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Official Publication of SDCMS

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Antimicrobial Stewardship in Long-Term Care Facilities  Antimicrobial Stewardship in COVID-19 Patients and Co-Infections  Preventing the Spread of Candida auris During the COVID-19 Pandemic  Seeing the Forest Despite the Trees

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Contents OCTOBER

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder


OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS. org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]





Antimicrobial Stewardship in Long-Term Care Facilities By Bridget Olson, RPH, and Michael Butera, MD


Antimicrobial Stewardship in COVID-19 Patients and Co-Infections By Travis Lau, PharmD, and John Engelbert, PharmD, BCIDP


Preventing the Spread of Candida auris During the COVID-19 Pandemic By Liz Jefferson, BS, PhD


Briefly Noted: Public Health • Prescription Drugs • Practice Management


Making a Connection Count By Adama Dyoniziak




What Lessons Did We Learn From COVID-19? By David L. Feldman, MD, MBA, FACS, and Laura Kline, CPCU, MBA

Seeing the Forest Despite the Trees By Mark H. Sawyer, MD




October 2020



CMA President Issues Statement on County Health Officer Resignations California Medical Association President Peter N. Bretan, Jr. MD, issued the following statement in response to recent county public health offer resignations: The California Medical Association (CMA) is severely troubled by the recent resignations of county public health officers in Placer and Humboldt counties. Earlier this month, Teresa Frankovich, MD, announced her resignation as Humboldt County health officer, citing stress and fallout from COVID-19 as her reasons for leaving her post. In Placer County, Aimee Sisson, MD, announced she will be leaving her post later this month after the Placer County board of Supervisors ignored her advice and opted to end the county’s COVID-19 state of emergency. The nearly 50,000 members of the California Medical Association want to offer our thanks to Drs. Frankovich and Sisson for their public service. Their departures now bring to 10 the number of county health officers who have resigned or left their positions since COVID-19 erupted on the scene in March. These physicians, and dozens of others who serve as county health officers around the state, have been on the front lines of the worst pandemic in recent history, and have come under intense political — and sometimes personal — pressure and attacks. Dr. Sisson’s resignation is a reminder that too often, politics continue to trump science in our policymaking. CMA is alarmed that basic science has become politicized in so many parts of our state and our country. Public health officers are public servants who seek to do what their job description states: to protect public health. They use science and medical expertise to make their decisions. CMA wants to commend public health officers around the state for the bold and courageous work they do every day to keep their communities safe, often in the face of political pressure and personal attacks. These important roles will become increasingly difficult to fill if the recommendations of public health officers are ignored, and those who serve continue to be subject to personal attack. We are all tired and weary after months of dealing with COVID-19. We understand that millions of Californians are struggling economically, and that mental health concerns from shelter-in-place orders are very real. But if we are to get through this pandemic together, we must listen to what the science tells us and continue to rely on the wisdom and guidance of those who have the expertise to best protect the public health.

Anthem PPO Added to Specialty Medication Policy ANTHEM BLUE CROSS RECENTLY

notified physicians that effective Dec. 2, 2020, it will expand its specialty medication policy to also apply to its commercial PPO and EPO plans. The new PPO policy, effective for dates of service on or after Dec. 1, 2020, mirrors policy previously implemented for Anthem’s commercial HMO and Medi-Cal managed care plans and will require that certain specialty pharmacy medications administered in the office or outpatient hospital setting be obtained exclusively through CVS Specialty pharmacy. The California Medical Association (CMA) remains concerned with the requirement to utilize CVS Specialty, citing its potential disruption of patient care and impact upon physician practices. CMA and several specialty medical associations had previously sent a joint letter to Anthem asking that it delay implementation of the specialty pharmacy policy. CMA is also concerned that, while Anthem first announced the policy change for its commercial HMO in April, it doesn’t appear that the payer has issued any further reminders to physicians about the July 1 effective date. Physicians who are unaware of the policy’s implementation and do not utilize CVS Specialty will, according to the notice, have their claims denied. These specialty medications are hard costs that the physician will have no way of recouping. CMA and the specialty societies are extremely concerned that implementation of this policy will cause further financial damage to practices at a time when 75% of physicians are experiencing a revenue decline of 50% or greater due to the COVID-19 pandemic. Anthem, in response to our concerns, advised it would not delay implementation of its new policy.



(AMA) recently released the 2021 Current Procedural Terminology (CPT) code set, which includes the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services. According to AMA, these foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking. The changes to CPT codes ranging from 99201 to 99215 are proposed for adoption by the Centers for Medicare and Medicaid Services (CMS) on Jan. 1, 2021. The E/M office visit modifications include: • Eliminating history and physical exam as elements for code selection. • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making or total time. • Promoting payer consistency with more detail added to CPT code descriptors and guidelines. The revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, and 69 revisions. The CPT code set continues to see growth in new and novel areas of medicine, with the majority (63%) of new codes this year involving new technology services described in Category III CPT codes and the continued expansion of the Proprietary Laboratory Analyses section of the CPT code set. Changes to the CPT code set are considered through an open editorial process managed by the CPT Editorial Panel, an independent body convened by AMA that collects broad input from the healthcare community and beyond to ensure CPT content reflects the coding demands of digital health, precision medicine, augmented intelligence, and other aspects of a modern healthcare system. This rigorous editorial process keeps the CPT code set current with contemporary medical science and tech-

nology, so it can fulfill its vital role as the trusted language of medicine today and the code to its future. Among this year’s important additions to the CPT code set are new medical testing services sparked by the public health response to the COVID-19 pandemic. The CPT code set has been modified with several code additions and revisions that have been approved for immediate use and published for the 2021 CPT code set. The CPT code set continues to be modified to respond to the fast-paced innovation among digital medicine services that can improve access to healthcare and improved health outcomes for patients across the country. This is illustrated by new codes for retinal imaging and external extended electrocardiogram (ECG) monitoring. The addition of code 92229 for retinal imaging with automated point-of-care, and revision of codes 92227 and 92228, better support the screening of patients for diabetic retinopathy and increase early detection and incorporation of findings into diabetes care. Innovative solutions like the augmented intelligence technology described by new code 92229 have the potential to improve access for at-risk patient populations by bringing retinal imaging capabilities into the primary care setting. Technological advances in the field of continuous cardiac monitoring and detection have prompted the addition of codes 93241, 93242, 93243, 93244, 93245, 93246, 93247, and 93248, along with associated guideline revisions. These codes will replace Category III codes 0295T, 0296T, 0297T and 0298T, which were deleted. These new codes utilize an innovative algorithmic technology that works in concert with a patch that is much easier to wear for patients and provides more accurate and complete data for physician interpretation. To assist the healthcare system in an orderly annual transition to a newly modified CPT code set, the AMA releases each new edition four months ahead of the Jan. 1 operational date and develops an insider’s view with detailed information on the new code changes.

