March 19, 2020

An update from our Quality Council and Chief Medical Officer:

Our Quality Council met Wednesday night and the following was discussed:

    • Considering further guidance on ‘medically necessary’ care for medical and surgical dermatology, given directives to reduce elective care and office visits
      • Reviewed feedback from providers; varies depending on geographic location, state mandates, type of practice, personal experience
      • Reviewed internal policies shared by numerous institutions
      • Further recommendations from Derm and Mohs societies pending
      • Clinical judgment remains paramount, but QC focused on responsible practice patterns to reduce exposures and maintain PPE supply
    • Unanimous support for augmentation of TeleDermatology platform
      • Recognized how effectively management/IT team identified vendor and preparing for rapid training and deployment
      • More details pending
    • Significant discussion on practical ‘lessons learned’ and best practices by different markets/practices regarding:
      • Maintaining social distancing among patients, staff
      • Communicating with patients about new visitor policy, safety protocols
      • Communicating with referring providers; offer biopsy and Mohs at same time if likely + lesion identified by TeleDerm – reduce visits/exposures
      • Consider developing ‘teams’ of provider/support staff with rotation of days/week to reduce ‘cross-contamination’ and wider quarantines
    • PPE discussion focused on prior QDP guidance and new information regarding exposure risk in health care setting and shortages of PPE for hospital/ICUs
      • Original QDP recommendation was based upon CDC guidance (Table 1 attachment from Monday’s message) for an ideal scenario with no shortages of PPE that shows Low Risk if all Derm providers/staff/triage personnel use mask/glove/eye protection for any PROLONGED PATIENT CONTACT; would prevent 14 day quarantine if patient tests + Covid19
      • QDP Guidance on PPE to be revised given 3 factors:
        • New information; rapidly evolving e.g.
          • Univ Pittsburgh Med Ctr COVID-19 Response Team
          • Many ask “Can I get infected by people who have COVID 19 but have no symptoms?”
          • Answer:
            • This concern naturally causes fear about giving care, wondering if people who seem well receiving care in your area can hurt you (or others). This creates desires to avoid caring for anyone.
            • While it is possible to contract COVID 19 from someone infected without symptoms, the risk is very lowoutside close/prolonged contact. Infected patients who feel well have low viral shedding and for a short time. Unless very close UNPROTECTED contact happens, you are not likely to get infected.
            • CDC recognizes this reality, and data reported on asymptomatic transmission aligns with this – most transfer is with very close or ongoing contact.
            • So, in routine care – absent close physical contact, or mouth/throat contact or without consistent contact – you have a very small risk of being infected from patients without symptoms. If you wash your hands and follow other hygiene guidelines, your risk is even smaller. N95 masks don’t add protection.
        • Community standards
          • Health care providers in other clinic-based specialties are not using PPE for routine medical care; procedures always require standard universal precautions
          • Plus, the intensive screening that is occurring further reduces risks to health care workers by identifying higher risk patients and sending them home or to PCP/testing.
        • PPE shortages for front-line hospital and ICU staff; QDP needs responsible policy revision to assist medical community
          • Front desk screeners use mask/eye protection given unknown risks (patient communications prior to visits reduce these risks by discouraging any sick patients)
          • Surgical Dermatology/Mohs utilizes PPE / Univ Prec
          • Standard Medical Dermatology care utilizes PPE / Univ Prec only for procedures; not routine Derm visits
          • Only provider needs PPE for procedures like biopsy, unless nurse/MA actively assisting and exposed; reduces waste
          • 1 mask used for entire day; unless soiled/contaminated
            • Consider using multiple days if possible
            • Use and remove PPE properly – never touch facemask; remove by straps only; folded inward; gloves for procedures but NO gloves worn outside of procedure rooms (false security and better to cleanse hands directly/frequently)
            • NEJM article shows viral load negligible s/p 3 days
              • Consider placing mask in ziplock each day x 3 day and then recycling masks if not soiled
            • Shared other strategies to reduce exposure risks; individualized
              • “Clean in; Clean out” = hand sanitize before/after visit
              • Limit visits to single entry/exit and minimize to one assistant per patient/encounter
              • Mohs patients maintained in single room throughout day
              • Enforce Limits on Visitors (0 or 1) – encourage drop off/pick up and phone communication to reduce contacts

A message from our CMO:

    • During times of stress, we all (myself included) tend to revert to prioritizing our own most basic physiologic and safety needs. Maslow famously developed the chart below outlining his ‘hierarchy of needs’. I am humbled and inspired by the QualDerm leadership that I witness daily, who are tirelessly working on strategies to help satisfy these needs and move us higher up the pyramid. I am also so impressed by the professionalism and dedication to quality and safety of every single employee that I encounter, in person or by phone or email.
    • This coronavirus crisis is naturally creating high anxiety and concern, particularly for health care workers and their families most intimately connected to it. During and following any traumatic situation, we see rising rates of anxiety, depression and post-traumatic stress. Please support one another! Ask each other how you’re feeling. Be kind. What galvanizes soldiers in the trenches is their ‘brotherhood/sisterhood’ mentality of taking care of each other and leaving “no man behind”. We truly need to help identify coworkers who are struggling and offer encouragement and refer them to the QDP resources at our disposal to help cope with their challenges. Ultimately, we will be a stronger workforce and company when we weather this storm.
    • We recognize the need for frequent communications since circumstances are so rapidly changing, almost by the hour, and we are committed to providing regular updates.


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