How this Kentucky outpatient clinic is readying for the expected spike of COVID-19
First, the vulnerable were separated from the less vulnerable.
Elective procedures at the outpatient White House Clinic in Richmond, including the facility’s dentistry services, were indefinitely suspended, and those health care providers were sent home or reassigned. Then it was staff over age 60, all pregnant women, and anyone immunocompromised — populations at high risk for contracting the novel coronavirus — who were asked to stay away, indefinitely.
At this suburban Central Kentucky clinic, and its sister locations in Berea, Irvine, McKee, Lancaster, Mt. Vernon and Paint Lick, where the turnover rate of staff is low, “that was a large number for us,” CEO Stephanie Moore said. It amounted to roughly a third of all staff.
The Richmond clinic is one of the dozens of health care providers that have adapted their treatment strategies indefinitely as the viral respiratory illness COVID-19 spreads across the state, infecting more than 400 Kentuckians so far and killing nine.
The goal is to diagnose patients who have COVID-19 without them ever setting foot in the clinic, reducing the risk of transmission for employees and other patients.
“We have switched our focus to trying to figure out, how do we keep people out of our office while they’re sick, as opposed to bringing them into our office for care?,” Moore said. In other words, “how can we manage you without asking you to come into our clinic right now?”
The Richmond clinic, like many other hospitals and health care systems, rolled out a new telehealth option in a matter of days as an alternative to in-person visits. This allows providers to assess patients virtually, over the computer, without the risk of transmission.
For those who do still require an in-person visit, a mandatory screening station separating sick patients from well patients was set up just inside the clinic’s front lobby. On Friday, those screeners were two female staff members, clad in protective gear — gloves, gowns, masks and protective glasses. One normally works as a dental assistant and the other in the patient referrals department. “Have you had a cough in the last couple of days?” one asks. “How about shortness of breath or pressure in your chest? Are you running a fever?”
No one who believes they may have COVID-19 and is showing symptoms is allowed in the building. Instead, they’re asked to return to their cars after the mandatory screening and pull around to the side of the clinic to an area designated by yellow cones, where doctors and nurses in full PPE assess them in their car.
“The goal is, if you’re sick [with possible symptoms], we want to keep you from coming into the facility, again to just provide the reassurances to those patients who do need to come in,” Moore said.
‘Platoon system’ care
There’s also been a transformation to what Moore calls the “platoon system.”
The clinics remaining health care providers in Richmond — roughly 60 out of 100 — were divided into two groups: those who would continue to work with patients and those who would remain healthy at home, waiting to be called in. In the coming weeks, that call will likely arrive in one of two ways: once the “surge” of cases Gov. Andy Beshear keeps referencing finally hits, necessitating more trained hands, or when another provider is invariably exposed to the virus. When that happens, a healthy replacement will be needed immediately, while the exposed self-quarantines for two weeks.
“We know there’s going to be a time where we’re really going to see a spike in cases,” Moore said Friday in the clinic.
In her clinic office, taped to the walls, were poster-sized sheets of paper scribbled with dozens of staff names and their roles in the new platoon system. Replacements were noted along with layouts of other White House clinics to visualize the traffic flow of a pilot pharmacy curbside pick-up program — all to limit the number of people actually coming inside the building.
The “worst case scenario is we see a patient early on in this pandemic, and we don’t know that patient is ill, and we have to then send [exposed] staff home to quarantine,” Moore said, leaving the clinic short-staffed at a critical time.
‘Prevent additional staff exposure’
Kentucky Department of Public Health Commissioner Dr. Steven Stack earlier this month likened the imminent COVID-19 surge to an offshore hurricane.
“Think about it this way,” he said in an American Medical Association interview. “It’s like there’s a Category 5 hurricane out to sea, about 7 to 10 days away, and we know it’s going to come, and we know it’s going to hit, but if we take action now, we can take steps to ... ensure people have what they need to survive the onslaught.”
“We have to, very quickly, free up as much capacity in our hospitals as possible in order to ensure, when the numbers of sick people start to increase, that our [medical providers] are fully available to help people who are most in danger,” Stack said.
That’s where Moore sees her team stepping in: to act as the first point of contact for many positive patients who may not be sick enough for hospitalization even though they meet the current threshold to be tested.
So far, seven patients across her clinics have been tested for COVID-19. The few sent to the state lab in Frankfort came back negative, but the rest, being processed by the commercial LabCorp, were still outstanding Friday.
Cortnie Davidson, a certified medical assistant at the Richmond clinic, has administered the only on-site COVID-19 test, called a nasopharyngeal swab, on a patient. The swab — basically a 10-inch-long Q-tip — that’s pushed deep into the nose. Luckily, she said, it came back negative.
But that hasn’t stopped Davidson from taking tremendous precautions, including at home, where she lives with her children and husband, who’s also a police officer.
Davidson is part of the skeleton crew treating only sick patients at the moment, while other providers are treating only well patients. Division of labor is another aspect of the platoon system to “prevent additional staff exposure” and minimize the risk of crossover spread of the disease to another patient, she said.
The first line of defense against that spread is protection equipment of which there is a critical shortage both in the state and the country. The White House clinics replenished some of their supply from the state and federal stockpiles trucked into Lexington and then distributed across the region earlier this month, but they’re still looking for more.
Last week, Moore was FaceTiming with another health care center, “and he was asking if we could trade some of our respirators for gowns, [which] he was running short on,” she said. “I think there’s a lot of bartering going on throughout the state as well.”
Meanwhile, it’s all about conserving, and that means allowing only frontline staff treating patients to use the protective gear, she said. It’s about “looking carefully at where exposure risk is, and where [PPE] can provide the greatest value.”
It’s a hard line to maintain, choosing which staff get to wear this equipment and which don’t, she said. But, “our worst case scenario is we use it inappropriately now, and then when the peak of cases hits, we don’t have what our providers or nursing staff needs.”
‘Career-defining situation’
The possibility of transmitting the virus at home is anxiety-inducing for staff, said Shannon Estes, a certified medical assistant.
Though patient traffic Friday afternoon was unusually slow, Davidson earlier this week saw about 20 sick patients in a day. Most had coughs, and all were worried they had COVID-19. At the end of that workday and all others, when she gets home, she takes her clothes off in the garage before going inside.
“I strip in the garage, and I’m straight to the shower, [with] just the hope that I don’t bring anything home,” she said. Whitney Peek, CMA, and Estes nodded their heads in agreement. They all wore matching shirts that read, “We risk our lives to save y’all’s.”
“Our shoes don’t go in the house,” Estes said.
Peek has an 8-month-old daughter. “I don’t touch her before I shower,” she said.
Many of the providers at the Richmond clinic have considered asking other family members to take their kids because that fear of transmission is too real, they said.
Dr. Alison Moncayo, a pediatrician only treating sick kids right now, dropped her children off with her parents almost two weeks ago, when she started working five days a week instead of three. Since her parents are over the age of 60, visiting even on the weekends is too risky, she and her husband decided.
“We actually realized yesterday it’s the longest we’ve gone without seeing them,” Moncayo said.
The unknown in all of this is “really the challenging part,” Moore said later in her office. It’s not knowing “how long are we going to need people to make this kind of sacrifice. We’re all dealing with something that is a career-defining situation.”
Later that day, Moore was slated to get a call back on LabCorp test results for a patient tested earlier this month whose condition had been worsening. The clinic asked that the testing be expedited.
“We know that we’re going to care for many positive cases,” Moore said, pausing. “But I think there will be something about that first one within the walls of our clinic. It’s going to make people step back, and make it a little bit more real.”
