What Can I Expect At My Office Appointment ?
Because of COVID-19, your office experience will be different than that to which you are accustomed and unlike the majority of physician offices out there. The first thing you will notice is that we begin your visit a day beforehand, with a call from our clinical staff to discuss your upcoming visit, verify medications, need for vaccination and understand any other concerns you may have. Upon arrival, you will first notice there is no longer a waiting room. Instead, you will be met at the door by clinical staff, your temperature will be taken and we will perform a mid-nasal swab to check for COVID-19.
We use a rapid antigen test which takes about 15 minutes. In the event that you would like somebody to accompany you to the visit- whether it be a family member or a caregiver – we ask that it be only one additional individual, preferably in the same household. That person will also be screened for COVID-19. The BD Veritor Antigen Testing System is displayed below. We also use the Quidel Sofia 2 Antigen Test as well.
Each examination room is equipped with a HEPA filtration device – these have been shown to be effective in removing viral particles in airplanes. Upon return of the antigen test, Dr. Bretsky will then begin the usual examination process. Since we do diagnostics and perform blood draws in our office, there is not a need to go elsewhere for these services.
Because time and proximity are the two key elements in COVID-19 spread, we take advantage of the large size of the office. We have three separate entrances and two clinical wings. Generally, only one patient will be in the office at a time. In the rare instances that there are two, they will be in separate clinical wings and will use separate doorways. We also have a dedicated room for patients who are actively ill with symptoms such as fever, cough, or congestion.
Staff members are separated from patients by extensive plexiglass barriers and doorways.
We have taken great effort to change the flow of patients in the office to eliminate contact with non-clinical staff. HEPA filters are also placed throughout the office as an additional source of protection against spread of the virus. Any referrals or requisitions for imaging such as mammograms or X-rays will be provided via email. Ultrasounds are performed in our office and so, again, there is not necessarily a need to go elsewhere for these services.
We have temporarily suspended our treadmill stress testing capabilities as well as lung function testing as these tests require vigorous activity which may contribute to viral spread.
Clinical staff members are equipped with N95 masks, face shielding and impermeable gowns. We have stepped up our disinfection protocols both within examination rooms as well as in the office as a whole. Masks, and gloves are changed between patients and face shielding is disinfected. A room where an actively ill patient was evaluated is closed and not used for a minimum of 4 hours after the visit – but most often is sealed for the rest of the day.
What Are You Doing About Annual Flu Shots and Other Vaccinations ?
This season the WHO, CDC and other health agencies have unequivocally recommended the 2020/2021 seasonal flu shot as a measure to protect against a ‘twindemic’ of COVID-19 and influenza. To facilitate such, our office engineered and created a ‘shot box’ made of plexiglass to allow for rapid vaccine administration in a safe environment.
I’m Interested in More Background. How Did Your Response Start ?
With a formal educational background in Infectious Disease Epidemiology, I had long been concerned that a respiratory pandemic would occur. I had believed that it would be a particularly deadly influenza strain. I began to take notice of reports from Wuhan in January and February of 2020, but though that a similar situation to SARS would emerge – wherein it would remain largely confined regionally with sporadic cases worldwide.
Since Los Angeles is a critical transportation hub, I purchased a small amount of PPE concerned that we would have some travel related cases in patient who had traveled to China and were returning to the US. However, what really got my attention was Dr. Nancy Messioner’s statement on February 25th 2020. Dr. Messonnier, the director of the CDC’s National Center for Immunization and Respiratory Diseases said that it was inevitable that novel coronavirus disease (COVID-19) would spread through U.S. communities, given the virus’s increasing incidence outside of China. “Disruption to everyday life may be severe,” she warned.
At that point, everything changed. We immediately stopped seeing patients with acute illness in the office and, two weeks later, stopped routine in office visits – switching entirely to video and telehealth modalities.
How Did for COVID-19 in March and April 2020 When Testing Kits Were Unavailable ?
As you may remember, testing kits and laboratory reagents were hard to come by in the early days of the pandemic – and shortages persisted in the months that followed. We performed our first test on March 11th – results returned 5 days later: Negative. Our first positive test was March 18th.
We began testing patients with a makeshift drive up alongside our building on 20th and Arizona. We still do this today so that patients can rapidly access a test without having to come into the office.
Soon after starting testing, we began to experience shortages in swabs, tubes and the solution (viral transport media) used to preserve the viral sample during transport from our clinic to the lab. At no point did we turn anybody away, however, as we were able to fashion our own viral test kits from materials in the office. I rummaged through every cabinet, every exam room and our two in office laboratories to find the materials needed to keep testing. Our commercial laboratory provider, LabCorp, to their great credit ran all the samples we sent them – even if not collected with one of their own kits. As our laboratory representative put it, “if you send it, we will run it.”
How Do You Test Now ? Does Insurance Cover It ?
At this point in time we are not experiencing any shortages of testing kits and we run both a rapid antigen test (with 15 minute results) as well as viral PCR (with results in 36-48 hours). The rapid antigen testing (we use both the Quidel SOFIA and BD Veritor platforms) are done on site. PCR testing is sent out to our commercial laboratory partner, LabCorp.
All tests (both antigen and PCR) are billed to commerical insurance providers. It is always important to check with your provider regarding coverage but, so far, we have not had any denials or non-coverage of COVID-19 testing. This includes both the rapid antigen test and the send-out PCR.
Have You Had Any Cases ?
In the practice we have had about 30 cases of COVID-19. Fortunately, we have not had anybody hospitalized and no deaths as a result of the diseases. We have had patients become quite ill in some instances and several continue to have residual symptoms months after their acute illness has resolved.