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ntibiotic prescribing in long-term care facilities (LTCF) has long presented many challenges. The vulnerability of this cohabited patient population, with their multiple comorbidities and more invasive processes, has contributed to the increasing prevalence of multi-drug-resistant organisms, a higher incidence of Clostridiodes difficile (C.difficile) infections, and now, the burden of COVID-19 viral infections. Excessive exposure to antibacterials has come to the forefront of resistance concerns in recent years, with more attention now in the world of the current pandemic. California has again led the establishment of regulations through a series of Senate bills sponsored by Senator Jerry Hill, which require tracking of antibiotic-resistant infections and deaths, and a physician-supervised, multi-disciplinary Antimicrobial Stewardship Program (ASP) at all acute care hospitals (2014) and all LTCFs (2015). While the practice of Infection Prevention focuses on preventing infections and transmission between patients, Antimicrobial Stewardship offers a complimentary antibiotic expertise and coordination of various disciplines for goals of optimizing antibiotic use, improving 4

October 2020

safety associated with antibiotics, and decreasing the development of antibiotic resistance. Core elements of ASPs have been developed specifically for LTCFs by the CDC, while the California Department of Public Health has established more specific ASP guidelines and toolkits. Antimicrobial use can cause harm to patients through associated adverse events, including a major risk of associated C.difficile infection (CDI). The high rates of antibiotic use in LTCFs are driving increased rates of antibiotic resistance formation. More than 2.8 million infections, with >35,000 deaths occur each year in the U.S., as a direct result of antibiotic-resistant infections. Decades of overprescribing and misuse of antibiotics have resulted in bacteria that are increasingly resistant, creating a growing threat of new superbugs that are difficult or even impossible to treat. The most alarming has been the emergence of carbapenem-resistant Enterobacteriacae (CRE).

In one study of post-acute care antibiotic use, 221 admissions to 7 different LTCF were analyzed: • 48% of residents received antibiotics • Prescribers relied on assessments made by someone else • 67% of antibiotics were ordered over the phone • 43% of LTCF-initiated antibiotic courses had no documentation of infection in the medical record Studies estimate that 30%–50% of inpatient antibiotic use may be considered inappropriate or unnecessary, with that figure as high as 75% in LTCFs. The majority of unnecessary antibiotic prescribing in LTCFs is driven by cultures of colonized sites of patients with endotracheal tubes, gastrostomy tubes, and asymptomatic bacteriuria. Asymptomatic Bacteriuria: Urinary tract infection (UTI) is the most common reason for antibiotic prescribing in LTCFs, accounting for 20-60% of systemic antibiotic courses. Asymptomatic bacteriuria (ASB) is a frequent finding in patients with abnormalities of the genitourinary tract that impair voiding, common in the LTCF population. Chronic indwelling catheters, and those with neurogenic bladder (spinal cord injuries, diabetes, and degenerative neurological diseases) usually cannot maintain a sterilized urine, even with antimicrobial use. The prevalence of ASB in LTCFs may occur in up to 50% of noncatheterized patients, with residents having pyuria without bacteriuria (30%) and with bacteriuria (90%). This makes the presence of pyuria insufficient for a diagnosis of UTI in LTCFs, and may only be useful for excluding UTI, if absent. Avoiding treatment of ASB is an important opportunity for decreasing unnecessary antimicrobial use. There are many aspects of LTCFs that contribute to the challenges of appropriate antibiotic prescribing: • LTCF patients are often advanced in age, with multiple comorbidities. • These patients may have invasive devices, previously reserved for acute care (central lines, chronic respiratory therapies, feeding tubes, in-dwelling urinary catheters, dialysis catheters, etc.) increasing the risk of device-associated colonization and invasive infection. • Frequent bacterial colonizations of infection sites exist, often with multi-drug-resistant organisms (MDROs) • Physician visits to LTC patients are only required monthly, allowing for more nurse-driven care, including decisions on when to culture and when to call physicians. • Antibiotics are often ordered over the phone, without proper patient assessments. • A consequent overuse of antibiotics results in the development of antimicrobial resistance and related complications. In the LTCF associated with our acute care hospital, our ASP found additional issues with the treatment of infections in LTCF patients: • On-call physicians needed guidance in dealing with calls for fevers after hours • Incomplete patient symptom reporting to physicians made patient evaluations and diagnoses difficult • Physicians were unsure of the best empiric treatment choices for the LTCF patients • Positive cultures and possible colonizations were often treated without considering the lack of clinical signs and symptoms of infection.



Fig 1a: Acute care culture growing 1 gram-negative rod. Fig 1b: LTCF respiratory culture colonized with many different bacterial organisms (B).

• Lack of follow-up of cultures to de-escalate or to stop antimicrobial agents Strategies were implemented at Sharp Coronado Hospital & Villa Long-term Care Facility, a small 181-bed community hospital with 59 acute care beds and 122 LTC beds, for patient workups and processes to aid in antibiotic prescribing: 1. Antimicrobial Stewardship Program with ID physician oversight 2. LTCF Fever/Suspected Infection Protocol with processes to ensure symptoms support antibiotic use: • Multi-disciplinary approach for evaluation of patients for initiation of antibiotics, reporting of symptoms, empiric treatment and follow-up (nurses, respiratory therapists, infection preventionists, pharmacists, and physicians). • Comprehensive patient assessments ensured in a checklist format, based on the Loeb Criteria, published guidelines that standardize identifying factors for infections in LTCF patients, who are often difficult to assess. The identification of infections should never be based on a single piece of evidence, but should always consider the clinical presentation, in addition to microbiologic and radiologic information. The criteria are provided for four main categories of infections: o Urinary tract infection (UTI) o Respiratory infection o Skin and soft tissue infection o Fever of unknown origin Prior to contacting the physician, nurses complete the patient assessment and review with the pharmacist, who considers the micro history, conferring with nursing to provide a recommendation for either continued observation or specific antibiotic treatment. Our ID specialist is available to review and recommend on more complicated cases, with the ASP pharmacist or RN. • Order sets with ID-physician recommended therapy and labs: Empiric antibiotic therapy (including durations) is defined, based on facility site-specific micro history, antibiotic sensitivities and studies demonstrating shorter course therapy (<7 days) is equally effective as longer course treatment for the most common bacterial infections in LTCF patients. Specific patient therapy considers patient allergies, renal/ hepatic function, history of resistant organisms, culture results, and Loeb Criteria symptoms.



• Education of all disciplines covers the principles and goals of the ASP, including the importance of limiting unnecessary antimicrobials, the differences between colonization vs. infection, symptoms to look for, and consideration for other causes of symptoms (vs. infection). With infrequent physician visits, nurses are the eyes and ears for the physicians. Their patient assessments and reporting determine whether antibiotics are ordered. Education of all levels of nursing (RN, LVN, CNA) is essential, both initially and ongoing.

2009-Began probiotic use (Saccromyces + lactobacillus) May 2010-- PPI-->famotidine in LTC patients for GI prophylaxis Jun 2010--ASP activities extended to LTCF

3. Initiatives implemented to combat C.difficile infections have brought success in reducing the high incidence at our LTCF. • improved antimicrobial use through Antimicrobial Stewardship • reduced proton-pump inhibitor use to maintain protective acidity • probiotic therapy with daily Lactobacillus acidophilus, casei and rhamnosus (Bio-k+®) during and after antimicrobial therapy, to help maintain the fecal microbiome

Probiotic Policy LTCF: August 2016 2012-Probiotic change: to a 3-species Lactobacillus combination

Figure 2. Quarterly incidence of C. difficile infection at the Long-Term Care facility at Sharp Coronado Hospital from July 2008 through December 2018. Incidence is reported in the number of cases per 10,000 patient-days. Different phases of the infection prevention strategy are demarcated with a vertical line.

