Successful Reopening Plans for ENT Practices Emphasize Safety

Otolaryngology practices are scheduling more office visits after severely curtailing them in mid-March when the COVID-19 pandemic took off in the United States. Masks, Plexiglas shields at check-in counters, and telemedicine are the new normal in otolaryngology, physicians say.

Practices that are successfully reopening have installed safety precautions to help prevent transmission of SARS-CoV-2, the novel coronavirus that causes COVID-19, although each facility follows different official recommendations.

Protective Practices

“We’re following the COVID-19 safety guidelines from the CDC, but we also adhere to our state’s guidelines. It varies county by county, depending on what phase we’re in, and that’s based on the number of cases and deaths,” said Kathleen C.Y. Sie, MD, division chief of otolaryngology–head and neck surgery and the Richard and Francine Loeb Endowed Chair in Childhood Communication Research at Seattle Children’s Hospital. Seattle saw some of the earliest COVID-19 cases in March, so her hospital had to adapt quickly. An emergency operations council sets all safety policies. “We didn’t have anyone else’s lessons to follow, but we had a well-defined plan to put in place earlier than some other cities,” she said.

Seattle Children’s Hospital screens all individuals, including patients, families, and staff, as they come into the building. Each person is asked screening questions about possible COVID symptoms, and their temperature is taken. “If they don’t pass those two things, then they’re denied entry,” Dr. Sie said. “Patients are asked to reschedule their appointments, and staff are asked to have COVID testing. We provide everyone who enters with masks. We have tape on the floor to mark 6 feet of distancing. Even our cafeteria has changed. We used to have a salad bar, but now all food is prepackaged.” Providers wear masks throughout the campus, and masks and face shields in patient care areas. Rapid coronavirus testing is available, with results in 50 minutes.

More people are now wearing scrubs in the hospital and changing into their street clothes before they go home. You see fewer people wearing a suit and tie. —Brandon Hopkins, MD

Masks are mandatory for all staff and patients at ENT Associates at Greater Baltimore Medical Center, which also recently installed Plexiglas shields at check-in counters, said otolaryngologist/head and neck surgeon Marc G. Dubin, MD.

“Social distancing starts at the front door as everyone stands in line to get their temperature taken. Patients must come alone unless they truly need physical assistance or are a minor,” he said. “Patients are asked screening questions about COVID-19 symptoms and exposure before the appointment is made, and again at the front door prior to entry.” Questions include whether you’ve visited an area with a high rate of COVID-19 cases or have potential symptoms.

Dr. Dubin said he’s comfortable with the level of safety and protection at their offices throughout Maryland. “We have the PPE [personal protective equipment] we need, we’re social distancing, we’re testing our surgical cases, and we’re wearing masks,” he said. The group employs more than 60 otolaryngologists, and in mid-March restricted in-person visits to urgent or emergent cases only. In late May, the group expanded clinic visits to include routine care. “With our protocols in place, we’ve had no cases of patient-to-staff, staff-to-staff, or patient-to-patient transmission within our facilities.”

At Cleveland Clinic’s main campus in Ohio, masks weren’t mandatory for every hospital visitor at first, but as national guidelines changed, the institution updated its stance and they’re now required for everyone, said Brandon Hopkins, MD, a pediatric otolaryngologist.

“Even before universal ‘cough etiquette masking,’ we implemented policies to make sure we had appropriate PPE for people in high-risk situations. Our infectious disease team and administrators have been leading this effort. They did everything in their power to protect our highest-risk patients and personnel,” Dr. Hopkins said. The Cleveland Clinic follows COVID-19 safety guidelines from the CDC, World Health Organization (WHO), and its own infectious disease department, requiring masks and social distancing within the hospital. “They’re looking at the evidence, and they’re considering what’s the most practical approach and what’s best for our local community.”

The Cleveland Clinic has designated specific entryways for all visitors and staff, where universal thermal screening is conducted, Dr. Hopkins said. At first, masks were provided to staff only, but as PPE supplies ramped up in spring, masks were given to visitors as well.

Physicians sport a new look from head to toe at the Cleveland Clinic, he added. “The culture has changed. More people are now wearing scrubs in the hospital and changing into their street clothes before they go home. You see fewer people wearing a suit and tie. White coats are being laundered more frequently than usual.”

At Colorado ENT and Allergy’s four offices in Colorado Springs and Monument, Colo., masks or other mouth and nose coverings are mandatory, chief executive officer Kevin Watson said. Patients must come to appointments alone unless they are minors or have special needs.

“We screen patients at the door to ask them if they have COVID-19 symptoms and to take their temperatures,” Watson explained. “If they’re over 100.6 F, we ask them to reschedule their appointments. We don’t have tape on the floor—we’re fortunate in that our main offices have fairly large waiting rooms. This allows us to perform social distancing.”

In-Person Care Returns, Slowly

Colorado ENT and Allergy is close to a “back to normal” workload at its offices, but from March through early June, most visits were remote, using telemedicine. ENT Associates in Maryland also switched most appointments to telemedicine in mid-March, as soon as insurance carriers publicized the fact that remote visits would be covered.

