A Physician-Patient Isolation Wall as a Solution for Continuing Clinical Services in the setting of the COVID-19 Pandemic. April 4, 2020
TDLR;
Facing mounting pressure (financial, quality of care, other), outpatient clinics need to re-open in the coming months. Current triage strategies (PPE for sick patients only) does not account for asymptomatic or very mildly symptomatic transmission. Until we reach a pandemic end-point (herd immunity, vaccine, effective treatment), clinics should consider droplet-protection PPE for all patient visits - sick or not. Then the problem is - 1. not enough PPE, and 2. 20+ don/doff everyday for busy clinicians has very high user error rate.
Solution? A plexiglass examination wall in each clinic to be used with every patient visit - droplet precaution is the default (low user error) and reduce need for PPE (only procedures or special tests). The cost is made up in less than 1 day of patient visits. Clean per protocol (EPA-recommended bleach or hydrogen peroxide - spray and wipe surfaces).
Current comments re coronavirus -
The consensus view is that coronavirus is just starting out in the US. Looking forward, the situation may look like Spain and Italy (high transmission, high morbidity & mortality overwhelming the healthcare system) or like South Korea and Taiwan (low transmission, healthcare system able to support the active acute cases) or most likely somewhere in between with regional variations between states, city / rural, and demographics.
The current crisis in NYC may be a sign of what the rest of the country can expect in the coming months.
The best estimation of mortality is about 1% currently. Survivors of severe coronavirus complications appears to have residual persistent lung damage – long-term sequelae is unknown.
The rosier possible end-points of the pandemic may be an effective vaccine and/or eventual natural herd-immunity and/or the virus mutates to be something more benign – this may be >12 months out. In between, there may be waves of resurgent outbreaks around the world.
As we know, the amount of PPE is critically low, but production will likely catch up with need over time.
Coronavirus is currently classified as requiring “droplet precautions” - which means transmission is by relatively large droplets that would drop out of the air within a 6ft perimeter. To take droplet precautions is to wear a mask (such as a surgical mask), wear a gown, and wear eye-covering. The CDC recommends aerosol precautions (N95 mask and negative pressure rooms) for procedures such a nebulizer treatment, intubation, etc. In reality, coronavirus transmission is somewhere on the spectrum between droplet and aerosol.
One of the most dangerous aspect of coronavirus is that studies are consistently showing asymptomatic but infective cases of coronavirus – between 20-50%. In combination with inadequate supply of PPE, this has led to increasing numbers of physician and nurses contracting and dying from coronavirus. This, in turn, puts their patients at risk as well.
What’s going on with outpatient clinics currently -
The current role of outpatient primary physicians in this pandemic is to evaluate / treat / triage respiratory complaints and continue routine management of non-coronavirus issues, both acute and chronic. To promote social distancing, almost all clinics have moved to tele-medicine (with or without video).
Some patients still need to be seen in clinic because the complaint cannot be safely evaluated over the phone or lab tests are needed. For the patients that are seen in person – the current common approach is for “sick” / respiratory patients to be seen with droplet precautions / PPE (eyes, gown, gloves, mask) and non-sick are seen without PPE (however some clinics are using surgical masks for all patients). This approach does not address the question of asymptomatic but infectious cases – the infected may be the patient or the clinician.
Most clinics have very limited amount of PPE. Available PPE is directed towards the hospital.
Telemedicine works better for low risk, young healthy patients. Older patients – possibly with less access to modern technologies, hearing & vision loss, cognitive decline, and over-all less resources and support are more difficult to safely care for via telemedicine. Telemedicine does not work well for complaints such as dizziness, chest pain, skin infection, musculoskeletal pains that need vitals and physical exam. A respiratory complaint of shortness of breath (such as in coronavirus) is very hard evaluate via phone. Telemedicine does not allow for labs, ECG, spirometry, vitals, etc.
What will probably happen in next 6-12 months -
In the first 1-2 months ahead, the most likely scenario is that clinics will continue telemedicine and allow a very limited number of in-person appointments. Chronic issues that are stable will likely stay stable. With each tele-med visit, clinicians will need to figure out how to balance the risk of a physical appointment vs the danger of a telemedicine mis-diagnosis / management recommendations. To err on the side of safety, more patients get referred to ER to rule-out something severe. To keep patients at home and treat over the phone, dangerous cases may get missed.
Beyond the next couple months, as a healthcare system, clinics may get over the shock of the pandemic and become more lax.The longer we go without in-person appointments and monitoring labs, the greater the danger of adverse events - this is especially true for geriatric and complex patients. Chronic issues that have been stable now may change. From a financial perspective, compensation for in-person appointments are also much better. Clinics have been on pause and we already see physicians getting pay-cuts and losing their jobs. With this pressure of maintaining high quality care and financial solvency, clinics likely will take greater exposure risk – gradually seeing more patients in-person with or without adequate PPE. If this happens, they may become nodes for transmission – which will be especially dangerous as the more complex and elderly patients return to catch up on routine but important services.