ASP Effects on Bacterial Resistance:

Fig 3. Comparative trends of Extended Spectrum Betalactamase (ESBL) formation of E.coli, the most common causative organism in UTI. LTC rates have decreased significantly, despite rising trends in the community.

Fig 4a-b. A 75% reduction in Fluoroquinolone use through ASP targeted actions of this class of antibiotics has allowed for increased levofloxacin susceptibilities of E.coli and Pseudomonas aeruginosa.


October 2020

COVID-19 Viral Infections and Antibiotic Use: Many patients hospitalized for SARs-CoV-2 (COVID-19) infections receive antibacterial agents in addition to treatments that have shown effectiveness against the virus. The WHO recommends against empiric antibiotic use in all mild-moderate COVID-19 patients, unless there is clinical suspicion of a bacterial infection (see Fig 5), reserving them for patients suffering from severe COVID-19, or for moderate cases of pneumonia in the elderly, especially those in LTCFs. Because the pandemic has caused a shift in resources away from antibiotic development, established ASPs at the patient care level will be critical to ensure judicious use of antibiotics. Summary and Conclusions: The establishment of ASP initiatives at Sharp Coronado’s LTCF has allowed for a better multi-disciplinary coordination of patient care, reduced bacterial resistance formation, and less transfers to acute care. Antimicrobial resistance remains a serious global threat. Antimicrobial Stewardship Programs have been shown to benefit LTCFs by helping to optimize antibiotic use, reduce complications of antibiotics, such as C.difficile infections (CDI), and to slow or even reverse the development of multi-drug-resistant organisms. ASPs, in combination with infection prevention practices, allow for a readiness to ensure appropriate antibiotic use in the treatment of COVID-19 viral infections in both hospitals and nursing homes. With CDI peaks typically occurring one to two months after respiratory infection peaks, appropriate antibiotic use is also

COVID-19 viral pneumonia may be more likely if the patient:

A bacterial cause of pneumonia may be more likely if the patient:

• Presents with a history of typical COVID-19 symptoms for about a week • Has severe muscle pain (myalgia) • Is breathless but has no pleuritic pain • Has a history of exposure to known or suspected COVID-19, such as a household or workplace contact.

• Becomes rapidly unwell after only a few days of symptoms • Does not have a history of typical COVID-19 symptoms • Has pleuritic pain • Has purulent sputum

Viral pneumonia more likely if:

Bacterial pneumonia more likely if:

• Insideious inset • Lower temperature • Tachycardia or tachypnea out of proportion to the temperature • A paucity of physical findings on pulmonary exam disproportionate to the level of disability • Bilateral positive lung finding

• Acute onset • Higher temperature • Unilateral positive lung findings

imperative in preventing a substantial increase in CDI cases following COVID-19 surges. Bridget Olson works for Sharp Healthcare in San Diego as a clinical hospital pharmacist with a specialty in infectious disease. She has developed strategies for reducing inappropriate antibiotic use in both acute and long-term care, which have been featured in training materials for CDPH, and a Pew publication, A Path to Better Antibiotic Stewardship in Inpatient Settings. Dr. Butera is a fellow of the Infectious Disease Society of America, past president of Infectious Disease Association in California, an epidemiologist at Sharp Coronado Hospital, and co-chair of the San Diego County Medical Society’s GERM Committee.

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When Do We Need Antibiotics? BY TRAVIS LAU, PHARMD, AND JOHN ENGELBERT, PHARMD, BCIDP “The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown” — H. P. Lovecraft


n Feb. 18, the San Diego GERM commission met to discuss COVID-19, and at the time only one local hospital had a confirmed case. COVID-19 arrived in late March at our hospital system in North San Diego County. By mid-April to the present, we have not had a day with less than 15 confirmed patients and at times had as many as 40 patients positive for COVID-19. In addition to providing the most effective therapeutics and supportive care, we have seen a very large increase in antibiotics use due to a concern of bacterial co-infections. Are antibiotics routinely required in COVID-19 pneumonia? The two cases below demonstrate the dilemma that healthcare providers often face in managing COVID-19 today: the decision to treat with antibiotics in the setting of COVID-19 pneumonia.


A 50-year-old male with history of diabetes and obesity presents to your emergency room with cough and progressively worsening shortness of breath over the last three days. He reports hosting a dinner party a week ago, with minimal social distancing. He shortly is requiring three 8

October 2020

liters of oxygen to maintain adequate oxygen saturation. Chest X-ray shows bilateral, ground-glass opacities and the COVID-19 PCR returns positive. Though his blood pressure and heart rate are stable, his inflammatory markers are mildly elevated. Procalcitonin is 0.12. Of note, he has leukocytosis with lymphopenia, is febrile and has a C-reactive protein (CRP) of 10, ferritin of 600, and d-dimer of 420.


A 60-year-old male with a history of diabetes and on dialysis reports the onset of his symptoms to be 10 days ago. He requires immediate intubation and transfer to the intensive care unit. Procalcitonin is 21 on admission, CRP is 21.1, ferritin is > 3000, and d-dimer is > 1000. Chest X-ray shows patchy airspace disease with the impression of severe pneumonia. COVID-19 PCR returns positive. He is requiring vasopressors to maintain adequate hemodynamics, has leukocytosis, and is febrile. He is started on ceftriaxone and later develops Clostridium difficile infection (CDI) after six days. As healthcare providers, we have a desire to heal. However, when faced with the unknown, it is difficult to ascertain what may truly benefit our patients. This is one of our greatest fears: the inability to help our patients. Seeing these cases six months ago, in the infancy of the pandemic, would have rightfully instilled fear

and uncertainty into many of us. When the first cases presented in the U.S. in February, many healthcare providers were navigating the unknown together. Over the course of the pandemic, a surplus of literature has been published, expanding our understanding of the virus and its clinical sequelae. Even today, additional data continues to surface on other treatments such as dexamethasone, remdesivir, tocilizumab, IVIG and convalescent plasma. An appreciation of increased risk of developing thromboembolic events has also gained attention as we ascertain proper anticoagulation in COVID-19 patients. As each day passes, more light is shed on how to best manage COVID-19. One area that remains to be elucidated is the addition of antibiotics for pneumonia co-infection. In the earliest data from Wuhan, 100% of patients were given antibiotics although bacterial infections were not common.1 What is the coinfection rate in COVID-19 patients? Does the co-infection rate differ depending on mild/severe or early/late presentation? What tools do we have to guide our decision to treat with antibiotics? What other medications might increase the risk? The decision to initiate, modify, or discontinue antibiotic therapy is the age-old quandary in antimicrobial stewardship. Though we have heard it is better to be safe, we must be mindful that good stewardship judiciously walks the line between over and undertreating. When faced with uncertainty, we tend to broaden antimicrobial coverage, but at the cost of increased selective pressure for resistant organisms and risk of CDI, as was the unfortunate consequence of the second patient case above. Though we do not want to miss the forest for the trees, we must first gain an appreciation for the coniferous artifacts that comprise the enigmatic jungle that is COVID-19.


