The Practice President: ‘It Still Feels Like We Are in the Fog of War’

Pre-Covid-19, we were screening about 2,200 patients per day in our offices. By week 2, we were down to 1,832, by week 3 we were down to 1,090, and as of [March 26], we were down to 722.

Sandip Basak, MD
President, University Radiology Group
April 7, 2020

On the state of New Jersey’s map of coronavirus infections, University Radiology Group’s (URG) service area overlaps precisely the hardest hit counties. During his segment of the Covera Health webinar on March 26, “Managing Covid-19 on the Front Lines,”Sandip Basak, MD, president, University Radiology Group, offered a chilling account of a busy, thriving practice serving multiple hospitals and imaging centers devolving into a skeleton crew intent on protecting patients, employees, shareholders, and locations during the Covid-19 siege.

URG is a 140-radiologist practice with 744 employees that interprets 1.8 million radiology exams annually in 10 hospitals and 22 ambulatory offices including an academic medical center. Its first introduction to the virus was on Feb 14. “We had an employee in China, 461 miles east of Wuhan,” Dr. Basak said. “She was there since January 1, and not returning until February 25th, and wanted to know what do on her return. Our director of nursing emailed our infectious disease consultant and the answer was 14-day quarantine.”

Dr. Basak then outlined actions taken during the next three weeks, providing useful insights on protocols for screening patients, managing referrals, determining essential versus non-essential imaging, and protecting staff from illness.

Week 1: March 1-7—A Growing Sense of a Threat Abroad

With concern growing over the situation in China and Europe, URG held its first internal meeting in response to the threat. “We really had more questions than answers,” he shared, but the meeting resulted in two employee communications based on CDC guidelines which:

  • Outlined infection control policies
  • Emphasized that PPE removal from office would not be tolerated
  • Required employee/radiologist to notify nursing department prior to return to work if they had traveled outside US or to a high-risk US location; and required clearance from nursing department for those patients prior to return
  • Created a dedicated email address for Covid-19 questions and concerns

“We did not institute verbal screening of patients at this time,” he said.

Week 2: March 8-14—From Recognition to Action

As URG moved into the second week, the practice experienced a major pivot in its perspective of the pandemic, significantly escalating the organization’s preparation. They:

  • Formed a Covid-19 task force that met 7 days a week: Pres, CEO, COO/CIO, Directors of Patient Access, Clinical Ops and Nursing, Marketing, and HR
  • Aggressively started screening employees and patients
  • Instituted a ban on all non-essential travel
  • Limited attendees of in-person meetings to 10 and strongly urged that all meetings be teleconferenced
  • Reassigned many radiologists and business office employees to work from home, requiring rapid mobilization of IT resources for employee reassignment
  • Enhanced employee screening with verbal screening; clinical criteria included fever over 100 degrees, cough, shortness of breath in addition to travel history
  • Began verbally screening patients who presented on-site for clinical symptoms and travel
  • “By the end of second week, we had a discussion with Dr Mickey on her invaluable experience on the West Coast,” Dr. Basak shared. “We knew she was several weeks ahead of us.”

Based on discussions with Dr. Mickey, URG made the following changes to screening guidelines:

  • Stopped travel criteria and assuming community spread
  • Modified clinical criteria to new shortness of breath, new cough, temp of 100

This discussion also informed the reversal of a decision to quarantine all employees of an imaging center in Teaneck and close the location. The manager of the Teaneck location had no symptoms, but her husband was sick, and a sibling had tested positive and was hospitalized. The manager self-quarantined and based on consultation with the NJ Department of Health and the infectious disease consultant—who recommended quarantining the entire staff for second degree exposure—the center was closed.

“Within 24 hours, we decided that this was not the best way to go, that quarantining second- and third-degree exposure would not be tenable long term,” Dr Basak shared. “We reversed the decision the next day.”

Meanwhile, the following policies and recommendations were issued:

  • Barnabas Health System stopped allowing visitors and elective surgeries; URG’s other hospital clients quickly followed suit.
  • The following week, ACR advised [March 15] medical facilities to reschedule non-urgent visits as necessary, including screening mammography, lung cancer screening, non-urgent CT, US, plain film x-rays and other non-emergent or elective radiologic and radiologically guided exams and procedures.

