|Kelsey Moody Mileski, OD|
COVID-19 has everything except essential services on hold, and it’s forcing a monumental shift in how clinicians provide those essential services. The optometrists, ophthalmologists, technicians and support staff at Emory Eye Center in Atlanta, GA, have been working overtime to postpone routine care, kickstart telemedicine and prepare to handle COVID-positive consults in the hospital setting. With more than 120,000 patient encounters annually and five locations, a VA Medical Center, 15 subspecialties and several hospital locations to cover, it’s no small feat.
But they had experience with something like this before, and it’s given them a leg up on at least one small aspect of the COVID-related changes.
All ODs are trained on personal protective equipment (PPE), but it’s a rarely used skill that takes time to adjust to, says Kelsey Moody Mileski, OD, an assistant professor of Ophthalmology at Emory Eye Center. In fact, she says getting used to wearing all of the PPE when seeing a patient has been one of the most surprising challenges.
Emory, however, has been ahead of the game when it comes to PPE preparedness, she notes. “Emory Eye Care physicians were involved both during and after the Ebola crisis, and several Emory retinal specialists examined Ebola survivors in both Atlanta and the Democratic Republic of Congo and had experience with the necessary PPE required,” she explains. “Due to this, PPE was addressed immediately within the Eye Clinic to begin training even before the closures started.”
“We luckily have plenty of training on PPE wear, but we don’t usually have to worry about it,” she explains. “The goggles and eye shields initially were a challenge, and the constant need to sanitize the equipment,” Dr. Mileski says. Her team realized quickly that wearing goggles makes BIO significantly easier than it is with a face shield. “The goggles don’t really get in the way at all.”
Still, no amount of training can prepare you for the extra time and effort it takes to don and doff proper PPE. Dr. Mileski says having two clinicians on a hospital consult is the best way to handle the situation. Only one OD has contact with the patient, but the two-man team makes the extra PPE and sterilization steps much easier.
Scheduling Chess Game
Of course, Ebola never grew to the pandemic we are dealing with now, and it’s uncharted territory for other aspects of patient care. Constant communication and exceptional organization have been the key, according to Mileski. The team used to have monthly faculty meetings, “but we initially moved to weekly and now biweekly remote staff meetings,” she explains.
Although only a few optometrists initially handled patient triage and urgent cases, all 15 ODs on staff rose to the challenge to help cover the rising number of higher-level visits on a limited schedule.
The biggest challenge, Dr. Mileski says, has been culling through the appointments to decide who does—and doesn’t—need to be seen. It took a few changes, but they settled on a system that identifies patients as time-sensitive or urgent. The latter patient group is either kept on the schedule or rescheduled for a specific day that the provider is in clinic, she explains.
“The trick is, we don’t know when we will be reopening to routine care, so the question is how long can a patient wait, and do we need to be concerned that they may lose vision within that time,” she says. “The patient who just needs an IOP check could wait one to two months as long as they have refills of their drops; however, we do not want them to be rescheduled several months later.”
Right now, they are rescheduling most for May, but she admits even those patients may be getting a call for yet another reschedule. “We are hopeful we could open in May, but we just don’t know.”
Even time-sensitive and urgent patients staying on the calendar need to be rescheduled to different days or times, she admits, to limit the number of patients in the clinic at one time. The new schedule spreads the appointments out as much as possible, which has proven particularly challenging for the high-volume clinics.
To keep track of the jigsaw puzzle that is now patient scheduling, the administrative staff put together comprehensive spreadsheets that include who is scheduled and why, when they were last seen and any pertinent patient data. But clinicians still have to dig through their patient files to determine whether each one needs to be seen in person, if a phone follow up is appropriate or if the patient is a good candidate for a telemedicine appointment.
“Most of the time patients are very willing to not come into the clinic, and if they can have their questions answered over the phone, that’s ideal,” she says.
One somewhat unexpected scheduling challenge has been the increase in urgent referrals, as Emory Eye Center is one of the only clinics in the area still seeing urgent patients and performing ocular surgeries. Added to that, a significant number of patients present to the emergency room for ocular complaints, or at least they did before the coronavirus hit, Dr. Mileski says. Those numbers have dropped considerably, and she suspects those patients are now calling the clinic directly in an effort to avoid the hospital.
Telehealth Pros and Cons
While the move to telehealth has been touted as the go-to intervention during the pandemic, Dr. Mileski says it’s a complicated decision. Patients must first have an ocular complaint that is likely easy to identify with a good patient history and external exam, such as a hordeolum or subconjunctival hemorrhage. It’s also working well for some follow ups, she says.
However, “if they need a pupil check, dilation or a refraction, we have to bring them into the clinic if it’s for an urgent complaint or rescheduled if it’s routine,” she explains.
Added to that, the patients have to be tech savvy enough to use their computer or smartphone for the telemedicine visit—something many older patient struggle with. During the crisis, they are using Zoom, but even that takes some technological know-how that some patients simply aren’t comfortable with. For patients who can’t do a virtual visit, clinicians must do their best to handle the concern over the phone or reschedule them a month or two down the road, reserving in-person appointments for those most in need.
Limiting viral spread means careful patient screening in the clinic. Staff ask about COVID symptoms when scheduling every appointment and during check-in. Patients who mention suspicious symptoms are asked to not come directly into the eye clinic.
“The goal is to examine them in the hospital or the designated COVID clinics they have now set up,” according to Dr. Mileski. “Luckily, the hospital’s new COVID-positive clinic now has a teleretinal camera, so it gives us some information that has been helpful.” The clinicians can also see the patient in person at the COVID-positive clinic and perform a full exam there to prevent exposure in the eye clinic itself.
As for hospital consults, they noticed early in the pandemic that only about 1% of COVID-positive patients develop viral conjunctivitis—and they don’t necessarily need an eye care consult for that. “However, just because you are COVID-positive doesn’t mean you can’t have other ocular issues at the same time that do need to be seen,” she emphasized.
Dr. Mileski saw her first COVID-positive inpatient for new onset floaters. “I started by triaging her over the phone to get her history so when I got to her room I could get straight to the eye exam,” she notes. “You also want to limit everything you need to take in with you, so we printed an eye chart and set it at the appropriate distance so when we were done we could just throw it away.” The same goes for the eye drops, she adds. All of the necessary equipment she needed had to be thoroughly cleaned after the exam.
Make the Most of A Bad Situation
None of this is ideal, but everyone is coming together to make the best of what they have. Most of all, Dr. Mileski is pleasantly surprised by the patient response.
“You never know how people will react to the situation, whether they will be upset about their appointment getting canceled, and it’s been a very positive experience, especially when it’s the provider themselves calling to cancel or reschedule the appointments,” she says. “This is unprecedented; we have never had to deal with anything like this before.”