An update from our Chief Medical Officer:

It’s been a tumultuous week for everyone, but at least we are one week closer to the recovery phase for all. The Governors in TN and GA (among others) enacted “Stay-at-Home” orders so all QDP markets are now impacted. We are seeing COVID-19 cases continuing to rise in most metropolitan areas nationwide. I know we all pray that shelter-in-place, travel restrictions, social isolation and hand hygiene measures start to flatten the curve over the coming weeks.

As the numbers rise, an area of ongoing attention amongst both our front-line employees and our management team is controlling the risks to our staff and creating the safest environment possible to care for our patients in need. While concern is very understandable, I would like to provide some reassurance that these risks, while never zero, seem to be both controllable and lower than expected by following the established measures that QualDerm has implemented.

Dr. Atul Gawande recently wrote in The New Yorker about the current evidence regarding health care worker COVID-19 infection and best-practice strategies to reduce the risks (1). He presents data from Hong Kong and Singapore regarding key tactics, where these nations successfully navigated their crises with limited mortality and business disruption. Singapore (as of March 21) appears not to have had a single recorded health-care-related transmission of the coronavirus, despite the hundreds of cases.

“All health-care workers (in Hong Kong and Singapore (2) are expected to wear regular surgical masks for all patient interactions, to use gloves and proper hand hygiene, and to disinfect all surfaces in between patient consults. Patients with suspicious symptoms (a low-grade fever coupled with a cough, respiratory complaints, fatigue, or muscle aches) or exposures (travel to places with viral spread or contact with someone who tested positive) are separated from the rest of the patient population, and treated—wherever possible—in separate respiratory wards and clinics, in separate locations, with separate teams. Social distancing is practiced within clinics and hospitals: waiting-room chairs are placed six feet apart; direct interactions among staff members are conducted at a distance; doctors and patients stay six feet apart except during examinations.”

“What’s equally interesting is what they don’t do. The use of N95 masks, face- protectors, goggles, and gowns are reserved for procedures where respiratory secretions can be aerosolized (for example, intubating a patient for anesthesia) and for known or suspected cases of covid-19.”

Transmission seems to occur primarily through sustained exposure in the absence of basic protection or through the lack of hand hygiene after contact with secretions. A case report of early COVID-19 experience from Singapore2 revealed that none of the 41 health care workers who took care of a patient with severe pneumonia before their diagnosis of COVID-19 became infected themselves or developed symptoms. These health care workers had been present during intubation and extubation of the patient; they were present for at least 10 minutes at a distance of less than 2 m from the patient, with 85% wearing a surgical mask and the remainder wearing N95 masks (3).

Early evidence in the US also suggests that through the use of standard PPE and careful hygiene, health care workers can stay safe. The first COVID-19 case at UC-Davis Medical Center resulted in the self-quarantine of 89 health care workers involved in the care, after which none had been infected. ‘Hot spots’ of Seattle, Sacramento and San Francisco have also not shown significant occupational transmission. While this may evolve and even one infection is too many, there does appear to be a lower risk than one might fear if following the safety recommendations above, which are consistent with the Quality Council guidance.

For anyone assisting or performing surgery on the nose or mouth, using N95 face masks is reasonable, as long as they have been properly fit-tested. The CDC does not require them, but it is appropriate if desired. Our supplier currently has some limited access to N95 masks, so please use them judiciously, given their nationwide shortage for other providers in high risk inpatient, critical care, and emergency departments. The OSHA officer in each facility can perform fit-testing (annually required for ongoing use) and provide guidance on proper use and disposal when soiled. To reduce waste, most institutions are recommending serial re-use of unsoiled N95 masks every 3 days, after placing them in a bag for 72 hours, given evidence that coronaviral loads are negligible after that time.

For our front desk receptionists, we are also initiating a policy to enhance the effectiveness of patient screening upon entry to all our facilities. There have been several recent incidents in which Mohs surgery patients were asymptomatic and screened negative at the front desk.

Nurses then later identified an unknown fever when checking vital signs, potentially increasing the exposure risk to other patients or staff in the interim period. Therefore, the COVID-19 Temperature Check Policy has been introduced for the education and training of front desk staff to perform a simple temperature check along with the screening questions. Our risk management advisors have approved of this policy. Our nursing personnel and clinic managers will assist with implementing this policy, which should further enhance the safety of our clinic environments.

I would also recommend that QualDerm follows the lead of most hospitals in performing temperature checks prior to each shift on each employee. Employees may opt out of this check without discrimination, but I would hope that everyone is committed to reducing the risks to coworkers and patients. Clinical staff at each facility can simply document this on a daily log.

Finally, I would like to thank and acknowledge the efforts of many employees involved in our ongoing TeleDerm initiative. In the near future, Drs Jake Turrentine and Kevin Stein along with Dina Gluck PAC will provide further ‘super-user’ guidance for any provider interested in tips and pearls for efficiency with the new platform. Josh Metzger and Chris DeGeorge have been instrumental with the IT and EMR technical aspects, while Cherie Adams and her RCM team is assisting with coding and billing processes. I apologize in advance for anyone I missed but suffice to say it has been a strong team effort, and one vitally important to QualDerm now and in the future.

Stay well and have a good weekend,

John G. Albertini, MD

1. Gawande A. Keeping the coronavirus from infecting health-care workers: what Singapore’s and Hong Kong’s success is teaching us about the pandemic. The New Yorker. March 21, 2020. https://www.newyorker.com/news/news-desk/keeping-the- coronavirus-from-infecting-health-care-workers
2. Ng K, Poon BH, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: a case report. Ann Intern Med.
3. Givi B, Schiff BA, Chinn SB, et Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg. Published online March 31, 2020.