COMMENTARY

Strategies for US Gastroenterologists During the COVID-19 Pandemic

David A. Johnson, MD

Disclosures

April 07, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

COVID-19 has really subsumed us all. If you haven't been affected, you will. To date, the most affected location has undoubtedly been New York City and the state of New York in general. Thankfully, five of the top key opinion leader gastroenterologists working in New York City during this crisis have taken time to put together and publish some very thoughtful recommendations for other healthcare providers. These recommendations are based on their unfortunate experience and exposure to a tsunami effect that has really started to make a difference in their practice.

New York City has emerged as the epicenter of US cases, and the timeline has been incredibly short. The first case in New York City was March 1. By the third week of March, there were close to 18,000 cases, leading to an incredibly strong demand for and drain on all healthcare resources. Approximately 13% of these patients require hospitalizations, most frequently needing urgent evaluation and potentially intensive care units (ICUs) and ventilation.

These key opinion leaders' first piece of advice relates to outpatients. Simply put, keep them out of your clinic and office. Instead, start to look at ways that you can distance, particularly using telemedicine. In fact, if there's any silver lining to this pandemic, it relates to the expanded use of telemedicine. It is something we haven't really used, primarily because it wasn't reimbursed very often. But now the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, and all the insurance companies seem to have waived this. This has certainly opened up a lot of opportunities.

There are two types of telemedicine. One is a simple telephone call. The second type is more platform-based, where you use a webcam to see the patient and talk to them. There may be a minimal expense involved in that. There may also be some requirements for documenting that the patient consents to this type of telecom as well. We've put this into our electronic medical records, but now it's potentially reimbursable at virtually the same parity as an office visit.

Certainly, the authors note that there are still occasions where patients need a face-to-face visit for more urgent scenarios, such as a new cancer diagnosis or if they're experiencing severe symptoms. But even in these cases, entry into the building is predicated by the ability to pass prescreening. The authors recommend prescreening these patients by phone and then screening them again at the entrance to the building, if you have access to do that. Patients with a temperature > 100.4º F are not allowed into the building, which is accordance with a recommendation from the Centers for Disease Control and Prevention. We employ a version of this at our own practice by granting entry only after obtaining a thermal scan, although we actually use 99.0º F as the threshold. Regardless of what you use, these safety guidelines should be strongly considered.

All elective procedures that can wait up to 3 months should be canceled, including standard screening or surveillance, motility studies, and pH testing. This is supported by a recent joint statement from various gastrointestinal (GI) societies and various local, state, and even federal recommendations.

These New York–based thought leaders also offered advice on semi-urgent/semi-elective and urgent procedures that should be performed. Semi-urgent procedures included new-onset severe iron deficiency anemia of a suspected GI source, percutaneous endoscopic gastrostomy placements, endoscopic ultrasonography staging for malignancy, and prosthesis removals that cannot wait for 3 months. Urgent procedures included upper and lower GI bleeding, dysphagia impacting oral intake, cholangitis, symptomatic pancreaticobiliary disease, and palliation of obstructive diseases in the GI tract.

Upper endoscopy procedures have become potentially more of a risk in light of the COVID-19 outbreak. We know that the respiratory tract tends to have a higher viral burden. This is certainly something to keep in mind when considering even the semi-urgent types of procedures in the upper GI tract, given the potential for micro-aerosolization of the virus. If a patient coughs, the nurse or the physician tends to be closer in proximity to them than they are perhaps with a colonoscopy. And as you start to use suction device, the potential risk of micro-aerosolization really ramps up.

Developing a COVID-19 War Plan

As it relates to inpatient care, the recommendation from these New York physicians is to consider strategies where you can potentially mitigate the strain on resources in caring for these patients. They noted that one hospital has adopted an almost military mentality, using gastroenterologists in four different waves of troop support, if you will. The intensivist may be placed in wave 1 in the ICU, whereas some of us gastroenterologists would be in a wave 4 for backfill, caring for hospitalized patients who didn't have COVID-19 or urgent requirements in the ICU. Young physicians and fellows, especially those who are internal medicine certified and have more recent exposure to ventilatory management and ICU care, could certainly be mobilized and moved up in the wave, freeing up other resources as it relates to care. No matter your position, the point is that all of us potentially could eventually contribute.

When it comes to how your own institution can prepare for COVID-19, the authors provide five specific recommendations.

Recommendation 1 is to encourage your local hospitals to gain the ability for COVID testing, including a rapid testing version that's now available. Widespread testing will limit exposure and potentially help us contain risk.

Recommendation 2 is to assume that everybody has at least the potential to harbor the virus. This certainly needs to be understood because, at the present time, about 40% of COVID-19 cases cannot be directly linked epidemiologically to exposure to an index case. [Editor's note: Since the recording of this video, the percentage increased to about 80%.] Given that microdroplets of the virus can persist on different surface areas, anyone anywhere at this moment may potentially have it.

Recommendation 3 is to conserve personal protection equipment (PPE). Not everybody needs an N95 mask. In a separate group of recommendations for limiting COVID-19 during endoscopy, I discussed the importance of stratifying patients as low-, intermediate-, and high-risk. Such efforts will allow us to conserve PPE.

Recommendation 4 is to begin a strong public outreach and advocacy plan in your community. This is something that you and your care team really need to be leaders on by telling everybody to stay home, practice social distancing, and wash their hands. This could easily be incorporated into and prioritized within the prerecorded cycling message that patients hear when they call into your practice and are put on hold. As care providers, we need to take the lead here. The more we can do that, the more we can help improve the credibility and compliance.

Recommendation 5 is to develop the information technology necessary to accommodate telemedicine. The infrastructure for this does not take a lot to get going. Everybody should be able to do this almost immediately.

The authors conclude that New York City is no stranger to crises and disasters. They've been through Hurricane Sandy, 9/11, and now find themselves at the epicenter of the US coronavirus outbreak. Nonetheless, these authors are still taking time to offer guidance for all of us to consider. They do not suggest that this is the absolute manual for how everybody has to respond to this crisis, just hard-earned knowledge they've had to quickly obtain and incorporate.

Having a plan to turn to in a crisis is one thing. Trying to develop that plan when the crisis is upon you is very short sighted. Thanks to these leaders for helping us at least evaluate ways we can develop a plan. Be active and think about it, but also understand that we all need to be moving on this.

This is Dr David Johnson. Thank you for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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