Rheumatology in the Time of COVID-19: Pre-Clinic Visit Screening and Triage

By Andrew L. Concoff, MD, FACR, CAQSM

An Ounce of Prevention is Worth a Pound of Cure

As we all know, given the contagiousness of COVID-19, the best way to prevent contracting the infection is to avoid exposure to those who are infected.  This is complicated by the potential for those with mild symptoms, or even those with asymptomatic infection, to transmit the disease.   Further, the lack of effective population screening with which to establish case prevalence and identify infected individuals and related contacts has complicated the scenario.  Accordingly, the importance of accurately screening patients prior to their arrival in the clinic becomes paramount.  Each of these considerations is dependent on a number of practice-specific factors. 

Such factors include the relative risk for physicians, practitioners, and staff as well as the local prevalence of disease and any local recommendations for isolation, limitations on congregation, etc.  The following are suggested methods by which such screening and triage functions may be accomplished with minimal risk of exposure and transmission. 

  1. Modifying Pre-Clinic Visit, Patient Communications
    Pre-clinic visit patient notifications, whether automated or via live phone call should be modified to aid in screening patients for COVID-19 infection or exposure. If an automated message system is utilized, a phone number should be provided to address questions that arise, which may or may not require an in-person visit.  Furthermore, it is inevitable that such a system may result in follow-up calls among those with concerns about specific symptoms of exposures that he/she/they are concerned may reflect COVID-19 infection.  Accordingly, some COVID-19 triage capability is required from all of our practices.

New elements of this message might include the following:

  • Patients that are sick cannot attend their visits and will be turned away if they do so. The most important element in this communication is to indicate that those patients with the symptoms of COVID-19 should not attend their visits.  A specific set of questions should be presented to patients that have upcoming appointments.  The questions seek to establish whether patients have any of the following:
    • Symptoms frequently associated with the infection:
      1. Fever
      2. Cough
      3. Shortness of breath
    • Symptoms less frequently, but occasionally associated with COVID-19 infection:
      1. Nasal congestion or runny nose
      2. Sore throat
      3. Diarrhea
    • Recent contact with anyone with either these symptoms, or someone who has tested positive for COVID-19.
    • Unfortunately, we all recognize these as non-specific symptoms.  Accordingly, those that have any symptoms of feeling as if they have a cold, flu, allergies, etc. should be encouraged to cancel their appointments. 

  • Consider text reminders
    • HIPAA regulations have been relaxed to allow direct text communication.
    • Text reminders might be something akin to, “We are looking forward to seeing you for your appointment. However, if you develop a fever, cough, shortness of breath or cold symptoms, please call before any upcoming appointment.”
    • More thoughts will follow as to how texting upon patient arrival can prevent the hazards of the waiting room.
  • Non-essential visits should be cancelled.
    1. Patients in whom disease activity is stable at an acceptable level should have appointments deferred as attending such visits increases the risk of the patient and office staff becoming infected.
    2. Laboratory monitoring does not necessarily require a face-to-face, in-clinic visit unless a lab draw can only be obtained from within the clinic. Lab results may be delivered by phone or portal, by availability.
    3. Practices may decide to limit routine clinic visits and/or new patient evaluations depending on a patient’s diagnosis. Specifically, those with mild or stable osteoporosis, particularly those already on medication, likely represent a vulnerable population for COVID-19 infection and might be best served by deferring any upcoming visits.  Those with non-disabling osteoarthritis likely fall into the same circumstance.  It is also likely that those with fibromyalgia, although clearly suffering, may not experience a substantial decline in their long-term outcomes as a consequence of a postponed visit, and as such, visits may be deferred.
    4. All patients need a functioning thermometer. This may seem ridiculous, but when we inquire as to whether a patient has had a fever, we are really interested in their measured, not subjective, temperature.  It is not unreasonable to ask our patients to take their temperature to determine if they can attend a clinic visit as the price on Amazon for a mercury thermometer as of 3/17/2020 was $2.00.  In fact, all of us ought to routinely check our temperature before venturing out into the world these days to ensure that we are not preclinically COVID-19 infected and at risk of spreading the virus, but I digress.
  1. Developing a COVID-19 Telephone Triage Plan 
    • The appropriate response for patients that have concerns and/or questions about COVID-19 symptoms and exposures varies tremendously. The goal is not to become an infectious disease expert or a CDC satellite office.  However, we all recognize that Rheumatology patients turn to us in times like these that require understanding that extends beyond our specialty-based knowledge as an expression of their faith, trust, and confidence because they know us, and we listen.  Thus, although you may try to dodge these calls or pawn them off on primary care doctors or others, these calls will still come in.  Accordingly, developing some facility with which to address COVID-19 questions seems wise.
    • Understanding that fielding these calls may rapidly overwhelm our practices, we are attempting to identify an appropriate Virtual Urgent Care option. This would allow practices to dramatically reduce the time spent on calls from patients with concerns about COVID-19 symptoms or exposure by simply diverting them.
    • As you likely have already determined, the CDC has abundant resources for this purpose. Patient triage issues are covered at: https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html.
    • Incidentally, for clinic staff symptoms or exposures, information can be found here:   https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.

Let us know what additional approaches you have implemented.  What else might we recommend?  Does this approach raise any concerns for you? 

The advent of the COVID-19 pandemic has fundamentally changed the practice of Rheumatology. One way that we can face such uncertainty and confront these challenges is band together virtually, by sharing our thoughts and approaches.  Please send your concerns, solutions, thoughts, and novel approaches to info@unitedrheumatology.com.

Stay safe, stay healthy, stay United. 

 

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