Failing to Prepare Is Preparing to Fail

EDITORIAL Failing to Prepare Is Preparing to Fail Kathleen A. Latino, MD, Deepak A. Kapoor, MD Integrated Medical Professionals, PLLC, Bethpage, NY [Rev Urol. 2020;22(3):91–92] © 2020 MedReviews®, LLC S evere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was initially reported in Wuhan, China, in December 2019.1 Worldwide spread was rapid—by mid‐January 2020 the first reported case was observed in the United States.2 The first confirmed case in New York City was on March 1, 2020,3 and a mere 6 days later, New York State Governor Andrew M. Cuomo declared a state of emergency.4 Within a breathtakingly short period of time, the healthcare system in the New York metropolitan area (comprising 95 inpatient facilities,5 including 12 academic institutions6) experienced overwhelming patient surge. As hospitals and independent practices nationwide grappled with the harsh economic realities associated with the deferral of elective procedures and greatly reduced patient throughput, providers in New York faced the additional challenge of providing services with constrained resources in the face of rampant viral spread. This issue of Reviews in Urology includes our experience with the impact of safety protocols (which included immediate coronavirus disease 2019 [COVID‐19] testing and contact tracing of exposed individuals) on exposure risk and virus transmission rates amongst employees in our large urology‐centric multispecialty practice operating within the national epicenter of the global pandemic. LUGPA practices are a vital component of loco‐ regional care across the country, providing nearly 40% of the nation’s urology services.7 The majority of LUGPA practices have expanded to include ancillary services critical to the care of urology patients,8 further increasing the importance of LUGPA groups to regional population health management. Our practice, Integrated Medical Professionals, PLLC (IMP), is no exception; in addition to outpatient multispecialty care at over 50 outpatient locations across the New York metropolitan area, IMP providers are on staff at 75 inpatient facilities and provide radiation oncology management services to two healthcare systems as well as another independent large multispecialty group. As many did nationwide, IMP formed a workgroup tasked with reviewing the dynamic flow of information regarding COVID‐19 that included representatives from all clinical service lines of the practice as well as individuals from the company’s billing, finance, information technology, and marketing infrastructure. Also included were experts in New York State labor law and IMP’s state advocacy apparatus. To streamline implementation of the workgroup’s recommendations, the IMP Board of Managers ceded operational control over the practice’s business and clinical operations to the COVID‐19 task force. Tasked with developing and deploying safety protocols and telemedicine workflows in a very compressed timeframe, within hours of its formation the IMP COVID‐19 task force faced an unexpected challenge. There were simultaneous geographically disparate reports of several of our own providers and employees either falling ill or being exposed to COVID‐19 within the workplace or from outside contacts. Not only did this create fear and anxiety amongst our staff, the guidelines from the Centers for Disease Control and Prevention and New York State required quarantine for anyone—absent testing—who (1) displayed symptoms of COVID‐19; Vol. 22 No. 3 • 2020 • Reviews in Urology • 91 4170020_03_RIU0878_V3_ptg01.indd 91 19/10/20 3:11 PM Failing to Prepare continued (2) had close contact with an infected person; or (3) could be considered a person under investigation (PUI). During the early part of the COVID crisis, regional access to COVID‐19 testing was extremely limited. Facing a significant gap between our need to provide care across our service lines and possibly not having adequate personnel to do so, our workgroup created a plan to offer testing to any PUI employed by the company possibly exposed to COVID‐19. To do so, IMP—in conjunction with P4 Diagnostix (Toms River, NJ)— developed a protocol that allowed for immediate testing of those directly exposed to COVID‐19 and included provisions for contact tracing and subsequent testing of those secondarily exposed to PUI. The response of our staff to these protocols was overwhelmingly positive; after the plan was initiated, fewer than 1% of employees expressed anxieties about coming to work. The task force found that close to 40% of our employees had direct or indirect viral exposure. But, as a direct consequence of these testing measures, along with additional protocols on social distancing, the use of personal protective equipment (PPE), and the rapid adoption of telemedicine, less than 10% of employees with possible COVID‐19 exposure ultimately tested positive for the disease. The success of these efforts should not obscure or diminish the human toll of providing services in the face of rapid viral spread: nearly one‐third of our partner physicians contracted COVID‐19 and, tragically, one advanced practice provider affiliated with our group succumbed to this disease. Our experience indicates that a systematic safety plan that includes access to rapid testing and immediate contact tracing, coupled with telemedicine services and proper PPE protocols, greatly mitigates staff anxiety, facilitates continuing clinical operations, and conserves practice resources. Indeed, including pandemic readiness as part of a practice’s emergency planning is no longer optional, but is an Occupational Safety and Health Administration mandate.9 Although we were the first LUGPA practice to provide care in the face of spiking COVID‐19 incidence, recent increases in disease rates nationally and the specter of a subsequent second wave almost assures that we will not be the last. Developing contingencies for staff testing and contact tracing should be incorporated into pandemic response testing for independent group practices. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497‐506. Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382:929‐936. West MG. First Case of Coronavirus Confirmed in New York State. The Wall Street Journal. March 1, 2020. https://www.wsj.com/articles/first-case-ofcoronavirus-confirmed-in-new-york-state-11583111 692?mod=searchresults&page=16&pos=7. Accessed August 17, 2020. New York State, Executive Office of the Governor. Executive Order 202: Declaring a Disaster Emergency in the State of New York. March 7, 2020. https://www.governor.ny.gov/news/no‐202‐declaring‐disaster‐emergency‐state‐new‐york. Accessed August 19, 2020. New York State Department of Health. Hospitals by Region/County and Service. https://profiles.health. ny.gov/hospital/county_or_region/. Accessed August 19, 2020. New York American College of Emergency Physicians. https://www.nyacep.org. Centers for Medicare and Medicaid Services. https://www.cms.gov. Kapoor DA. In‐office ancillary service exception. Presented at: Urology Joint Advocacy Conference; Washington, DC; February 2016. United States Department of Labor. Occupational Safety and Health Administration. OSHA Fact Sheet: Protecting Workers During a Pandemic. https://www.osha.gov/Publications/OSHAFS-3747. pdf. Accessed August 19, 2020. 92 • Vol. 22 No. 3 • 2020 • Reviews in Urology 4170020_03_RIU0878_V3_ptg01.indd 92 19/10/20 3:11 PM