Initial estimates of bacterial co-infection in COVID-19 was thought to be similar to those in influenza. During the 2009 A(H1N1) influenza pandemic, up to 30% of critically ill patients and 12% of noncritically ill hospitalized patients were reported to have a bacterial co-infection. However, data is emerging suggesting the rate in COVID-19 is fortunately much lower than we anticipated. A meta-analysis by Langford et al. included 24 studies

that evaluated patients with confirmed COVID-19 and reported the prevalence of acute bacterial infection.2 Bacteria detected from non-respiratory-tract or non-bloodstream sources were excluded. This review representing 3,338 patients reported bacterial co-infection on presentation occurred in 3.5% of patients. Secondary bacterial infections, those that developed during therapy, occurred in 14.3%. Overall bacterial infection was more common in studies including only critically ill patients (8.1%) compared to those including all patients (5.9%). Of note, 71.9% of all patients received antibiotics. Another systematic review and metaanalysis by Lansbury et al. found similar results concerning bacterial co-infection rate.3 The most common bacteria were Mycoplasma pneumoniae (42%), Pseudomonas aeruginosa (12%), and Haemophilus influenzae (12%). This is in contrast to influenza co-infections in which Staphylococcus aureus and Streptococcus pneumoniae are common co-pathogens. Based on the data from these two studies, it is reasonable to not empirically treat patients with mild to moderate COVID-19 on presentation with antibiotics, such as in our first patient case. As for critically ill COVID-19 patients, these are a caseby-case basis. Currently, the Surviving Sepsis Campaign recommends empiric antimicrobials in mechanically ventilated patients with COVID-19 and respiratory failure.4 The WHO recommend empiric antibiotics in patients they classify as severe COVID-19.5 This risk for developing co-infection increases the longer a patient is on corticosteroids, mechanical ventilation, and in particular, patients receiving the immunosuppressant tocilizumab. In septic patients that are critically ill, it may be reasonable to empirically cover for P. aeruginosa and methicillin-resistant S. aureus (MRSA). Evaluation of empiric coverage should follow that of current IDSA community-acquired pneumonia guidelines with daily assessment for treatment duration and de-escalation. Should anti-MRSA antibiotics be initiated for pneumonia, a negative MRSA nares screen is useful in narrowing therapy due to its high negative predictive value.6 A useful tool we can use to guide antibiotic initiation and duration is procalcitonin (PCT). .7 It is an inflammatory biomarker with a higher specificity for identifying bacterial infections when

Figure 1. Lower Respiratory Tract Infection (LRTI) Procalcitonin Algorithm by University of Nebraska Medical Center

compared to other markers such as CRP and ESR. It is most useful in differentiating bacterial from viral pneumonia. PCT rises within two to three hours in presence of a bacterial infection and the degree of the rise correlates with infection severity. PCT peaks at six to 12 hours and has a half-life of 20â&#x20AC;&#x201C;24 hours. Fungal infections may also increase PCT, although not to the same magnitude. One must be aware of other factors such as renal failure, recent major surgery, severe trauma or burns, prolonged cardiogenic shock, and small-cell lung carcinomas, which can increase PCT as well. Algorithms to guide initiation and de-escalation of therapy have been developed, such as the one by the University of Nebraska Medical Center (Figure 1).8 But can we use PCT reliably in COVID-19 to rule out bacterial co-infection? A study by Hu et al. showed PCT was not severely elevated even in critically ill COVID-19 patients despite other elevated inflammatory markers such as CRP, erythrocyte sedimentation rate, and ferritin. The study defined critically ill

Figure 2. PCT levels in COVID-19 patients (n=95) with differing severity of COVID-19. Data are the mean + standard deviation. * P <0.5; ** P <0.01; **** P <0.0001



as those requiring mechanical ventilation, in shock, or with other organ failure requiring intensive care unit admission (Figure 2).9 Therefore, PCT remains a useful tool in COVID-19. As patients remain ventilated for prolonged periods of time, the risk of nosocomial infections increases. COVID-19-associated pulmonary aspergillosis (CAPA) show a wide range of reported prevalence rates up to 30%.10 Though CAPA does occur in severe COVID-19, diagnosing CAPA is not a simple task. Obtaining a bronchoalveolar lavage specimen is difficult and is an aerosolizing procedure that increases risk of COVID-19 exposure. Of note, Bartoletti et al. reported probable CAPA in 27.7% of mechanically ventilated patients after a median 4 days from ICU admission.11 However, these patients were receiving methylprednisolone equivalent to 13 mg dexamethasone daily as well as tocilizumab which may significantly increase risk of secondary fungal infection due to immunosuppression.


In a relatively stable patient whose chest X-ray and biomarkers are not indicative of bacterial infection, it may be reasonable to not initiate antibiotics. PCT may be helpful to rule out bacterial pneumonia (consider a threshold of > 0.5 ng/mL to start antibiotics in patients with other elevated inflammatory markers). If antibiotics are started, then trending a PCT every two to three days can assist in deescalation. PCT is expected to decrease by approximately half every 24 hours based on the half-life if therapy is effective (though may be longer in renal impairment as PCT is ~30% renally cleared). In an intubated patient, decompensation may be investigated for a nosocomial bacterial or fungal pathogen. For further guidance, Armstrong-James et al. has an excellent example of a screening and diagnostic algorithm for CAPA.12 In summary, antibiotic stewardship during COVID-19 should apply the following principles: • Antibiotics should not be routinely

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prescribed in all patients with COVID-19 pneumonia. Bacterial co-infections appear to be lower than expected in COVID-19 pneumonia than other viral infections such as influenza. In COVID-19 bacterial co-infection, the causative pathogens are different from that of influenza. Although PCT is slightly elevated in COVID-19 due to the underlying inflammatory process, it remains a useful tool in determining if a bacterial pneumonia is present. If COVID-19 patients remain mechanically ventilated the risk of bacterial infections increases, especially if the patient is on corticosteroids and/or tocilizumab. Broad-spectrum antibiotic therapy may then be required. A MRSA nares screen is helpful in determining the need for MRSA-specific antibiotics. CAPA has been identified as the most common nonbacterial co-infection in critically ill patients with prolonged (~4 days) mechanical ventilation.

