Caring for Patients during the Coronavirus Pandemic
COVID-19 is a rapidly evolving situation. In this episode of Butts & Guts, Conor Delaney, MD - Cleveland Clinic's Chairman of the Digestive Disease & Surgery Institute - joins to discuss patient care and surgical procedures during this pandemic. Topics include the steps Cleveland Clinic is taking to ensure our hospitals are safe for patients and caregivers, as well as the future of medical treatment in a post-Coronavirus world.
Caring for Patients during the Coronavirus Pandemic
Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
Hi, again, everybody. And welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're going to bring you a special episode talking about patient care during the coronavirus pandemic and more specifically surgery, as well as the future of healthcare and living in this post coronavirus world. I'm very pleased to have Dr. Conor Delaney, who's the chairman of the Digestive Disease and Surgery Institute at the Cleveland Clinic here, and Conor, You've been a guest on before. Welcome back to Butts & Guts.
Conor Delaney: Thanks for having me, Scott. Pleasure to be here.
Scott Steele: For those of you who have not heard your past interview, so if you could very quickly give a little bit of a background about yourself before we dive right into coronavirus.
Conor Delaney: Okay. So I'm a colorectal surgeon by training and I've been chairman of Digestive Disease & Surgery Institute at Cleveland Clinic for the last five, almost six years. And that's obviously gastroenterology, hepatology, colorectal surgery, and all the surgical sub-disciplines from transplant to trauma to other things. I write a little bit, I operate a little bit and work with a great group of colleagues here at the clinic, including yourself, Scott. So thanks again.
Scott Steele: So Conor, I think we can all understand that coronavirus has absolutely disrupted pretty much everybody's lives, everybody who's listening here. And we're living in very uncertain and scary times for a lot of people. And I know I speak on behalf of all of us here at the Cleveland Clinic who would like to thank all of the listeners who are working both in healthcare and just within their daily jobs and in their communities trying to help those others in need.
And so the background to today is, as the COVID-19 health crisis evolves, here at the Cleveland Clinic one of our top priorities is, and our top priority has always been patient care, and remains in terms of caring for our patients in the safest way possible, as well as protecting our caregivers. And so, again, Conor, you're here with me today and we're going to discuss a little bit about what we're doing here to help keep the patients safe and help keep our caregivers safe to begin with. So can you give us just a little bit of a high-level overview of COVID-19 for the listeners out there? I know there's a lot of different resources out there, but let's start there.
Conor Delaney: So rather than talking about the virus or clinical manifestations, maybe I'll just start with some of the initial rapid changes, because it seems like years, but it's just in a few weeks really that this has evolved in healthcare. And so initially, obviously, we saw all the reports from China and then we saw reports from Europe. And what was clear about this was, this was becoming a pandemic and this was growing exponentially. And so a lot of healthcare organizations including here at Cleveland Clinic, we started to plan for that very carefully. And that was things like storing personal protective equipment, so PPE, and looking at supply chain and thinking of processes for patients and safety and care and sterility and temperature checks. And so we evolved a lot of those processes very quickly. We put an incident command together on multiple operations teams, and then we also had a strong modeling team.
So a really important part of these evolving disasters and managing them is how you try and predict the future. And so obviously everyone's seeing all the different curves that have been published around incidents of coronavirus and percentage of people getting hospitalized and needing ICU and other things. Well, we've used that data very carefully to try and predict what our needs would be in healthcare. And that's allowed us to manage things very carefully, and as you say, look after our patients, look after our caregivers. And more importantly now, as we move into the recovery phase, define how we're going to practice in the future.
Scott Steele: So Conor, I want to touch on a couple of different things, but one of the first things I want to... I put myself in a situation that I am a patient or potential patient that's out there. A few top-level questions, if you will. First of all, understanding that depending on when our listeners listen to this things may rapidly change as we've all seen over the past several weeks and months, what type of procedures are patients able to come in for?
Conor Delaney: So many states, and I'll give Ohio as an example, came out with government recommendations to defer non-essential surgery. And so non-essential surgery really depends on your perspective, right? If you're a patient with severe knee pain that's limiting your ability to move, it seems pretty essential. But largely, most States and organizations came down onto restrictions of surgery that was non-essential meaning non-emergent. So bowel obstruction, bleeding, and then also putting in that category cancer and things that were symptomatic. So the governor in Ohio came out with a list of things that were emergent based on that, or based on severity of symptoms or based on loss of organ dysfunction.
