Healthcare Charlie Foxtrot by Scarlett Doc
Since social distancing interventions have been implemented to limit the spread of COVID-19, many industries have faced significant changes in the way they function. Some businesses have been temporarily shuttered. Others continue to function with work-from-home initiatives. Still others remain open with significant operational changes. While these changes have been implemented with the goal of ‘flattening the curve’ to limit impacts of the virus on our healthcare system, blanket expansion of these interventions into the healthcare system may be causing more harm than good.
Much like the rest of society, the healthcare system has been modified to shift emphasis to essential services, while limiting services deemed nonessential. Many outpatient offices have closed or switched to tele-health visits exclusively, lab and imaging centers have stopped taking non-urgent appointments, and non-emergent surgeries have been cancelled or postponed. As a healthcare worker whose social circle is dominated by other healthcare workers I have been privy to the impacts of these changes on a variety of patients, and the potential downstream effects are concerning.
For example, multiple cancer patients have had their post-chemotherapy tumor resections postponed until after the various ‘shut-down’ directives are lifted. Prompt tumor resection following chemotherapy reduces chance of tumor recurrence and improves long term outcomes. Delaying resection could prolong chemotherapy treatments – which result in immunosuppression in addition to multiple other side effects – and ultimately lead to increased risk of infection, worse outcomes, increased healthcare burden, and increased morbidity and mortality. Patients presenting with lumps and bumps that may be cancer have had diagnostic biopsies postponed – early identification and treatment of cancer is vital to prevent spread of tumors to other organs. For patients being discharged from the hospital after surgery, treatment for life-threatening illness, or psychiatric stabilization, locating appropriate follow up is more complicated now. Many offices are not taking new patients, and those who are often offer only tele-health visits. Close follow-up with monitoring of vital signs and at least a targeted physical exam is important to prevent complications and readmissions.
The patients falling in the uncertain land between routine follow up and emergent care are also encountering difficulty accessing appropriate care. Uncomplicated injuries such as a broken arm or torn ligament can often be managed in person at an outpatient orthopedic or primary care office, and imaging can be done at an outpatient imaging center. In states and counties with stay-at-home orders in place, these outpatient services can only be accessed in person with an order from an emergency physician. As a result, other-wise healthy patients are being diverted to the emergency room, where they are more likely to be exposed to infections such as COVID-19.
If the emergency physician doesn’t place a referral for an orthopedist and imaging, patients are often left in the lurch of delayed care. Non-life-threatening acute injuries, without appropriate and timely follow up can become chronic injuries that require more significant intervention when finally addressed, take longer to heal or heal incompletely, or can become complicated by infection. This translates to increased morbidity, increased mortality, preventable complications and increased healthcare utilization.
For patients who can get in to see a provider for an orthopedic injury, many will require occupational or physical therapy to help restore function and prevent muscle atrophy. Occupational and physical therapists are important not only for patients recovering from broken bones – their interventions can reduce pain and improve function for patients with chronic and soft tissue injuries, stroke and other neurological injuries, and patients recovering from surgery. These types of therapy often require hands-on assessments and use of various tools (weights, resistance bands, balance balls, etc.) that are shared between patients. Due to the high risk of infection and the non-emergent nature of the care, these therapy offices have almost entirely closed across the country. While not immediately apparent, patients who don’t receive timely access to this follow up intervention can suffer from delayed restoration of function, increased morbidity, decline in quality of life, and an overall increased burden on the healthcare system.
While many patients receiving routine follow-up care may find themselves mildly inconvenienced by closed outpatient offices, there is a minority who are disproportionately affected. Many effective medications require regular monitoring of labs to prevent adverse outcomes and help attain and maintain therapeutic levels of medications. Clozaril, for example, requires lab draws as often as once a week. It is an antipsychotic that, while very effective, can cause significant damage to the immune system. Regular lab monitoring and strict reporting requirements have produced a system that closely monitors patients for this severe outcome and forces intervention if it develops. Restrictions have been temporarily lifted to allow patients to fill their scripts without labs, but the system is there for a reason, just like monitoring guidelines for other drugs and illnesses exist for a reason – to prevent negative outcomes and catch problems before they land a patient in the emergency room.
In closing down healthcare indiscriminately, we have created delays in care that is known to reduce negative outcomes down the road. Delays in non-emergent care place patients at risk for increased complications that can result in more office visits, more emergency room visits, decline in quality of life, and increased morbidity and mortality. The appointments and surgeries that are being postponed will still be there when stay-at-home restrictions are lifted, in addition to the routine burden on the system. These delays will catch up to us. The healthcare system moves at a constant, rapid pace, and we just stopped the factory for over a month. A month of follow up appointments. A month of surgeries. A month of therapy appointments. A month of new but non-emergent injuries. A month of labs and imaging. A month of acute complications of chronic illnesses. A month trying to avoid overwhelming our system with one illness. I think we will find when things open again that instead of being overwhelmed with one illness, we will be overwhelmed with all of them.
In addition to delaying care, we are putting healthcare staff out of work. Hospitals and offices can’t afford staff they aren’t using and therefore have been implementing furloughs, mandatory PTO, and letting staff go. Hopefully those nurses, techs, CNAs, doctors, ARNPs, PAs, CRNAs, etc., will still be around when we need them, otherwise facilities will be even less equipped to accommodate the increased demand that will develop when we open again.
In sum, the effects of halting care for over a month will reverberate for years – first in the surge of appointments that will likely exceed non-emergent capacity, then more chronically, with the illnesses that worsened or the increased complications from surgeries, supportive treatments, and diagnostics withheld. I don’t know that the chronic effects will be as marked as the acute, but the longer this shut-down goes on, the worse it will be.
These outcomes could be mitigated if we opened up healthcare prudently. Sure, keep the at-the-door screenings. Continue to limit the number of visitors in the hospital and companions at appointments. But also, take a page from grocery stores and reserve early morning appointments for elderly and immunocompromised patients who are most at risk for infection. Transform our waiting rooms to resemble pediatric waiting rooms with separate areas for patients with possible communicable infections as opposed to patients coming in for routine follow-up care or orthopedic injuries. Where this can’t be done effectively, modify outpatient schedules with specific times for ‘sick’ and ‘well’ visits. Educate patients about appropriate use of masks, gloves, hand-washing, and hand-sanitizer, and make these available in the waiting area and throughout offices. Continue to utilize tele-health visits for appointments that don’t require a physical exam, and employ medical device companies to outfit our patients who require regular monitoring of blood pressure for example with the appropriate equipment to monitor from home and communicate these values with their providers. Put our physical therapists, occupational therapists, lab technicians and imaging technicians back to work, with extra time between appointments to clean equipment properly.
Shutting everything down comes at a future cost, but we also can’t resume business as usual. Many of these operational changes will benefit patients not only in limiting transmission of COVID-19, but also influenza and other communicable diseases that are omnipresent. We should have been doing these things before COVID-19, but we can’t go back, only forward.