As the COVID-19 pandemic continues to spread across the United States, several members of the Ob.Gyn. News Editorial Advisory Board shared their experiences.
Catherine Cansino, MD, MPH, who is an associate clinical professor in the department of obstetrics and gynecology at the University of California, Davis, discussed the changes COVID-19 has had on local and regional practice in Sacramento and northern California.
There has been a dramatic increase in telehealth, using video, phone, and apps such as Zoom. Although ob.gyns. at the university are limiting outpatient appointments to essential visits only, we are continuing to offer telehealth to a few nonessential visits. This will be readdressed when the COVID-19 cases peak, Dr. Cansino said.
All patients admitted to labor & delivery undergo COVID-19 testing regardless of symptoms. For patients in the clinic who are expected to be induced or scheduled for cesarean delivery, we are screening them within 72 hours before admission.
In gynecology, only essential or urgent surgeries at UC Davis are being performed and include indications such as cancer, serious benign conditions unresponsive to conservative treatment (e.g., tubo-ovarian abscess, large symptomatic adnexal mass), and pregnancy termination. We are preserving access to abortion and reproductive health services since these are essential services.
We limit the number of providers involved in direct contact with inpatients to one or two, including a physician, nurse, and/or resident, Dr. Cansino said in an interview. Based on recent Liaison Committee on Medical Education policies related to concerns about educational experience during the pandemic, no medical students are allowed at the hospital at present. We also severely restrict the number of visitors in the inpatient and outpatient settings, including only two attendants (partner, doula, and such) during labor and delivery, and consider the impact on patients’ well-being when we restrict their visitors.
We are following University of California guidelines regarding face mask use, which have been in evolution over the last month. Face masks are used for patients and the health care providers primarily when patients either have known COVID-19 infection or are considered as patients under investigation or if the employee had a high-risk exposure. The use of face masks is becoming more permissive, rather than mandatory, to conserve personal protective equipment (PPE) for when the surge arrives.
Education is ongoing about caring for our families and ourselves if we get infected and need to isolate within our own homes. The department and health system is trying to balance the challenges of urgent patient care needs against the wellness concerns for the faculty, staff, and residents. Many physicians are also struggling with childcare problems, which add to our personal stress. There is anxiety among many physicians about exposure to asymptomatic carriers, including themselves, patients, and their families, Dr. Cansino said.
David Forstein, DO, dean and professor of obstetrics and gynecology at Touro College of Osteopathic Medicine, New York, said in an interview that the COVID-19 pandemic has “totally disrupted medical education. At almost all medical schools, didactics have moved completely online – ZOOM sessions abound, but labs become demonstrations, if at all, during the preclinical years. The clinical years have been put on hold, as well as student rotations suspended, out of caution for the students because hospitals needed to conserve PPE for the essential personnel and because administrators knew there would be less time for teaching. After initially requesting a pause, many hospitals now are asking students to come back because so many physicians, nurses, and residents have become ill with COVID-19 and either are quarantined or are patients in the hospital themselves.
“There has been a state-by-state call to consider graduating health professions students early, and press them into service, before their residencies actually begin. Some locations are looking for these new graduates to volunteer; some are willing to pay them a resident’s salary level. Medical schools are auditing their student records now to see which students would qualify to graduate early,” Dr. Forstein noted.
David M. Jaspan, DO, chairman of the department of obstetrics and gynecology at the Einstein Health Care Network in Philadelphia, described in an email interview how COVID-19 has changed practice.
To minimize the number of providers on the front line, we have developed a Monday to Friday rotating schedule of three teams of five members, he explained. There will be a hospital-based team, an office-based team, and a telehealth-based team who will provide their services from home. On-call responsibilities remain the same.
The hospital team, working 7 a.m. to 5 p.m., will rotate through assignments each day:
- One person will cover labor and delivery.
- One person will cover triage and help on labor and delivery.
- One person will be assigned to the resident office.
- One person will be assigned to cover the team of the post call attending (Sunday through Thursday call).
- One person will be assigned to gynecology coverage, consults, and postpartum rounds.
To further minimize the patient interactions, when possible, each patient should be seen by the attending physician with the resident. This is a change from usual practice, where the patient is first seen by the resident, who reports back to the attending, and then both physicians see the patient together.
The network’s offices now open from 9 a.m. (many offices had been offering early-morning hours starting at 7 a.m.), and the physicians and advanced practice providers will work through the last scheduled patient appointment, Dr. Jaspan explained. “The office-based team will preferentially see in-person visits.”
Several offices have been closed so that ob.gyns. and staff can be reassigned to telehealth. The remaining five offices generally have one attending physician and one advanced practice provider.