CMS and insurance companies just recently (past 1-2 weeks) revised billing rules to allow for better compensation for telemedicine visits. This will help keep clinics afloat a bit, but will not match the baseline since profitable elective procedures will still be on hold and billing for higher level eval/management services are still not allowed. Clinics will still struggle to stay open.
What should happen ...
In the near term, primary care clinics should, with full droplet transmission precautions, operate at maximum capacity including in-person visits to keep patients out of the ER. Clinics can manage and triage acute respiratory possible coronavirus complaints as well as non-respiratory complaints. Non-acute and stable chronic issues should stay home or be managed via telemedicine.
For ALL in-person patient visits, whether sick or not, in the short-term and until we reach an end-point of the pandemic, outpatient clinics ideally should use full droplet precautions – consistently wearing gloves, gown, mask, and face-shield for every visit.
… but likely won’t.
There is not enough PPE allow clinics to operate at maximum capacity. That’s not likely to change in the short-term. We will see more misdiagnosis and adverse events due to reliance on telemedicine. Will see more referrals to ER also – “just in case”.
Over time, the production of PPE should catch up with need. However, to use disposable PPE at every visit is not optimal. A clinic will go through 20-40 sets per clinician per day. It is a massive amount of waste and financial drain. Also, to put on and take off all those sets every day will test compliance and invite user error from a busy clinician and staff.
A solution?
The most elegant solution I can think of is for examination rooms to provide built-in droplet protection. This would minimize waste and cost, minimize user error and non-compliance, and provide a persistent solution until an end-point is achieved.
I propose that each primary care clinic should install an isolation wall in one or two examination rooms. All (sick or not) patients that need in-person appointments would be seen in this room. Continue telemedicine for everything else.
The Physician-Patient Isolation wall:
The PPIW is simply a structure of three acrylic panels held together with an aluminum frame. It is lightweight, self-standing and on wheels for easy mobility and flexible arrangement. The center wall has an extended-length stethoscope passing through it and a set of dexterous 15mil tear-proof neoprene gloves.
All of the patient-facing “interior” side of the wall is sufficiently sealed and smooth enough to facilitate easy cleaning/sanitation between each session without requiring frequent cleaning of the physician’s side. Though it is highly advisable that the physician wear a reusable facemask at the same time, for extra safety. The majority of a standard physical exam should be able to be completed through the wall without additional PPE.
Currently, the height is 7ft tall the width 10ft and the depth 3ft; but all dimensions can be modified.
It can be taken apart and put back together in about 1-1.5 hour for transport or storage.
The cost to build and install each wall is potentially under $1000 given a fabricator with sufficient equipment, labor and suppliers. If all the supplies are in available, it should take less than 5 days from order to installation. The clinician can recoup that investment easily with just about 10 additional patient visits.
The current model of the wall provides protection from droplet transmission. To further mitigate the risk of aerosol transmission, a suitable ventilation module can be attached (in development) to mimic a negative pressure environment.
After each patient visit, the room and wall is sprayed and wiped down using EPA-recommended solution (simple hydrogen peroxide or bleach mix). This cleaning should be happening after each visit, wall or not. Actually, it is easier with a wall since there is a less area overall and there is a flat surface rather than a room full of furniture.
The wall does not allow for all examinations – clinics still need occasional PPE for procedures, ECGs, spirometry and so on. Depending on individual policy, clinics may or may not require PPE to clean the room after each visit. Even if PPE is required to clean the room, it’s probably safe to re-use 1 set for the day.
The choice of clear acrylic for the walls has several benefits over most alternatives: it is non-porous, chemically resistant, relatively lightweight and rigid, easy to cut, sanitary (and easy to sanitize), clear and because it is clear does not block light which would require supplemental lighting.
The version 2 design is already being developed to make it feasible for simplified fabrication and distribution. We have strong reason to believe that this may be done through the national sign shop industry that has a presence across all parts of the country and with exactly the machinery and supply infrastructure need to produce the necessary parts.
I’ve spoken with local community physicians about these concerns and this idea of the isolation wall. The uptake has been lukewarm. With what we know so far about coronavirus, the reasoning as above seems solid to me. The cost of adoption is relatively low and the benefit is very high. We physicians as a group are conservative minded – first do no harm, follow the guidelines, minimize risk for patients and ourselves.
I think, for this shift in routine patient care, we need recommendations from medical and political leadership and a decreased threshold for adopting the policy of full droplet precautions for every patient visit – whether through this PPIW or another solution.
EL 4/4/2020