Health System in New York City.
“We’re consolidating offices and office hours so that we’re minimizing exposure,” Dr Kapoor said, “but it is essential that we be there so our seriously and acutely ill patients can be kept out of emergency rooms.” To this end, his practice has postponed elective procedures and uses telemedicine as much possible. On April 3, he said, urologists in his group had more than 500 telemedicine visits—up from no telemedicine encounters 2 weeks before.
‘All hands on deck’
Urologists are among the medical specialists who have stepped forward to assist where they can by filling in for doctors who have fallen ill with the disease and performing supplemental tasks in emergency departments. In New York City, the healthcare community is being asked to do more than manage their own practices. Dr Kapoor said he has had conversations with administrators at different health systems regarding what his urology group can do to ease the burden on hospitals, such as sharing equipment, staff, and facility space. The mindset is to do “pretty much anything to help. It’s really all hands on deck here.”
While urologists might not have the expertise to manage patients on ventilators, they are looking to perform other duties that free up critical-care personnel, Dr Kapoor said. Depending on how far out urologists are from their residencies, they may even be able to handle some emergency department cases so emergency physicians can devote attention to more critically ill patients, he said.
The shortage of physicians extends to urology. Dr Kapoor spoke with a chairman of a New York health system in which a number of practitioners are unable to take calls due to COVID-19 exposure. The lack the staff to take calls in hospitals and emergency departments has led to an urgent need for qualified assistance. “So our doctors are pitching in to take urologic calls in those hospitals and emergency rooms,” he said.
Practices nationwide should heed the developing situation in New York City by working now to develop clinical and business strategies to navigate this crisis, Dr Kapoor said. “We went from business as usual to completely overrun in no time,” he said.
Anne Arundel Urology in Annapolis, Maryland, adopted telemedicine immediately as soon as the COVID-19 danger became apparent, said Mara R. Holton, MD, the group’s CEO and president. Now, urologists in the group see more than two-thirds of their patients via this modality. Like other practices, Anne Arundel Urology has deferred elective surgeries. As for the clinical impact of these postponements, Dr Holton, who also participated in the April 2 LUGPA webinar, said, “I think most of us believe that, for many surgeries, a month or two would not necessarily impact long-term morbidity. Unfortunately, in these uncertain times, I believe we may well be looking at delays of 6 months or more in which case the implications may well be significant.”
Ambulatory surgery option
Dr Holton said her practice is weighing which surgical cases could be managed in an ambulatory setting. “We are evaluating every surgical procedure carefully for appropriateness for site of care and have worked with providers to consider staging procedures, thereby making them more reasonable in an outpatient setting,” Dr Holton said. “In addition, we have ongoing conversations with our anesthesia group about broader patient selection for the outpatient setting.”
She noted that “beyond the lives harmed or lost directly due to the virus and the personal ramifications of social distancing and the resultant strange new world in which we all find ourselves,” the biggest impact of the pandemic “is the massive decline in patient volume with consequent reduction in revenue. The impact of this on our bottom line is staggering, particularly in light of the unclear timeline. To that end, I believe this represents an existential crisis in independent medicine and a critical threat to the existence of many facets of our current health care delivery system.”