URG interpreted the ACR advisory to pertain primarily to hospitals and surgery centers to allow for mobilization and conservation of PPE, medical equipment, and clinical resources and did not restrict procedures at its imaging center locations. “We continued to do diagnostic imaging including screening and diagnostic mammography,” Dr. Basak said.  

URG did implement the following clinical care policies:

  • Began to triage interventional procedures and prioritized urgent to be done sooner rather than later.
  • Decreased the number of outpatient IR days and we asked IRs and patients to wear surgical masks in cases where the IRs face would be close to patients, such as in thyroid biopsies.
  • Categorized hospital IR cases as elective, urgent and emergent.
  • Postponed hospital outpatient IR that could result in a hospitalization, needing an ICU bed or ventilator, require a blood transfusion
  • Triaged biopsies of lymph nodes and solid organs were triaged on case-by-case basis: Routine biopsies were postponed but procedures for cancer patients continued, including ports, biopsies, tunneled catheters, thoras and paras for symptomatic patients and biopsies for cancer patients

Week 3: March 16-20—Screening Volumes Declined by Half

By week three, the vast majority of URG’s business office employees were working from home, as were many radiologists. At the beginning of the week, office staff remained relatively unchanged, but management quickly realized that office volumes were drastically declining. “Pre-Covid-19, we were screening about 2,200 patients per day in our offices,” Dr. Basak explained. “By week 2, we were down to 1,832, by week 3 we were down to 1,090, and as of [March 26], we were down to 722.”

URG instituted several new policies that week:

  • Schedulers began verbally screening patients by phone, and high-risk patients were not scheduled in the office.
  • Limited screening mammography to five offices, further limited IR procedures, closed four low-volume offices, reduced office hours practice-wide from 8 AM to 6 PM and closed offices on weekends.
  • Reduced radiologist staffing in hospitals and suspended anesthesia/sedation procedures in two flagship offices.
  • Reduced hours for most but not all employees, placed some on leave of absence and others took voluntary leave.

URG’s priority in all HR decisions was to protect employee health insurance.

Week 4: March 22-26: Where We Are Now?

As of March 25, office volumes were down 66%, and hospital volumes had declined by 33% and continue to decline.

“It still feels like we are in the fog of war,” Dr. Basak said. “By the end of this week we will have closed 9 offices and significantly reduced hours in all others. We expect additional office closures next week.” URG also made the decision to:

  • Stop doing screening mammography as of March 27.
  • Have patients wait in their cars after they came into the center to register, and text them when it is time to come in and be imaged
  • Stop imaging of high-risk patients—no exceptions
  • Add new clinical criteria: new onset of loss of smell or taste
  • Drastically reduce the number of radiologists and employees on the schedule.

Over the past three weeks, seven employees have been quarantined—currently down to just three—all asymptomatic with no conversions. “Luckily,” Dr. Basak noted. “We’ve allowed our staff to wear masks upon request, but we have not required it, recognizing the shortage of PPE.” Daily Covid-19 meetings continue.

“I’ve gone over numerous difficult and troubling concepts,” Dr. Basak concluded. “I want to remind everyone that this crisis will end, but before we finish, I can share a few insights from University Radiology.”

URG Recommendations

  • Organize a task force early on with your key leaders and meet daily.
  • Keep minutes—there will be a lot of info flowing back and forth and very important to communicate those issues at next meeting and to others.
  • Maintain daily communication with office managers and directors to understand what is happening on the ground.
  • Obtain as much data as possible to guide decisions and present in an organized format. URG created a daily dashboard to look at volumes, future scheduled studies, no. of furloughed radiologists and employees, no. of quarantined employees and radiologists.
  • Communicate frequently and clearly with radiologists and employees to reduce anxiety
  • Listen to employees and radiologists—everyone will have an opinion and not everyone is right, but it is important to listen.
  • Understand that balancing safety with employment while providing the community with non-Covid-19 imaging services is extremely difficult.
  • Try to stay one step ahead, but don’t react impulsively.
  • Be creative and decisive.
  • Above all, stay calm.

Dr. Basak thanked everyone at URG for their patience, understanding, and tolerance during this very difficult time.

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