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October 2020

REFERENCES 1. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513. doi:10.1016/S01406736(20)30211-7. 2. Langford BJ, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and metaanalysis [published online ahead of print, 2020 Jul 22]. Clin Microbiol Infect. 2020;S1198743X(20)30423-7. doi:10.1016/j.cmi.2020.07.016. 3. Lansbury L, et al. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect. 2020;81(2):266-275. doi:10.1016/j.jinf.2020.05.046. 4. Alhazzani W, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/ CCM.0000000000004363. 5. World Health Organization. Clinical management of COVID-19: interim guidance. 2020. https://www.who.int/publications/i/item/

clinical-management-of-covid-19. 6. Dangerfield B, Chung A, Webb B, Seville MT. Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for MRSA pneumonia. Antimicrob Agents Chemother. 2014;58(2):859-864. doi:10.1128/AAC.01805-13. 7. Samsudin I, et al. Clinical Utility and Measurement of Procalcitonin. Clin Biochem Rev. 2017;38(2):59-68. 8. University of Nebraska Medical Center. Procalcitonin (PCT) Guidance. Accessed August 16, 2020. https://www.unmc.edu/intmed/divisions/id/asp/procalcitonin-pct-guidance/ index.html 9. Hu R, et al. Procalcitonin levels in COVID-19 patients. Int J Antimicrob Agents. 2020;56(2):106051. doi:10.1016/j.ijantimicag.2020.106051. 10. Alanio A, Dellière S, Fodil S, Bretagne S, Mégarbane B. Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19. Lancet Respir Med. 2020;8(6):e48-e49. doi:10.1016/S22132600(20)30237-X 11. Bartoletti M, et al. Epidemiology of invasive

pulmonary aspergillosis among COVID-19 intubated patients: a prospective study [published online ahead of print, 2020 Jul 28]. Clin Infect Dis. 2020;ciaa1065. doi:10.1093/cid/ ciaa1065. 12. Armstrong-James D, Youngs J, Bicanic T, et al. Confronting and mitigating the risk of COVID-19 Associated Pulmonary Aspergillosis (CAPA) [published online ahead of print, 2020 Jul 23]. Eur Respir J. 2020;2002554. doi:10.1183/13993003.02554-2020.

Travis Lau is a PGY-2 infectious disease pharmacy resident at Palomar Medical Center in Escondido. He graduated pharmacy school from the University of Colorado, Denver, and completed his PGY-1 pharmacy residency at Providence St. Peter Hospital in Olympia, Washington. John Engelbert is a board certified infectious disease pharmacist and is currently the antibiotic stewardship pharmacist and program director for the post-graduate year two infectious disease residency at Palomar Medical Center in North San Diego County.


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rior to the start of the coronavirus disease 2019 (COVID-19) pandemic in the United States, it was the “superbug” fungus called Candida auris (C. auris) that was making the news. The Centers for Disease Control and Prevention (CDC) classifies this pathogen as an urgent public health threat because it can cause invasive disease and can be readily transmitted in healthcare settings .1 Now with the COVID-19 pandemic in full swing, this multi-drug-resistant yeast cannot be forgotten especially with so many high-risk, critically ill patients. In 2016 the CDC reported the first cases of C. auris in the U.S. Now the organism has been identified in at least 30 countries, including 20 U.S. states.2 According to the CDC’s C. auris website (updated Aug. 13, 2020), there are now 1,238 confirmed clinical cases of C. auris in the U.S. More than 2,000 C. auris colonization cases have also been identified through targeted surveillance screening. 3 The cases of C. auris are believed to have arisen from persons who have had international healthcare and returned to the U.S., where transmission occurred in healthcare settings. 3 The first case of clinically significant C. auris was reported in 2009 when an isolate was recovered from the external ear canal of a Japanese patient. 4 Interestingly, whole-genome sequencing of C. auris isolates show at least four distinct geographic clades (South Asia, East Asia, South Africa, and South America) where C. auris is believed to have simultaneously emerged. 5 How and why C. auris emerged are questions that largely remain unanswered. 12

October 2020


A significant difference between C. auris and other Candida species is that C. auris is a skin colonizer while the majority of other clinically significant Candida species (except for C. parapsilosis) are human gastrointestinal tract colonizers.6 C. auris can be shed from the skin of colonized patients, contaminating the patient’s environment and creating a reservoir for transmission. 7 Large-scale outbreaks in the United Kingdom8 have been associated with multi-use axillary thermometers, while in Spain, multi-use blood pressure cuffs were to blame. 9 C. auris is a hardy yeast and requires an Environmental Protection Agency (EPA) registered, hospital-grade disinfectant effective against Clostridioides difficile (C. diff.) spores (List K). Many hospital-grade disinfectants will not work.3 Another challenge with C. auris is that it has been misidentified using traditional biochemical methods for yeast identification. Accurate identification of C. auris requires the use of DNA sequencing or mass spectrometry. The CDC provides excellent guidance to laboratory staff for C. auris identification.3 Furthermore, the local and state public health authorities can arrange for free C. auris testing through the CDC’s Antibiotic Resistance Laboratory Network (ARLN). Lastly, C. auris can be challenging to treat, and consultation with an infectious disease specialist is advised. The CDC reports that 90% of the C. auris isolates in the U.S. are resistant to fluconazole, 30% show resistance to amphotericin B, and 5% are resistant to echinocandins.3 Bloodstream infections can be persistent and difficult to treat, and crude mortality rates of approximately 30%–60% have been reported.3 Treatment of disease should be guided by antifungal susceptibility testing results, although echinocandins are recommended for empiric therapy.10 The majority of U.S. cases of C. auris have been in New York, New Jersey, and the Chicago area, but cases are popping up in California now. In May 2019, the first cases of C. auris in Southern California were described in a Los Angeles County Department of Public Health alert.11 The majority of these patients were from Long Term Acute Care facilities.


In March of 2020 as the first COVID-19 patients were being hospitalized, the first clinical case of C. auris was identified at a local San Diego hospital. The hospital’s microbiology lab identified C. auris from a wound infection isolate using matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF). Prior to admission the patient had received healthcare in a country known to have C. auris transmission. Hospitalization abroad is an automatic trigger for contact isolation and screening for carbapenemase-producing organism (CPO) colonization. The patient was found to be colonized with a CPO early in the hospitalization. When CPOs are identified in patients with hospitalization abroad, San Diego Public Health recommends that patients be screened for C. auris colonization.3,12 An axilla and groin composite swab tested positive for C. auris colonization (test performed by ARLN arranged by San Diego Public Health). This case highlights the importance of CPO surveillance screening for the early detection of C. auris colonization.


The identification of just one case of C. auris requires aggressive action to prevent a subsequent hospital-associated outbreak. With guidance from San Diego Public Health and the California Department of Public Health (CDPH), a containment plan was developed. Both the CDC and CDPH websites have excellent detailed guidelines for preventing the spread of C. auris . 3,13 All screening swabs have been negative for C. auris to date. Furthermore, the index patient recovered and later tested negative for C. auris colonization.


The prompt identification, management, and containment of patients infected or colonized with C. auris require collaboration by hospitalists/ intensivists, microbiologists, infectious disease experts, and infection control and prevention practitioners. Table 2 summarizes some key action items when C. auris colonization or infection is suspected or detected.

Keep a high level of suspicion

• Patients who have received healthcare outside of the U.S. especially in countries where C. auris is prevalent • Patients infected or colonized with CPOs • Patients on a mechanical ventilator or have a tracheostomy who are being transferred from long-term acute care facilities or from skilled nursing facilities. • Patients who fail to respond to empiric antifungal therapy and from whom an atypical or unidentified yeast is isolated

Consult with infection prevention, microbiology, and infectious disease

• Be aware of the yeast identification methods used by your lab and refer suspicious or confirmed isolates to the laboratory for further testing. • Request the laboratory to identify the species of Candida isolates obtained from both sterile and non-sterile sitesparticularly from patients with a high risk for C. auris. • Antifungal susceptibility testing is recommended for all clinical C. auris isolates. Treatment of disease should be guided by antifungal susceptibility testing results, although echinocandins are appropriate for empiric therapy pending these results. • Early consultation with an infectious disease expert is recommended especially given the possibility of the emergence of pan-resistance and treatment failure. • Treatment of asymptomatic colonization is not recommended.

