AAOA COVID-19 Member Alert

First and foremost, we hope you are all safe and healthy. These are not easy times — with so many questions and no real answers.

Several of you have reached out with your questions. While we wish we could offer a onesize fits all answer, it is just not possible. Many of you are confined by choices defined by your health system, employer, or state. Many are confined by your practice structure and physical space.

We do want to share resources as we become aware of them. Below are two from over the weekend. At the end, we list other resources.

CMS Telemedicine Tool Kit Link
https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf​

While this tool kit is focused on Medicare and Medicaid, it seems private payers are also encouraging telehealth as an option. It may require some internal inquiries to confirm what is allowed and the process for each payer with whom you participate. Like many things, this too may be very dynamic and evolving.

AMA Quick Guide to Telemedicine
https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice

Also, early last week, the Office for Civil Rights (OCR) notified covered entities, including physicians, that it would exercise enforcement discretion for physicians using telehealth. OCR has issued new FAQs on this notice, which we wanted to bring to your attention. Additionally, SAMHSA has issued an FAQ on 42 CFR Part 2, seeking to ensure that substance use disorder treatment services are uninterrupted during this public health emergency.

ENT Today Link to Stanford Statement
https://www.enttoday.org/article/otolaryngologists-may-contract-covid-19-during-surgery/

Leaders in rhinology have issued the warning above in ENT Today regarding the potential for increased risk for otolaryngologists during nose and airway procedures. While some of this is anecdotal evidence, there is some concern due to high viral shedding in the nasal cavity.

NY Times Article on Link to Symptoms of Smell and Taste
https://www.nytimes.com/2020/03/22/health/coronavirus-symptoms-smell-taste.html

“Doctor groups are recommending testing and isolation for people who lose their ability to smell and taste, even if they have no other symptoms….” NY Times article noting loss of smell could be an indicator of coronavirus. Given this potential link, anosmia may be an initial presenting symptom in an otherwise asymptomatic patient and, as a results, necessary precautions should be taken to avoid unnecessary endoscopy and related risks.

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In talking with members, we have heard about several approaches — from reducing care to only acute or limiting to allergy to patients on maintenance with injections spread out to somewhere within the JCAAI Guidelines of 2-6 weeks to closing clinics for 2 weeks and laying off staff temporarily. There is concern about patient exposure; There is concern about staff exposure; There is concern about medical supplies; And the list goes on.

Because each practice is unique in how they are addressing COVID, we are sharing some of what our leadership from our Socioeconomic Committee is doing.

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Here’s how my practice is dealing with the allergy patients:

For new patients, we are still offering in vitro & in vivo allergy testing, but we are not starting these patients on immunotherapy for the time being. For our established allergy subcutaneous immunotherapy patients, these patients have the option to continue their immunotherapy with home immunotherapy, whether it means continuing their maintenance dose or a much slower escalation period (for those not already on maintenance).

~ Alpen

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Albany ENT & Allergy Services has shared the following message with its patients. Albany ENT & Allergy is a large group with a large immunotherapy practice. It should be noted, its physical layout and allergy clinic is separate from the rest of the clinic too, facilitating unique allergy patient workflow and throughput. One thing to note, Albany ENT reached out to all its patients directly — immunotherapy and others. In addition, all the social media outlets are kept up-to-date to help keep their patient community informed. Communication is key to help keep everyone informed and maintain all the safety precautions.

1. Most allergy patients will continue their current treatment regimen and current dosing, without interruption.
2. Patients starting subcutaneous immunotherapy (allergy shots or SCIT), or have a stronger vial to be tested, will delay initiation of treatment or testing, in order to avoid the 30-minute wait time required for weekly dose escalation.
3. Patients currently undergoing dose escalation for allergy shots (SCIT) will continue treatment at the strength of the last dose given, without further escalation until further notice.
4. For patients on sublingual immunotherapy (oral allergy drops taken under the tongue or SLIT), initiation of treatment and dose escalation will continue. These patients will be kept in the same treatment room during the 30 minutes to limit contact/exposure to other patients.

*This process will allow us to continue administering immunotherapy safely during this seasonal transition without significantly impacting treatment outcomes.

For more information please visit our website https://albanyentandallergy.com/allergy-immunotherapy-covid-19/

ALSO: considering plan for providing “drive-through” maintenance allergy immunotherapy, if necessary.

~ Gavin

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We have cancelled immunotherapy until April 3rd. Appointments have been decreased to urgent only. Additionally, we’ve been isolating shot patients to wait 30 min in their own room.

~ Doug

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ASC closed. Only emergency cases in the hospital. Office has limited hours and staff with highly screened patients that might otherwise burden the ER. Allergy shots stretched to 2-3 weeks and trying to limit access for those patients. Trying to keep biologics on schedule. Rolling out telemedicine platform next week.

~ Chris

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Miami is shut down. Very limited new patients. Allergy shots are not available until further notice. Biologics patients keeping on schedule.

~ Paul

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Similar to what others have reported, no new patients, emergency cases only, and keeping shots stretched to a 2-3 week schedule.

~ Ayesha

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My hospital has suspended all elective procedures in the OR for 30 days, and we have reduced clinical activities in the office. We are requesting existing elderly or other patients at increased risk of severe infection to either discuss their issues by phone, or delay their appointment. We are not set up for telemedicine, working by telephone only. We are logging these patients; perhaps telephone-only visits may be reimbursed in the future. We are screening patients upon arrival, which may still risk exposure if afebrile or asymptomatic. We have continued immunotherapy for asymptomatic patients thus far, however, that may change this week. We have not had firm guidance from my institution with respect to outpatient clinic management. We have a severe shortage of PPE, and very few tests county-wide. I think we all feel like we are shooting at a rapidly moving target, as these are truly unprecedented times.

~ Melissa

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For those wanting to continue IT we are working on the following:

We are stopping anyone under 6 months of build up and will restart after the shelter in place order ends.

We are stopping anyone at their current build up dose if they are between 6 months and maintenance.

Then we are moving everyone to home immunotherapy injections.

~ Keith

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I’m doing similar things as you have all mentioned but now have some new ideas. I have instituted a two-team approach in my office where we divided all doctors/mid levels and staff to see patients on alternating days. That way if one team is exposed and needs to be quarantined for 14 days, the other team can keep seeing patients and not shut down the clinic. 

~ Kevin

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I’m having asthmatic patients get peak flow meters and chart their flow.  They are instructed to call in when flows deteriorate. Rotating skeleton 3 person front office staff teams run the office when a doctor is there, and answer phones when they are not.  Nearly everything is being done from home, on line.

Labs are still doing in vitro tests, so we can still get allergy information in important cases like stinging insects and anaphylactic foods.

I am calling every allergy patient who has an appointment cancelled or postponed, and doing a virtual visit to be sure they are stable, meds are refilled, and to give coronavirus safety info.  These are billable for Medicare/Medicaid, and we have yet to find out about commercial payers, but are trying.  It is taking me more time than usual, because now I do not have dictation service available!

~ Bruce

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We know you have questions and concerns, and we are doing our best to monitor the situation, which is changing day by day. At any time, please feel free to contact [email protected] with questions or to share what you are doing.

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Other resources:

AMA
https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians

AAOHNS
https://www.entnet.org/content/coronavirus-disease-2019-resources

AAAAI 
https://education.aaaai.org/resources-for-a-i-clinicians/covid-19

ACAAI 
https://acaai.org/news/important-information-about-covid-19-those-asthma

New Yorker 
https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers

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