How one Texas GI group navigates testing, staffing & looming COVID-19 questions

With 12 physicians and seven advanced-practice providers, Gastroenterology Consultants is the largest gastroenterology group in the Houston metropolitan area. 

The group was founded by its current president, Nat Bala, MD, in 1983. It has one main location out of which all the physicians practice, as well as five satellite locations with two to three physicians each.

Gastroenterology Consultants services about eight acute care hospitals with two outpatient endoscopy centers in Houston: the Memorial Hermann Bay Area Endoscopy Center, which is operated through partnership with Memorial Hermann, and the Pearland Surgery Center, which is entirely physician-owned.

When stay-at-home orders came down in the early days of the pandemic, Gastroenterology Consultants closed both outpatient endoscopy centers, limiting outpatient services to exclusively urgent procedures in the hospital setting. Otherwise, patients could use various telehealth options depending on preference and insurance coverage.

In addition to implementing infection control measures recommended by the CDC and the Texas Medical Association, Gastroenterology Consultants convened a five-member committee focused on COVID-19-related strategy and safety measures. ACG Practice Management Committee member and gastroenterology specialist Sumanth Daram, MD, chairs that committee, which also includes a practice administrator and a practice manager. Since March, the COVID-19 committee has met at least once a week, sometimes on the fly.

With the practice's endoscopy centers and offices now reopened at about 80 percent of normal levels, Dr. Daram spoke to Becker's ASC Review about how he and his colleagues handled the pandemic up to this point, moving quickly to adopt new safety measures and monitor local COVID-19 case levels despite continued uncertainty surrounding the virus.

Seven key focus areas for Gastroenterology Consultants:

1. Testing. Beginning May 3, Gastroenterology Consultants resumed "full-fledged" operations at its offices and endoscopy centers. Although national GI societies didn't recommend testing until later for facilities with the capabilities, the practice decided upon reopening to test every patient scheduled for a procedure at its outpatient endoscopy centers.

"A lot about COVID-19 is still unknown at this time, and a lot more was unknown back in March and April. We didn't want to take any chances," Dr. Daram said. "We could be contaminating the endoscopy center or the office or a scope — then, you've got infection to others."

With this rationale, Gastroenterology Consultants partnered with a diagnostic lab that sends technicians to both endoscopy center locations to test patients not more than four days ahead of their procedure date. For the most part, results come back within 24 hours. It sometimes takes up to 48 hours, but turnaround times any longer have been "very rare," Dr. Daram said.

Staff preparation has also helped in terms of testing logistics. When facilities reopened, practice managers and office managers "were educated very well as to what the requirements are and how you'll have to fix your flow for this to happen in an uninterrupted manner," he said.

If a patient tests positive for COVID-19 — or in the rare case the patient doesn't go through with the test — his or her procedure will be canceled and rescheduled for a later date.

2. Unanswered questions. "Invariably, we are going to see more and more of these patients who come to the office for the procedure saying, 'I tested positive for COVID-19 two months ago or two weeks ago,'" Dr. Daram said. "So, when do we feel safe seeing these patients in person? When would it be safe to have this patient come back for a procedure? Do we need to retest them?"

To answer these questions to the best of its ability, Gastroenterology Consultants reviewed local and national return-to-work guidelines. The CDC stipulates that healthcare workers can return to work 10 days after being diagnosed with COVID-19, as long as they have been symptom-free for at least 24 hours (a parameter shortened from the original 72 hours).

"So, at this time, we're extrapolating that" and incorporating a one-week buffer, Dr. Daram said. "We want them to be symptom-free for 48 hours without medicine, 10 days since the diagnosis and we want to wait a week out from that point, so practically at about three weeks from their COVID-19 diagnosis" is when patients can return for an elective procedure.

As for retesting patients at that point, Gastroenterology Consultants decided it's not necessary within the first 90 days of initial infection because there's some evidence — albeit sparse — that any antibodies may not last beyond that time.

3. Personal protective equipment. When they're seen in the office, all patients are required to wear masks. In "the rare instances" where a patient doesn't bring a mask, Dr. Daram said one is provided by the center. All office employees are using PPE as well, with medical assistants taking extra precautions due to their direct role in patient care. They layer a surgical mask over an N95 mask to prolong use of the N95 before it must be replaced.

4. Social distancing. Per CDC guidelines, Gastroenterology Consultants spaced out office furniture and implemented visitor restrictions with exceptions for patients needing extra assistance, such as elderly patients and those with language barriers. Furthermore, employees are asked to avoid congregating to eat in staff lounges and common dining areas. At any given time, there should be no more than one staff member eating in those areas without a mask. As an alternative where possible, employees are encouraged to have a quick lunch in their cars.

5. Rooming. The practice also thought through how adjusting room utilization could protect patients and staff. In the past, medical assistants would place a patient in each of a facility's four exam rooms, where the patient could spend upward of 30 minutes waiting for the physician. Now, no more than two rooms are to be used at any given time. The strategy accounts for typical human behavior: a potentially asymptomatic patient waiting in a room alone for 30 minutes isn't likely to keep his or her mask on the entire time, increasing the risk of infection for medical assistants and physicians.

6. Staffing. Gastroenterology Consultants is being abundantly cautious when it comes to staff illness because it's not a matter of if every person gets COVID-19; it's a matter of when, according to Dr. Daram. The practice has already had a few staff members get diagnosed with COVID-19, but most had mild symptoms.

"When staff call and say, 'I'm coughing but I think it's my allergies,' we're saying, 'No, you cannot come to work, please stay home until those symptoms go away. Come for a COVID-19 test later today, and if you're negative and those symptoms have been gone at least 48 hours, then we ask them to come back,'" he said.

This hard line is meant to prevent a catastrophic domino effect: If one staff member infects others and they all have to self-isolate, the resulting staffing shortages could force the practice to revert to urgent procedures only.

7. Community. Gastroenterology Consultants facilitated roughly 1,100 COVID-19 tests between March 15 and May 15, with only about six asymptomatic patients testing positive, Dr. Daram said. From May 15 to July 15, the 900 tests conducted had a positivity rate 6 percent higher than in the previous testing period, reflecting a worsening situation locally. On a July 23 phone call, Dr. Daram said new signs of improvements could be at least in part attributed to a mandatory mask order that had gone into effect about two weeks prior.

"We need to be very much aware of what's happening on the ground here in Houston, in terms of the infectivity rate, how the population is practicing safe distancing or the mask protocols," he said. This kind of information will inform whether the practice needs to implement even more strict protocols, or whether its current policies will continue providing adequate protection for staff and patients.

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