Prevent an outbreak

• Notify local public health officials immediately (C. auris is publically reportable to the local health department and the CDC). • Notify the infection prevention and control team. • Be vigilant with shared patient equipment such as stethoscopes. Be sure to wipe them down with an EPAregistered, hospital-grade disinfectant effective against C. auris or C. diff. • Order composite swab of axilla and groin to test for C. auris colonization as requested by infection prevention and/or public health authorities. • Remove invasive devices (such as urinary catheters, central venous catheters, and endotracheal tubes) as soon as possible to reduce the risk of invasive infections from colonized patients. • Be sure to inform the transferring facility of the patient’s C. auris status. SanDiegoPhysician.org



Patients who develop candidemia caused by C. auris usually have risk factors in common with patients with disease caused by other Candida species. These include hospitalization and, in particular, admission to an intensive care unit, use of central venous catheters, surgeries, and exposure to broad-spectrum antibiotics or antifungals. The COVID-19 pandemic has brought C. auris a new population of patients to potentially infect. Early detection of both infected and colonized patients is critical to prevent the spread of C. auris. There have been unprecedented challenges during the COVID-19 pandemic. The pandemic has caused shortages in personal protective equipment, masks and disinfectants. The

shortage of sporicidal disinfectants could allow C. auris to spread from unidentified colonization cases. Since the start of the pandemic, an outbreak of C. auris has already been described in a Los Angeles County Health Alert Network issued on July 17, 2020 titled: “Resurgence of Candida auris in Los Angeles County”.11 It is critical that healthcare systems are optimized to prevent the spread of C. auris. During the COVID-19 pandemic this optimization may fall short. Dr. Wun-Ling Chang, infectious disease physician and medical director at Scripps Memorial Hospital La Jolla, believes that “in pandemic mode or not, continuation of surveillance and good infection prevention measures are key to protecting the spread of infections by these present and emerging resistant organisms.”

References: 1. Antibiotic Resistance Threats in the United States 2019: https://www.cdc.gov/ drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf 2. Tsay S., Welsh R.M., Adams E.H., et. al. Notes from the field: ongoing transmission of Candida auris in health care facilities - United States, June 2016-May 2017. MMWR Morb. Mortal. Wkly Rep. 2017; 66 : 514-515. 3. Centers for Diseases Control and Prevention Candida auris website: https:// www.cdc.gov/fungal/candida-auris/index.html 4. Satoh K., Makimura K., Hasumi Y., Nishiyama Y., Uchida K., Yamaguchi H. Candida auris sp. nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanese hospital. Microbiol Immunol. 2009; 53:41-44. 5. Lockhart S.R., Etienne K.A., Vallabhaneni S., et al. Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by wholegenome sequencing and epidemiological analyses. Clin. Infect. Dis. 2016; 64:134-140. 6. Lockhart S.R., Berkow E.L., Chow N., Welsh R.M. Candida auris for the clinical microbiology laboratory: not your grandfather’s Candida species. Clin. Microbiol. News 2017 July; 39 (13): 99-103. 7. Piedrahita C.T., Cadnum J.L., Jencson A.L., et. al. Environmental surfaces in health-care facilties are a potential source for transmission of Candida auris and other Candida species. Infect. Control Hosp. Epidemiol. 2017; 11, 1-3. 8. Madder H., Moir I., Moroney R., Butcher L., Newnham R., Sunderland M., Clarke T., Foster D., Hoffman P., Moore G., Brown C. S., Jeffery K.J.M. Multi-use patient monitoring equipment as a risk factor for acquisition of Candida auris. bioRxiv 2017:149054. 9. Gordon M., Ruiz J., Villarreal E., Sáez Esteve I., Simó Martín C., Pérez Riera I., Gil L.Á., Castañeda Segura M.J., Ruiz A., Frasquet J., Peman Garcia J., et. al. First report of a textile environmental reservoir outbreak of Candida auris in a medical intensive care unit. In ECCMID April 22, 2018, Madrid, Spain. 10. Pappas P.G., Kauffmann C.A., Andes D.R. et. al. Clinical Practice Guidelines for the Management of Candidiasis 2016 Update by the Infectious Diseases Society of America. Clin. Infect. Dis. 2016, 62, e1-e50. 11. Los Angeles County Department of Public Health Alerts: http://publichealth. lacounty.gov/lahan/ 12. California Department of Public Health CRE website: https://www.cdph. ca.gov/Programs/CHCQ/HAI/Pages/CRE_InfectionPreventionStrategies.aspx 13. California Department of Public Health Candida auris website: https://www. cdph.ca.gov/Programs/CHCQ/HAI/Pages/Candida-auris.aspx


October 2020


Grace, Kang, Senior Public Health Nurse, Epidemiology and Immunization Services Branch, County of San Diego Health & Human Services and the California Department of Public Health. Liz Jefferson is an infection prevention and epidemiology scientist with Scripps Memorial Hospital La Jolla.


Making a Connection Count By Adama Dyoniziak

Priya Kalyan-Masih, MD

Priya interpreting for a patient before surgery



serving the community and all things Spanish (culture, food, language). My happiest days while volunteering … were when I would get to speak Spanish to a patient, even for 20 minutes.” Dr. Priya Kalyan-Masih, a native New Yorker, enjoys bridging the gap between the patient and the doctor, and having the background and knowledge to ensure clarity during a medical appointment. Dr. Kalyan-Masih volunteered as a Spanish interpreter during high school at a local prenatal clinic. She received her BA in Spanish with a pre-med track at Trinity College in Connecticut. Her career has included post-baccalaureate research in spinal cord injury in Puerto Rico, a medical degree in Guadalajara Mexico, an internship program in Puerto Vallarta, and a Postdoctoral Research Fellowship on the interplay between diet, post-traumatic stress disorder (PTSD), and mild

traumatic brain injury at Loma Linda University School of Medicine. All of this work came to a halt in 2015 when her car was rear ended by a semitruck on the freeway. It was a miracle that she walked away with only a backache and a totaled car. Her severe post-traumatic stress disorder, along with her need to be of service in medicine and the Spanish language, led her to Champions for Health. “The organization’s completely aligned with mine,” Dr. Kalyan-Masih says. “Providing medical care to those that don’t have access to healthcare and providing medical interpretation for their appointments: Say what?! I see you, God!” Two years and 300-plus hours later as a volunteer medical interpreter for Project Access, Dr. Kalyan-Masih was awarded Medical Interpreter of the Year at the Champions Soiree in 2019. “I love volunteering for Champions for Health,” she says. “You get respected as an interpreter here. There is so much you can do like

surgery day, blood pressure screenings, immunizations, and Speaker’s Bureau presentations.” Dr. Kalyan Masih goes nonstop in her personal life too: She’s a wellness coach, experimental chef, LA Galaxy soccer fan, and succulent garden master. She also volunteers as an interpreter with Casa Cornelia for victims of human and civil rights violations, and is an active member with the Association of Translators and Interpreters in the San Diego Area (ATISDA). She is studying for her board exams in order to practice in the U.S. “Through these overlapping experiences, I have rediscovered my why and found my way in a niche market that I craved but didn’t know existed or how to find,” she says. “I am combining my MD from Mexico, fluency of Spanish, and love of community outreach all into one. I’m able to bridge the gap in a population that I love that is often ignored in today’s society. It’s clear to me now, almost two years later, that my car accident was the best thing that happened to me!” Make your connection count: To share your time and talent with our most vulnerable San Diegans through Project Access, please contact Adama Dyoniziak at adama.dyoniziak@championsfh.org or call (858) 300-2780. Also, help us help others by sharing your treasure and click on the donate button at www.championsforhealth.org. Adama Dyoniziak is executive director of Champions for Health.