And so what happened rapidly was hospitals scaled back the care they were providing to patients and for this call, perhaps particularly the surgery they were providing to patients, for two primary reasons. One was to build a buffer and capabilities to look after the potential surge in COVID patients, meaning beds in ICU. And the other was to protect personal protective equipment because a lot of facilities really didn't have a lot of days on hand of PPE. And so A, they didn't have great stores, and B, our ability to get resupplied wasn't known. So the perspective on what gets deferred or canceled is different depending on whether you're the patient or provider, but it was done in a way to try and maximize safety, deal with the things that were necessary, while also looking after health care organizations so that we could provide care to the patients who really needed it.
Scott Steele: So let's say that I fall into the category where one of those procedures or surgeries is able to be done. So what is the Cleveland Clinic, or what have you done or are you planning on doing in order to keep patients safe? I know a lot of patients out there, they're a little bit worried about even going outside of their houses, much less going into a hospital for a procedure.
Conor Delaney: Yeah. So I think that's really important, Scott, and I'll answer it in two ways. First I'll talk generally, and then I'll talk specifically about the Cleveland Clinic. So generally I think providers and caregivers are afraid of picking up the disease, and patients are afraid both of getting it at home and of getting it if they come in for healthcare. And we can see that because if you look at the incidence of certain conditions... And there was a recent report around acute myocardial infarction, that you wouldn't expect to be changed by a viral respiratory pandemic, and the rate was down 38%. And I think if you look at acute care surgery programs, you see their incidence of people coming in with appendicitis and other things seems to be down. That's because patients are just afraid to come into hospital.
So the good news is that I think there's fairly convincing evidence, and certainly here at Cleveland Clinic, that hospitals are extremely safe. If you look at the incidence of coronavirus in our 66,000 caregivers, it's extremely low, lower than the surrounding population, and this is a safe place to come. And I think hospitals have done a good job nationally of coming up with the right protocols to keep patients safe. So I think it's safe for patients to come in. There's temperature checks, there's masks now commonly being used, which are basically good cough etiquette and wearing a mask stops you giving something to somebody else. So it's group protection, so it's a safe place for patients to come into. And I think we've got great structure around personal protective equipment, what should be used in what situations to keep caregivers safe, whether it's an aerosolizing procedure or a non-aerosolizing procedure. So all that's been set up.
And then the final big chain that's evolving is testing. Testing is becoming more common, and I'm talking about PCR-based testing for the virus, as opposed to antibody testing, which is a whole separate discussion. So PCR testing is becoming more accessible and institutions are rapidly going to evolve towards testing patients before surgery, particularly major surgery. And that's what we're doing here. We're testing. And we're bringing in a goal of mandatory testing people before surgery and surgical procedures, and that allows us to do a couple of things.
First is standardize the processes and the way we look after patients. Second is give our caregivers more comfort in knowing that they're not going to unsuspectingly be looking after a patient who's pre-symptomatic. And third, and perhaps one of the important things as well at the moment, is know that a patient isn't pre-symptomatic who's having major surgery, because just think about somebody who has a pancreatectomy or a proctectomy or whatever, but major cavity surgery, and on day two or day three post-op they get a pneumonia. And if that's a COVID-related pneumonia, we know how severe they can be and in somebody who's post-op it could be catastrophic potentially. So testing is going to change it. So we're starting to operate on cases. We're expanding within the governor's criteria the patients we operate on with symptoms. And as of today, being May 1st 2020, we're doing outpatient surgical procedures consistent with the state guidelines.
Scott Steele: So Conor, next set of questions is probably something that understandably is going to be rapidly evolving and can change, and we encourage everybody out there to contact their local health institution to check up on the latest guidelines. But a few of the questions I've heard along are should patients wear masks when coming in, or can I bring a visitor in if I'm going to have surgery? Things along like that, whereas surgery in and of itself, or having a procedure in and of itself, is oftentimes a stressful time and to have that support network is key. So what are some overall general guidelines in terms of answering those questions?
Conor Delaney: Yeah, absolutely. So I think masks are going to be here to stay, at least until we have a sustainable vaccine, which is a year or two years away, whatever. And masks, when we think about them, are in two, actually maybe three situations. So first there's the N95 mask, or respirator. And that's something that we wear in environments or situations where there's risk of aerosolization. Surgical masks are worn in non-aerosolizing situations for staff. So doing open abdominal surgery, for example.
But the other side of masks is protecting others. And so cloth masks are coming in at many institutions, including our own, and staff and caregivers are recommended to wear a cloth mask, and that's to protect others, so you're not pre-symptomatic, you might sneeze or cough accidentally and spread it to somebody else. And now we're doing that for patients, and as visitors start to come back in, for visitors who will be with them as well. So there are things that are actually going through right at the moment. And I think we're going to see that across many social situations, let alone healthcare situations in the US. Masks will become widespread with the concept of protecting others.