We have approached treatment primarily with supportive care – rest, hydration, and Tylenol (not Motrin / Ibuprofen). We have also been a strong supporter of clinical trials and, early on, referred patients (both with disease and recently exposed) to Hydroxychloroquine studies run out of the University of Minnesota. These studies both showed that Hydroxychloroquine had no effect on either COVID-19 acquisition or progression. Currently, we refer patients to ongoing trials of Regeneron’s REGN-COV2 antibody.
How Do You Manage Isolation and Quarantine?
In March, the United States was already lagging behind other countries in terms of a coordinated response. The Centers for Disease Control (CDC) was slow to develop testing kits and establish clear protocols for case isolation and quarantine. Because of this, I began to look to other countries for guidance.
Ottawa, Canada provided clear, accurate and comprehensive materials on topics ranging from self-isolation to contact tracing (Link: https://www.ottawapublichealth.ca/en/public-health-topics/novel-coronavirus.aspx). The only aspect that needed clarification for US patients is that 2 meters = 6 feet.
I initially looked to Singapore for testing and quarantine guidelines but their public health department actually sends an epidemiologic services officer to your home in the event of COVID-19 exposure or infection. So there was nothing published that would help my efforts.
South Korea had an early and effective COVID-19 response, partially shaped by their disastrous experience with a different, but far more deadly), coronavirus – Middle East Respiratory Syndrome (MERS). Their website (Link: http://www.cdc.go.kr/cdc_eng/) outlines their detailed methodology for case isolation and quarantine. In it, a person testing positive for COVID-19 is isolated for two weeks beginning the day of their first positive test. To be considered for release form isolation, they must meet both clinical (no fever without taking fever reducers and show improvement symptoms for at least 72 hours) and testing criteria At the end of 10 days (initially this was two weeks), the patient is tested twice in a row with at least 24 hours between tests. If both are negative, the patient is released from isolation. If positive, the patient may retest at their physician’s discretion – all are released from isolation after 21 days.
Can I Get A Test Today ?
Absolutely. In terms of things that I am most proud about our response to COVID-19 is that at no point did we ever turn a patient away for testing. If you want a test for any reason – recent or upcoming travel, exposure to a known or possible case, concerning clinical symptoms or because you are going to visit a high risk relative – we will provide you with a test. We perform both rapid antigen testing (15 minute result, on two separate platforms: BD Veritor and Quidel Sofia) as well as PCR (which we send out to LabCorp). For patients with high risk exposure or concerning symptoms we also provide self-directed testing, which limits healthcare worker exposure. We also test patients in a drive-through motif using the three car cutout next to our building.
We do not charge any additional fee for testing. To date, LabCorp has accepted insurance payment for PCR testing as payment in full. We also charge insurance for the rapid antigen testing – reimbursement rates have ranged from $8 (Blue Shield) to $56 (United Health Care) for this testing.
What Is The Current Situation in the US and in Los Angeles ?
I provide regular updates regarding COVID-19 prevalence rates and spread on our Facebook page (@santamonicaprimarycare) and Blog (www.drbretsky.com/blog). I have focused on Los Angeles County primarily but also compare our response to that of Riverside and Orange Counties as well as San Francisco. Other times, I do look at hyper-local Santa Monica data as well.
What Do You Think About Treatments ?
If there has been one positive in the COVID-19 epidemic, it has been the significant improvement in hospital-based treatments. One need look no further than mortality rates which have plummeted in Los Angeles County (Figure below).
At its highest points (early April and late July), there were 0.43 daily deaths per 100,000 population in Los Angeles. By October that rate had decreased to 0.08. A number of factors have influenced this massive drop including decreasing incidence of cases and a case distribution towards younger individuals who, generally, fare better than those that are older. Efforts to ‘flatten the curve’ have prevented hospital ICUs from becoming overwhelmed so staff can provide comprehensive and effort-consuming care for each individual, rather than triaging critical cases. But improvements in-hospital treatment has also played a significant role. Prone positioning, delaying intubation, early initiation of steroids and supportive care have decreased mortality rates. The precise role of remdesivir is still being debated, but remains part of the National Institute of Health’s current treatment recommendations.
There is general agreement that case fatality rates in the United States from COVID-19 have dropped because of improved in hospital treatment. There is little being done differently, however, in an outpatient setting. Supportive care with rest, hydration and Tylenol is the mainstay of our approach. I have provided patients with pulse oximetry devices to measure their blood oxygen levels at home which gives an objective measurement of the severity of the respiratory effect of COVID-19.
What Do You Think About Vaccines? When will I be able to get one?
Very early on in the pandemic, Bill Gates wrote in his Gates Notes (well worth following) that an comprehensive response to COVID-19 would require a treatment that was at least 95% effective or a vaccine or both.
We now have two FDA approved vaccines available in the United States – one from Pfizer/BioNTech and the other from Moderna. According to recent press reports, a third candidate from Astra-Zeneca will undergo consideration soon in the United Kingdom with updated efficacy data.
Our office sought and obtained approval to function as a vaccine delivery site for the Moderna vaccine. Unfortunately, the Pfizer/BioNTech vaccine requires ultra-cold chain storage at -70°C and refrigeration equipment that we simply do not possess. However, we do have adequate storage and monitoring equipment such that we sought and received approval for the Moderna vaccine.
Vaccine distribution is a three stage approval process in California. In the first, we received certification from the California State Department of Health (took about 5 days) and then 24 hours later had CDC approval. Now we are waiting to hear from local health officials in the County of Los Angeles.
In the meantime, we wait. There is no clear timeline about when vaccines will be available to the general public – much less to health professionals. While I have some colleagues that have already received their first vaccination, I have had no communication from the hospital where I am on staff about when I might expect one.