The remaining team of ob.gyns. provides telehealth with the help of staff members. This involves an initial call to the patient by staff letting them know the doctor will be calling, checking them in, verifying insurance, and collecting payment, followed by the actual telehealth visit. If follow-up is needed, the staff member schedules the follow-up.
Dr. Jaspan called the new approach to prenatal care because of COVID-19 a “cataclysmic change in how we care for our patients. We have decided to further limit our obstetrical in-person visits. It is our feeling that these changes will enable patients to remain outside of the office and in the safety of their homes, provide appropriate social distancing, and diminish potential exposures to the office staff providers and patients.”
In-person visits will occur at: the initial visit, between 24 and 28 weeks, at 32 weeks, and at 36 or 37 weeks; if the patient at 36/37 has a blood pressure cuff, they will not have additional scheduled in-patient visits. We have partnered with the insurance companies to provide more than 88% of obstetrical patients with home blood pressure cuffs.
Obstetrical visits via telehealth will continue at our standard intervals: monthly until 26 weeks; twice monthly during 26-36 weeks; and weekly from 37 weeks to delivery. These visits should use a video component such as Zoom, Doxy.me, or FaceTime.
“If the patient has concerns or problems, we will see them at any time. However, the new standard will be telehealth visits and the exception will be the in-person visit,” Dr. Jaspan said.
In addition, we have worked our division of maternal-fetal medicine to adjust the antenatal testing schedules, and we have curtailed the frequency of ultrasound, he noted.
He emphasized the importance of documenting telehealth interactions with obstetrical patients, in addition to “providing adequate teaching and education for patients regarding kick counts to ensure fetal well-being.” It also is key to “properly document conversations with patients regarding bleeding, rupture of membranes, fetal movement, headache, visual changes, fevers, cough, nausea and vomiting, diarrhea, fatigue, muscle aches, etc.”
The residents’ schedule also has been modified to diminish their exposure. Within our new paradigm, we have scheduled video conferences to enable our program to maintain our commitment to academics.
It is imperative that we keep our patients safe, and it is critical to protect our staff members. Those who provide women’s health cannot be replaced by other nurses or physicians.
Mark P. Trolice, MD, is director of Fertility CARE: the IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He related in an email interview that, on March 17, 2020, the American Society for Reproductive Medicine (ASRM) releasedPatient Management and Clinical During the Coronavirus (COVID-19) Pandemic.” This document serves as guidance on fertility care during the current crisis. Specifically, the recommendations include the following:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations, in vitro fertilization including retrievals and frozen embryo transfers, and nonurgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Continue to care for patients who are currently “in cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and nonurgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
As a member of ASRM for more than 2 decades and a participant of several of their committees, my practice immediately ceased treatment cycles to comply with this guidance.
Then on March 20, 2020, the Florida governor’swas released, stating, “All hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices in the State of Florida are prohibited from providing any medically unnecessary, nonurgent or nonemergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.”
As a result, my practice has been limited to telemedicine consultations. While the ASRM guidance and the gubernatorial executive order pose a significant financial hardship on my center and all applicable medical clinics in my state, resulting in expected layoffs, salary reductions, and requests for government stimulus loans, the greater good takes priority and we pray for all the victims of this devastating pandemic.
The governor’s current executive order is set to expire on May 9, 2020, unless it is extended.
ASRM released anof their guidance on March 30, 2020, offering no change from their prior recommendations. The organization plans to reevaluate the guidance at 2-week intervals.
Sangeeta Sinha, MD, an ob.gyn. in private practice at Stone Springs Hospital Center, Dulles, Va. said in an interview, “COVID 19 has put fear in all aspects of our daily activities which we are attempting to cope with.”
She related several changes made to her office and hospital environments. “In our office, we are now wearing a mask at all times, gloves to examine every patient. We have staggered physicians in the office to take televisits and in-office patients. We are screening all new patients on the phone to determine if they are sick, have traveled to high-risk, hot spot areas of the country, or have had contact with someone who tested positive for COVID-19. We are only seeing our pregnant women and have also pushed out their return appointments to 4 weeks if possible. There are several staff who are not working due to fear or are in self quarantine so we have shortage of staff in the office. At the hospital as well we are wearing a mask at all times, using personal protective equipment for deliveries and C-sections.
“We have had several scares, including a new transfer of an 18-year-old pregnant patient at 30 weeks with cough and sore throat, who later reported that her roommate is very sick and he works with someone who has tested positive for COVID-19. Thankfully she is healthy and well. We learned several lessons from this one.”