Scott Steele: So let's flip it to the other side for those people who say, "Listen, I'm going to hold off for a while." And I know a lot of this depends on what particular disease process or symptom or something depends. But can you talk a little bit about the potential impact, if at all, of delaying treatment for some of the digestive issues, or cancer, things like that?
Conor Delaney: Yeah, well, as I said, for acute myocardial infarction, this is really important that patients don't delay treatment of issues. And there are many issues that get worse if you don't have them treated, and that's everything from cardiac care to breast cancer to many GI conditions to everything else. So I think the most important message is that you discuss this with your doctor, you make sure that the hospital has the right processes in place to keep you safe, but hospitals are safe places to go, and leaving conditions untreated tends to be unwise. One of the things we're seeing now from reports is that mortality rates are probably 50% higher than the virus mortality rates, because people are probably dying from other conditions. And that's probably an opportunity for us to look after patients better, patients who are afraid to come in.
So I think the concise message is, if you have something wrong, you should be in touch with your healthcare providers, and you should be going and having it looked after. And that's very different now to the way it used to be. It's changed in a couple of months. Often it's a phone call or a virtual visit over your phone. But there are ways to get care now, which will be changed for the future forever, where it's much easier. You don't have to leave your home and you certainly don't have to even be exposed to risk of infection, if that's your concern. And you can get assessed and you can get plans for treatment, and then the treatment can be provided safely.
Scott Steele: That's fantastic stuff. And so let's go one quick truth or myth, which I like to do here on this podcast. So let's just say I'm asymptomatic. I don't have a strong family history and I'm at the age where I should be getting my colonoscopy. Is it okay for me to push it off for a while?
Conor Delaney: I mean, you can push it off for a while, but it's not something you should really change. Going in for an outpatient procedure like that is completely safe. Patients are cohorted. It's something that needs to be done. And a screening colonoscopy is never urgent this week or next month, but it's not something that needs to be deferred. This is something that can be provided safely and has a huge amount of evidence that it reduces the risk of cancer. Now, the one qualifier that's got is that if you're in a city that's in the middle of the pandemic... And it even comes down to specific hospitals. Some hospitals have really had huge inpatient volumes of patients with COVID-19, and other parts of the country are really minimally exposed to it. So again, it comes down to, if in doubt, you reach out to your healthcare provider and they'll coach you to doing the right thing, but care is safe and appropriate and needs to be provided to our patients.
Scott Steele: Before we close up here, just a couple more things. Conor, for patients that maybe haven't been to a hospital in a while, or into a medical facility in a while, how do you envision that things may look different in terms of logistics or doctors wearing masks or where they can go or can't go, or sit or can't? What are your thoughts on that?
Conor Delaney: Yeah, so I think it's going to be very different, Scott. So the first thing I alluded to is the concept of virtual visits. So the government and [inaudible 00:14:58] and hospitals are rapidly changing towards virtual visits. Obviously we've been doing it for years, but this allows patients to see their physicians from the comfort of their home. We can make a lot of decisions and plans so that the visit, when it is in person, can be very specific things being done, specific imaging, and specific tests.
When you arrive at the hospital or care facility, now you can expect to get a questionnaire. Do you have a fever? Do you have a cough? Have you traveled? And that's to keep you and others safe. And maybe have your temperature checked. And then currently there's going to be limitations on the number of visitors that are with people, outside of extenuating circumstances, looking after kids, somebody who's very ill, somebody who needs other care or support. But the care itself won't be very much different. It's the same people providing the same care. They just may be wearing a mask when you're going asleep for your surgery or coming in for your appointment even.
Scott Steele: And just a final take-home message for our listeners. In this era, and as we obviously have a lot of unknown as we go forward, what is your take-home message to our listeners out there?
Conor Delaney: The take-home message is that care is safe. Reach out to your physicians and healthcare providers to get the right answers. Everywhere is putting together protocols and practices to look after you safely. So whether you need a screening colonoscopy or you're having bleeding or weight loss or something else that is troubling you, or you have an ongoing active condition that needs maintenance or medications, get your healthcare, because it's the right way to look after yourself for the long term.
Scott Steele: Yeah, absolutely. We can't emphasize that enough, is that your basic maintenance for your healthcare is critically, critically important. And if it's anything urgent to obviously contact your local emergency department. So from the most up-to-date information on COVID-19, including appointment and visitor policies, please visit clevelandclinic.org/coronavirus. That's clevelandclinic.org/coronavirus, C-O-R-O-N-A-V-I-R-U-S. And to speak with a specialist in the Digestive Disease & Surgery Institute, please call (216) 444-7000. That's (216) 444-7000. Conor, we really appreciate you taking the time out to come and talk to us about this very, very important topic.
Conor Delaney: Likewise, Scott. Thanks very much.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.