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MARCH 12, 2020 -- The novel coronavirus has hit Seattle and the surrounding suburbs hard, with 83 confirmed cases and 17 deaths to date. But while Seattle may be the first US city affected, it is a herald spot — one that portends a long, difficult fight against COVID-19 and its spread. The general internal medicine center at the University of Washington has 100 healthcare workers — including attending physicians, residents, and nurse practitioners — with a population of about 12,000 patients. Medscape Medical News spoke with Jacob Berman, MD, MPH, the clinic's medical director, to get a better understanding of what it's like at the front lines and how others can learn from their experience. This interview has been edited for length and clarity.
What do things look like right now in the clinic?
Berman: We are seeing a substantial volume of calls from patients, particularly those with respiratory symptoms, wondering if they should be concerned, seek care, and more generally whether they should stay home or go to work. Others who are calling don't have symptoms but have questions concerning what to do to minimize exposure: "Should I go out, come into a healthcare facility, plan for a trip?"
The most challenging patients are the ones who are calling in with mild-to-moderate symptoms whose diagnostic possibilities include pneumonia or other things that are difficult to assess over the phone. For patients in that group — and it's not a small number of people — we advise them to come into clinic so they can be assessed. We want to make sure we can take vital signs, listen to their lungs, and get a chest x-ray and bloodwork if needed.
How has your office screening protocol changed, and how do you separate out symptomatic patients?
That's been the number-one focus for us in the clinic over the past week. We don't have "sick" and "well" waiting rooms the way a lot of pediatrics clinics do.
So instead, at check in, we screen every patient for fever, runny nose, cough, shortness of breath. And if they're positive on any of those symptoms we provide a mask right away and seek to room them immediately in one of several designated rooms we've set aside for caring for patients with acute respiratory symptoms.
For patients who schedule through our portal and indicate they have respiratory symptoms, we first link them to a nurse for triage by phone. Then we add a flag to their scheduling appointment note and, when they come in, we know they should be masked and roomed promptly.
What does your access to testing look like?
Initially, it was a challenge. The University of Washington healthcare system developed its own assay, and access to testing has ramped up in the last several days. We're able to order the test now through a patient's electronic [health] record. Testing capacity has improved over the course of the last week and should continue to increase significantly.
My hope is that we're at an inflection point as university labs and commercial labs come online. Testing is still a limited enough resource that the public health and infectious disease experts have developed pretty rigid testing guidance, preserving testing for the sickest patients, where it may have a direct impact on management, or for infection-control precautions in the hospital or community.
The other thing that seems to be a barrier to testing is access to personal protective equipment for specimen collection, and I think that may sometimes be the rate-limiting step. There are a lot of people at all levels working hard on that problem. But we're continuing to order tests for patients as appropriate and to test healthcare workers as appropriate.
How has limited testing affected your clinic?
We're seeing it at two levels. On the community level, people would like to know their infection risk and whether they can return to work. And the other level is in healthcare workers, who are at increased risk and whose ability to work with symptoms is restricted.
There's a particular push around what can we do to make testing for health-care workers more accessible to our community. In these early days, some colleagues with upper respiratory infection symptoms have had to stay home for longer than might have been necessary because they couldn't get tested.
How are you and your staff handling things? Are you feeling at all overwhelmed or anxious?
It's an extraordinary time. And in healthcare, we are definitely in this accelerated, intensified mode of trying to be as prepared and responsive as possible. Personally, I feel a heightened sense of vigilance and urgency around making sure we're doing everything we can to responsibly care for patients. And mostly I am just constantly prioritizing and trying to identify gaps that we need to address and how to do that even as circumstances and guidance shift.
The staff and providers have been great — there has definitely been the feel of "all hands on deck." As we learn more and more about the virus, there's an expected degree of personal concern around it. But we have sought, at the clinic and hospital level, to provide as much concrete, specific, actionable information as possible so people know what to do or what resources to go to for guidance.
Has anything about this surprised you?
At the macro level, I'm surprised that the testing took so long to become more available. But otherwise, this is so novel and requires such an adaptable mindset that, while we want to be clear on standard-of-care and protocols, it's almost hard for things to be surprising because it's such a novel scenario. And once you make that psychologic shift to expect surprises, that's kind of a pivot point.
I have been struck by how our community here in Seattle has reacted. The general atmosphere hasn't been panicky or complacent. In general, people seem vigilant and appropriately concerned.
What are you doing at the clinic level to be ready and nimble? And how are you handling, or planning to handle, predicted supply shortages?
We've had a lot of proactive messaging from our health system about national and global shortages and the importance of stewardship, while ensuring providers and staff have adequate equipment. Because of the potential of hand-gel shortages, there's been a shift to preferentially using soap and water for hand hygiene when possible. And there is a very conscientious approach to using gowns and gloves and masks. We've been fortunate so far to have had adequate inventory, but are working carefully to maintain our supply.
We're minimizing how many people go into the room with a patient during an encounter. It's advisable from an infection standpoint, but also helpful in minimizing utilization of personal protective equipment. We're a teaching institution, so there are often larger teams in the hospital or clinic who will see a patient. But given the extraordinary circumstances and resource constraints, we have really sought to streamline that.
How have things changed in the last week or so?
In the clinic, we've seen a steady stream of clinical and infection control concerns. We're thinking creatively about the structure of our schedule and the way we provide care, so we've launched into a rapid implementation of telehealth.
And as the volume and intensity of patients rises, we're trying to be proactive in the guidance we're giving around coming to clinic, staying home, going to the ED, using telehealth, and more. It underscores the value of strong communication in managing any crisis and how valuable that's been at the clinic level and the hospital- and health-systems level. And it shows how important it is to think very concretely about the concerns of patients and healthcare workers and how to address them.
What would you tell your colleagues in areas of the country that haven't yet seen a case?
It's great to be as prepared and anticipatory as possible, and to think about the nitty-gritty front line at the clinic level. If providers and teams have the bandwidth to mock up specific scenarios, they should think about what patients will be calling about and presenting with. And then, at the point of care, what do you do in that moment? What do you advise your teams to do? What does each step of the process look like, including donning and doffing of personal protective equipment? Thinking that through and actually practicing it at the clinic level is invaluable.
Lauren Gravitz is the editorial director for Medscape features. She has covered science and medicine for a variety of publications, including Nature, Technology Review, Nature Medicine, and NPR.