“Telemedicine is challenging in otolaryngology because our examinations are almost physically impossible to do over a computer screen,” Dr. Dubin said. “We look inside deep, dark places. Telemedicine is a totally appropriate surrogate for office visits that don’t require physical exams; imaging reviews or tonsillectomy follow-ups are reasonable examples. Beyond that, though, so much of what we do is procedure-based. It’s impossible to do a meaningful hearing exam over the phone or look up someone’s nose or do an ear exam [using a webcam link]. Telemedicine did, however, allow for screening of patients to see if they truly justified an in-office visit during the peak of COVID-19 cases in our community.”

Although the Cleveland Clinic had some telemedicine systems in place before the pandemic, Dr. Hopkins and fellow otolaryngologists rarely used them before March, when virtual visits ramped up quickly. “We went from less than 5% to more than 60 to 70% virtual visits. I’m pleased that we’re opening up more platforms for telemedicine. The virtual visit isn’t the same as an in-person visit, however. There’s only so much you can do over telemedicine,” he said.

Physicians may conduct telemedicine visits unmasked, so their voices are less muffled, and patients who are deaf or hearing impaired may read their lips, Dr. Sie said. Still, telemedicine is far from ideal for patient communication. “When we conduct telemedicine visits, our faces are uncovered, but the audio can be distorted. Closed captioning can be very helpful, but this requires setting up a contract with the telemedicine platform.” Clear masks exist but are hard to find, she said.

Although Seattle Children’s Hospital is scheduling office visits, some families are reluctant to come in, Dr. Sie said. “We’re working to get telemedicine sites with carts to do otologic exams. Telemedicine is a good way to follow up, check in, or triage patients to see if kids need to come in or not.” Some families lack computers or internet access. Her department added a social worker in mid-April to help doctors address healthcare access disparities, such as identifying low- or no-cost computer resources.

Telemedicine likely is here to stay in otolaryngology, although in limited situations, Watson noted. “If we can market telemedicine as an option for initial consultations, such as a short visit with a patient who may have been seeing a primary care physician for sinus problems to see if they need to schedule an appointment with one of our specialists, it may be a less expensive, quick way to screen patients at home,” he said.

Helpful Academy Guidance

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) released two comprehensive sets of recommendations regarding COVID-19 safety precautions, including one on May 7 for general practice settings and another on May 15 for surgical procedures in specialty areas. Otolaryngologists said these recommendations were useful as they devised specific precautions for their offices.

“The academy did a very nice job sending out recommendations using the best available information,” Dr. Dubin said. “COVID-19 disease penetrance and regulations differed and continue to differ from state to state and region to region. The guidance has been very helpful in parsing out the most useful information available in a common-sense approach.”

Dr. Hopkins and his colleagues also follow the AAO-HNS recommendations, which he calls helpful and broad, advocating for maximum PPE at all times. Cleveland Clinic issued its own internal guidelines for PPE use in each type of patient interaction.

“If an N-95 mask were perfectly comfortable, your patient could see you through it, and you could talk through it, that would be great,” he said. “But they’re hard to talk and breathe through. It can be difficult to wear them for an extended amount of time, with many finding it difficult for more than four hours. Even after 10 minutes, I start to feel confined.” Masks and other PPE are used during all aerosol-generating procedures at the clinic, and patients are tested for SARS-CoV-2 three days before any surgical procedure.

Dr. Sie follows AAO-HNS news releases for updated COVID-19 safety recommendations. “The information coming from the academy is very balanced and consistent with CDC recommendations. Some of the information coming from specialty societies hasn’t been evidence-based. Working in a pediatric hospital, we’re more tied to the CDC and state guidelines,” she said.

COVID-19’s Personal Impact

Whether it’s due to physical distancing, more staff working from home, or the surge in remote visits, some personal interaction is lost, Dr. Hopkins said.

“Human contact is important to our work,” he explained. “My job is drastically harder because I’m trying to interact with a 5-year-old or a parent with a mask on. Trying to assess hearing loss is harder. And it isn’t just patient interactions that are more difficult right now—provider interactions are harder, too. Right now, we would be celebrating our program’s graduates. Naturally, there’s some dissatisfaction that we can’t do that, and we can’t get together as colleagues.”

Telemedicine is challenging in otolaryngology because our examinations are almost physically impossible to do over a computer screen. We look inside deep, dark places. It’s a totally appropriate surrogate for office visits that don’t require physical exams. … Beyond that, though, so much of what we do is procedure-based. —Marc G. Dubin, MD

From March through May, many otolaryngology patients simply didn’t seek care for conditions that weren’t considered urgent, although they impact quality of life, Dr. Dubin said.

“Patients can’t hear, they can’t breathe through their nose, they have a nagging sore throat, they can’t smell. Before all of this, people were filling our offices to get care for these complaints. For months, they ignored what may be indicators of more serious conditions for which an evaluation should not be delayed. Now, I hope that they feel, ‘If I can get a haircut, then it’s OK to see why my nose is bleeding every day.’”

With current safety measures in place, if COVID-19 cases surge this fall, Dr. Dubin said he believes that local hospital capacity and intensive care unit (ICU) bed availability should dictate how practices continue to offer care for those nonurgent conditions.

“Assuming that facilities have the PPE they need, I’m hopeful that we can ensure that elective healthcare access is maintained both at an outpatient and ambulatory surgery center level,” he said. “While we certainly don’t want elective medical care to be a drain on the system, at some point, this care needs to be provided.” 

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Susan Bernstein is a freelance medical writer based in Georgia.