Establishing Mayo Clinic’s Coronavirus Disease 2019 Virtual Clinic: A Preliminary Communication
Introduction
The index case of coronavirus disease 2019 (COVID-19) in the United States was documented on January 20, 2020, ∼3 weeks after it was first recognized in China in late December 2019 (Refs.1,2). Over the next 3 months, we would see arguably one of the most widespread public health crises unfold in modern history. Given the rapid exponential increase, and dire burden that COVID-19 is placing on health care systems around the world, there has been a public call for widespread distribution of rapid testing methods.3,4 To meet this demand, the Mayo Clinic recently started a drive-through testing unit. However, we identified two potential subsequent care gaps. The first, due to a shortage of testing supplies, how do we determine who we should test acutely? Second, how do we monitor and care for our growing number of patients who test positive for COVID-19 while navigating a dearth of personal protective equipment (PPE) and keeping our staff safe? In an attempt to address these gaps, our group created a COVID-19 virtual clinic (CVC). We would like to share our experience in establishing a CVC and our practice in identifying, monitoring, and treating outpatient COVID-19 patients virtually. Our hope is that health care systems elsewhere would see this as a unique opportunity to replicate our process in their own communities so they too may continue to deliver high-quality health care.
Methods
Our CVC team consisted of two arms—the patient screening arm primarily covered by resident physicians and the COVID-19–positive patients arm primarily staffed by attending physicians and an advanced practice provider (APP). Both arms received support from nurses, schedulers, and an administrative assistant.
Screening Arm
The screening arm of the CVC is designed to function in conjunction with the enterprise’s drive-through screening unit outside the main hospital. To minimize PPE usage, we have six nurses/APPs in full PPE on-site at the drive-through tents obtaining nasal swabs from screened patients in their personal vehicles. An additional 15 staff members guide traffic between stations as shown in Figure 1. The COVID-19 screening algorithm we employed is outlined in Figure 2. Screening guidelines were outlined by the Mayo Clinic Infection Protection and Control team in line with Centers for Disease Control and Prevention (CDC) guidelines.
Fig. 1. Drive-through testing map of stations.
Fig. 2. COVID-19 outpatient screening algorithm. COVID-19, coronavirus disease 2019; ED, emergency department; EMR, electronic medical record.
Screening was conducted live through phone calls to patients’ cell phones in their personal vehicles when they come to the drive-through screening line without a prior order. Patients meeting screening criteria were instructed to proceed and on-site staff were notified. Patients not meeting criteria were instructed to exit the line and continue self-care practices as recommended by the CDC. Screening through phone calls affords resident physicians the ability to telework remotely. Patients being screened are then tracked in a protected manner only accessible to Mayo Clinic staff directly involved with the CVC.
COVID-19–Positive Patients Arm
The more robust aspect of the CVC is to inform patients of positive results and to establish regular follow-ups. The workflow for staff physicians and APP is outlined in Figures 3 and 4. All patient interactions occur either through phone calls or through real-time audio/visual telemedicine with patients in their homes. This affords continued quarantine for patients, zero exposure for clinicians, and no need for PPE. However, if clinical deterioration is observed during these check-ins, patients can be referred to the emergency department (ED) with advance notice of an incoming COVID-19–positive patient given to the ED for further escalation of care.
Fig. 3. Positive result notification to patient by provider. CDC, Centers for Disease Control; EMR, electronic medical record.
Fig. 4. Follow-up video visit by provider. CVC, COVID-19 virtual clinic.
These patients are also tracked in a protected manner only accessible to Mayo Clinic staff directly involved with the CVC. Clinical data currently suggest that ∼80% of patients who contract COVID-19 will experience relatively mild symptoms that can be managed with supportive care at home. As patients’ symptoms improve, we then employ retesting parameters as outlined by the CDC to ensure their convalescence of the virus before discharging them from our care (Fig. 4). The established streamlined workflow allows for rapid onboarding of more clinicians to meet the demand as the patient enrollment inevitably grows. Lastly, in line with social distancing protocols, providers meet regularly through online videoconferencing to discuss administrative tasks.
Discussion
In this pandemic, we have had to rapidly adapt to new care models that minimize infectious transmission by avoiding physical contact between the clinician and patient.
In the first week of full operations, we screened 1,153 patients through the drive-through screening tents for COVID-19. Of these 1,153 patients, 63 tested positive and were enrolled in the CVC. We discharged three patients from the CVC with resolution of COVID-19 infection as of the 8th day of full operation. By comparing PPE usage in the drive-through operation in that first week with estimated PPE usage in the ED for equivalent number of patients, we estimated a 96%, 97%, and 47% reduction in daily total consumption of masks, gowns, and gloves, respectively, through the drive-through operation.5
In our experience so far, these patients have had to cope with not just the physical symptoms but also the mental toll of uncertainty and anxiety that having the virus takes on them. Having a regular touch point with the same provider on the CVC team has helped alleviate most of their concerns.
As patient enrollment expectedly increases, we are able to rapidly bring on more staff to our CVC team. This allows for repurposing of the physician and APP workforce to contribute to the collective effort against the pandemic.
Conclusions
COVID-19 is a formidable pandemic that is causing a significant disruption in society. Health care systems here in the United States are currently beleaguered by the sheer number of patients either seeking testing or screening positive and needing care. This not only puts patients at risk of decreased access to adequate health care, but also puts health care providers at significant risk of contracting the virus. It is our fervent hope that other health care systems may be able to learn from our experience using telemedicine care to screen and care for patients with COVID-19. This, in turn, can redirect resources to care for the more severe cases of COVID-19 while simultaneously minimizing unnecessary exposure to health care workers.
Acknowledgments
We thank our nursing, nursing assistants, and APP staff working tirelessly at the drive-through testing to obtain screening samples from patients.
Disclosure Statement
No competing financial interests exist.
Funding Information
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References
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