Cancer Never Stops – and Neither Do We
Organizing our ocular oncology service in unprecedented circumstances
Carol Shields | | Longer Read
The Ocular Oncology Service at Wills Eye never stopped working during the COVID-19 pandemic – instead of putting the brakes on patient care, we flipped the switch and nearly overnight converted to a telehealth system. Our cancer patients needed us, so we balanced patient care with clinician and staff safety. At first it seemed daunting to decide on how to evaluate an ocular oncology patient under these novel circumstances but, in the end, we discovered new ways to implement care without requiring the doctor to be present.
In fact, we have been able to deliver care with a skeleton crew of two office staff at a remote setting, taking patients in one by one, with family waiting in the car, and turning over care every 15-20 minutes, including all imaging, teleconferencing with the doctor and family, and a personally dictated letter to the referring physicians. It might sound impossible, but with an already solid base in ophthalmic imaging, and with outstanding photographers and technicians, we set up imaging “camps” to keep patients away from the downtown Philadelphia virus “hotspot.”
If I had to select five steps that we specifically focused on during this overwhelming transition, I would include: i) safety in the clinic, ii) constructing telehealth confidence for eye cancer, iii) COVID-19 testing on patients before surgery, iv) maintaining employee and patient satisfaction, and, the most important one, v) establishing imaging centers in the suburbs of Philadelphia.
Safety in the clinic
Virtually overnight we realized that our exposure to patients required more than a mask and hand sanitizer. To reduce contact, we asked new patients to wait in their cars until we were ready for them to check in, leaving all family members in the car. Only the patient entered our office, with a mask and sanitizer, checked in, and had their vision and intraocular pressure checked, and images taken. Then the patient was examined by a doctor using a transparent shielded slit lamp and shielded indirect ophthalmoscopy.
That was followed by a virtual review of images on the computer, short counseling, and letter dictation to a tablet. The patient only occupied one room during their stay, and only up to four patients were allowed in the waiting room. Following the consultation, the patient met virtually with our surgical coordinator and the surgery was scheduled. Upon departure, technicians applied sanitizer and the room was cleaned. From arrival to discharge, the new patient spent no longer than an hour in our office.
Constructing telehealth confidence for eye cancer
New cancer patients and emergency patients were evaluated in person, but existing patients were redirected to telehealth services. In our office, the technician would contact the patient, take the history, gather information on visual acuity, motility, and visual fields, and then pass the case to the doctor who would review any recent fundus images or diagnostic tests taken, counsel the patient, and dictate a letter. Initially some patients found this setup unsatisfactory, but after participation, nearly 100 percent of them enjoyed the convenience, the one-on-one with the doctor, and the rapid evaluation. Satisfaction and confidence in telehealth escalated quickly during the pandemic.
COVID-19 testing on patients before surgery
From the start, we required COVID-19 testing on all patients before surgery, even children being examined under anesthesia. This provided some safety for operating personnel. The testing was done within two days of surgery and we luckily caught a few infected patients before it was too late.
Maintaining employee and patient satisfaction
It is highly important to recognize the sacrifice of the office staff to maintain care during the viral pandemic. This disruption to our normal office and operating flow could have led to anxiety and depression in those who give and receive the care. Physicians should be careful to recognize distraught or stressed persons and give them the time and help they need – often virtually. I must admit, our employees have been strong and willing to make this new arrangement work. Our patients have been completely satisfied with their telehealth experience and very happy with our remote imaging centers (camps), sparing them the extra travel time and avoiding COVID-19 hotspots.
The big one: establishing imaging centers in the suburbs of Philadelphia
Developing remote image centers was our best idea and it solved numerous problems. We realized that adequate assessment of an ocular oncology patient required high-quality imaging of the entire eye. This quality often surpasses that available in an average ophthalmology office, so we established three remote imaging centers approximately one hour from Philadelphia to the east, south and northwest, to capture images for patients who wished to avoid traveling into the city. These centers were fitted with high-quality fundus cameras (with autofluorescence), ultrasound (and UBM), and OCT. It was an investment. Patients appreciate the shorter travel, quicker visit and suburban options.
We staff each center with two employees: one ophthalmic photographer and one technician, both connected virtually to our “mothership” at Wills Eye Hospital. We have invested in the best imaging cameras for best patient care. For now, each center is open one day a week to provide ophthalmic care and imaging, followed by immediate virtual consultation with the ocular oncologist. We sense that this will increase as patients get comfortable accessing this type of care. This arrangement has allowed us to continue to offer the highest quality of care, while minimizing direct patient contact.
The pandemic brought fear, anxiety, and sickness, but it also brought an education on how to best help our patients in an efficient, virtual manner. Cancer and COVID-19 are a “double whammy” but, at Wills Eye Hospital Ocular Oncology Service, we worked to “tame the tiger” and managed to solve the seemingly insurmountable challenge.
What does the future hold?
I think imaging centers with virtual doctor consultations are here to stay. These centers impressively simplify medical care for patients, without the need to wait long hours, travel long distances, and risk exposure in crowded circumstances. In fact, the remote location is attractive because the doctor is “virtually transported” to the patient. I believe patients will seek this convenience once they experience it. However, “in-person” initial consultation remains a gold standard, especially for ocular oncology, as evaluation of specific details can best be done in person. As I see it, the role of virtual examination will likely be used mostly by follow-up patients.
Over the past five months of the pandemic – which is by no means over – Ocular Oncology at Wills Eye Hospital has survived, and patient visits are increasing. I am confident we will get back to a “new normal,” with our usual volume of patients spread over four offices. Our staff have taken leadership roles in this transition, and together we have journeyed into this new world of ophthalmic care.