e are all anxious, if not desperate, for a Sars-CoV-2 vaccine. The media pepper us every day with updates on progress toward one. I am optimistic we will have one in 2021, but in the meantime, it would be wise if we refocus our efforts and our patientsâ&#x20AC;&#x2122; attention on regular vaccines. Right now, we are behind, a gap created by closed offices and parents/patients being reluctant to come in for routine care. The figure from the California Department of Public Health shows the difference in routine vaccine delivery in children across California, as indicated by delivery of MMR vaccine, this year compared to last. There is a big gap from March to June that, so far, hasnâ&#x20AC;&#x2122;t been made up. Presumably there is a similar gap for adults who have been staying home as well.

On top of that we have our usual gap in uptake of annual influenza vaccine. Based on CDC data nearly 40% of children and 55% of adults do not get an annual influenza vaccine . Among the highest risk group for hospitalization and death from influenza, adults 65 years of age or older, 40% do not get immunized. We all know that influenza vaccine is not as effective as we would like, but there is ample evidence that it prevents hospitalization and death in all age groups . This year three of the four strains in influenza vaccines are new, making it more important than usual to get immunized so that you are protected from antigenically drifted strains. There are new influenza vaccine products available this year and almost all are quadrivalent, containing two influenza A and two influenza B strains.

Data from the California Immunization Registry


October 2020

It won’t take long for us to be reminded how important community immunization levels are. Outbreaks of measles, mumps, varicella, and pertussis are right around the corner if we don’t catch up. Likely these outbreaks will start when schools get back in session, colleges restart, and people start mixing again. We can hope that mask wearing and the distancing we are practicing will help, but vaccinating our patients will work better. The challenge we face is convincing our patients, who have been told to stay home. As providers we need to continue to send the message that it is safe to come into the office or clinic and that we are open for business. One important step in that effort is careful attention to infection control in the office. This will help maintain our patients’ confidence that they won’t get COVID by coming in for a checkup and vaccines. Another vital step is to take advantage of opportunities to vaccinate outside of routine preventive visits. Use sick visits and follow-up visits to check every patient’s immunization record and catch them up with needed vaccines. Set up prompts in the chart to remind everyone to check immunizations. If you don’t already use standing orders to deliver vaccines in the office, you should. This is an evidence-based practice proven to improve immunization delivery. Connect to the San Diego Immunization Registry maintained by San Diego County Health and Human Services Agency. This is a countywide database of vaccine records that exchanges data with San Diego Health Connect, community pharmacies, schools, and public health clinics. Seamless interfaces with your electronic medical record make it easy to find vaccines given to your patients elsewhere and to accurately determine what they are missing. The importance of focusing efforts on influenza vaccine delivery can’t be overstated. Imagine the hospital and ICU census with both influenza and Sars-CoV-2 raging at the same time — we will be right back to the days where we are running out of personal protective equipment and counting every ventilator. The good news is that there should be a good supply of

influenza vaccine this year and no delays in shipment are anticipated. In addition to our offices, community immunization sites such as pharmacies and outreach efforts to specific facilities (e.g. skilled nursing facilities and group homes) should provide enough infrastructure to deliver this year’s vaccine. We need to get our patients in to get immunized. We can increase demand for influenza vaccination by reminding our patients that if they get influenza with symptoms identical to COVID, they may be placed on quarantine for up to 14 days. Worse yet, imagine getting both Sars-CoV-2 and influenza infections back to back. That will lead to weeks and weeks out of school and work, not to mention the morbidity and mortality of each of these potent viruses. Our work is cut out for us because so much attention is being paid to SarsCoV-2 and a vaccine to prevent it. It is no wonder that other routine health issues are being ignored. Let’s work together to help our patients remember the importance of routine immunizations, that it’s safe to come into our offices and clinics, and that influenza vaccine is really important this fall. Let’s not lose sight of the forest for the trees and replace one epidemic with another one. Dr. Sawyer is a professor of clinical pediatrics and a pediatric infectious disease specialist at the UC San Diego School of Medicine and Rady Children’s Hospital San Diego. He is the medical director of the UCSD San Diego Immunization Partnership.



CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or Sub-Investigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential. Our team of Clinical Research Professionals will conduct the clinical trials under your supervision. Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact jsaleh@ paradigm-research.com or anguyen@paradigm-research. com or Afalconer@paradigm-research.com PHYSICIAN OPPORTUNITIES NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego CountyHigh Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link below to be directed to our website to learn more about our organization and view our careers page. www.Nhcare.org PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other lowincome, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at 844-200-2426, Ext 1046 or at crubio@samahanhealth.org DEPUTY PUBLIC HEALTH OFFICER - COUNTY OF SAN DIEGO: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Salary: $220,000-$230,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy and procedure, developing strategy, and overseeing quality assurance and quality improvement efforts for County of San Diego health services programs. Salary: $190,000-$200,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. For more information click here. FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@ gmail.com. Immediate opening. INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice


October 2020

opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and EMR. Interested parties, please email lisas@ sdsm.net CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811. PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides familyfocused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130,000-$150,000 annual compensation, up to 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds.sdcoxmail. com or 619-504-5830 with resume in .doc, .pdf or .txt. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at 760-291-6637/nshields@ graybill.org. You may view our open positions at: https:// jobs.graybill.org/ BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@ grossmontdermatology.com PHYSICIAN CONSULTANT FULL-TIME: San DiegoImperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application. DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https://www.governmentjobs.com/careers/ sdcounty/jobs/2359704/deputy-public-health-officer19092204u?keywords=Deputy%20Public%20health%20 &pagetype=jobOpportunitiesJobs

TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.Bhatia@sdcounty.ca.gov or call (619) 542-4008. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCareaffiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www. sharp.com/sharpcare/ or email interest and CV to glenn. chong@sharp.com PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowship-trained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position. Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 977-6300 or email Ngoc.B.Truong@dmu.edu. PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at 760-943-1011. CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research.Contact E-Mail: CL9636750@ gmail.com (Posted 9/13/2019) PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: on-

site x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@synergysmg.com for more information.

SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619606-3046.

SUBLEASE IN SHARP HOSPITAL: Sublease of a shared office space on the Sharp Hospital campus a small office on the third floor that is now shared with one other physician. Includes: two exam rooms, an office for the doctor, space for three employees, and a small amount of storage space. Please contact kspotz@synergysmg.com for more information.

OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4. It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and half a mile from Swami’s Beach. Contact Kristi or Myra 760-7538413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types.

REDUCED PRICE - EL CAJON MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 3,700 square foot standalone medical building with 11 exam rooms & huge private parking lot available for sale or lease! Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $950,000. Asking Lease: $5,500/month + NNN. Terms are negotiable. Seller financing is available. Please contact: Dillon.Myers@ TonyFrancoRealty.com | (619) 738-2318 MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/ space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share part-time, half days or full days 4 exam rooms. Rent depends on usage. For more information, call 858-550-0330 extension 106. ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking. Contact Jean ( 858) 673-9991. MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease. The office is located in Imperial county and is approximately 910 sq ft. Please email us at info@carlsbadimaging.com with any with further questions or needed details. (Posted 03/04/20) NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@gmail. com or call/text (858) 243-6883 (Posted 1/29/20) MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call 858-430-6656 or text 619-417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla - 9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at 858-622-9076 if you are interested. LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hospital between 1-5 and 1-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 733-4068 or jo@siosd.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact 858-633-6959. MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com. MEDICAL EQUIPMENT / FURNITURE FOR SALE OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi.eisenhauermd@yahoo.com, 760753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS, ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment: MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi. eisenhauermd@yahoo.com, 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at 760-730-3536 if interested in purchasing, pricing or have any questions. Thank you. NON-PHYSICIAN POSITIONS AVAILABLE PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@steinermd.com.

DIRECTOR OF NURSING - PUBLIC HEALTH SERVICES - COUNTY OF SAN DIEGO: The Director of Nursing in Public Health Services (PHS) will lead the clinical nursing enterprise of PHS, serving on the Executive Team of the PHS Department. This position will directly oversee clinical nurse management and all nursing personnel for six programmatic branches within PHS, as well as directly oversee all Public Health Nurse Managers or Leads in each branch. This position will work with Public Health Nurses in other Health and Human Services Agency (HHSA) departments such Aging and Independence Services, Child Welfare Services, and Regional Operations. Additionally, this position will have a dotted reporting line to HHSA’s Chief Nursing Officer and receive direction from the Chief Nursing Officer to HHSA-wide nursing practices. Salary: $124,092.80-$150,822.80 annually. For more information click here. PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@steinermd.com. EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https:// apptrkr.com/1852486. FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@sdsm.com. NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and processrelated outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@ rudolphia.consulting | www.rudolphia.consulting





What Lessons Did We Learn From COVID-19? By David L. Feldman, MD, MBA, FACS, and Laura Kline, CPCU, MBA Each year, The Doctors Company assembles healthcare leaders to discuss the most pressing issues affecting physicians, practices, and systems across the spectrum of care. The 2020 Executive Advisory Board meeting gathered top healthcare executives for a virtual discussion of shared pandemic experiences and lessons learned that can help healthcare organizations navigate through COVID-19 and beyond. Here are the top 10 meeting takeaways:


October 2020

Follow federal, state, and local guidelines — and don’t apologize for change. Southern California’s Hoag Medical Group followed guidelines from the Centers for Disease Control and Prevention (CDC) and their local health authorities to the letter. Then, the moment those guidelines changed, Hoag leadership announced the change to physicians and staff. This provided consistent messaging and allowed them to manage expectations. “The minute you go out on your own, you become very vulnerable to criticism and accusations of lack of fairness or lack of taking responsibility,” says Martin Fee, MD, senior VP and chief clinical officer at Hoag Memorial Hospital Presbyterian in Newport Beach, and an infectious disease specialist. “Following the guidelines protects you, and then you just have to be nimble to change course as quickly as the recommendations change.”


Change your own mindset to succeed. Andrew Racine, MD, PhD, system senior VP and chief medical officer at Montefiore Medical Center in the Bronx, New York, reflects on his experience with COVID-19 at the heart of the crisis in New York City: “Everything about what you are used to doing and how you are used to doing it had to be discarded, had to be put aside … Where were you going to do things? What kind of equipment were you going to use? Who was going to do things?” he says. “You have to be flexible. You have to adapt to the circumstances.” And, “You have to be proactive.”


Plan for what’s coming next. Dr. Racine says that Montefiore has systematized lessons learned. “We have a very detailed plan about what will happen if we get 10% more patients than we currently have, if we get 20% more patients than we currently have, if we get 100% more patients than we currently have.” And Dr. Fee describes contingency plans that incorporate not only medical realities, but political ones — factoring for predicted executive actions from California’s governor.


Communicate with honesty, empathy, authenticity, and consistency. Dr. Racine describes the need for empathy in effective communication. “People were frightened. They were anxious. They were angry, they were grieving. And the communication had to acknowledge that,” he says. In addition, Dr. Racine stresses authenticity: “People were not going to accept communication coming from just anybody,” he says — which was why Montefiore’s communications came from its CEO. Dr. Fee notes a communication lesson learned: “Initially, I was trying to be very reassuring with the physicians and saying, ‘We’re going to get through this and everything’s going to be OK and this will be over soon.’ In retrospect, that’s not true … What I would have done differently is say, ‘We’ll have to just see,’ but maybe not be too reassuring.”


Recognize the pandemic’s silver lining: innovation. Dr. Fee says Hoag had been planning on a nine-month telehealth implementation in 2021, “but all the regulatory and financial barriers came

down and we were able to launch that very quickly.” Overall, the rerouting of usual workflows “forced us to be innovative quickly,” says Dr. Fee, “which I think was a silver lining.” Chad Anguilm, MBA, VP of in-practice technology services at Medical Advantage Group, a subsidiary of The Doctors Company, says that sustained shifts across technology and workflows are already progressing: “Like we saw with telehealth — the big boom in the spring — we’re seeing something similar with wearables now where we’re getting many requests to start integrating wearables into the EHR systems,” he says. “To have that constant flow of data from those with chronic conditions” could positively impact physicians’ ability to treat patients in real time.


Do telehealth right — it’s a long road ahead. “Obviously, telehealth is having its moment right now,” says Anguilm. “However,” he cautions, “We still have a ways to go to make it stick,” and the technology itself is no longer the obstacle. “It’s more about eliminating barriers, and proper reimbursement.” “Truly long-term decisions are going to be based on the quality of care we can provide through telehealth services,” Anguilm says.


For telehealth, beware of access gaps. Patients who don’t have technology access for a virtual visit “often tend to be sicker people,” says Eugenio J. Hernandez, MD, VP of clinical affairs for Gastro Health in Miami, Florida, citing higher risks for diabetes, hypertension, and other conditions among the same populations who may

lack telehealth access. Acknowledging this, David L. Feldman, MD, MBA, CPE, FAAPL, FACS, chief medical officer for The Doctors Company Group, points out that the access question cuts both ways. “We know that these sometimes are the same patients who can’t afford the cab fare or bus fare” to see a doctor in person, he says — but when telehealth offerings are accessible by cell phone as opposed to a laptop, many low-income patients can access virtual visits. Anguilm agrees. “The ability that the EHR venders and some of the telehealth venders have to utilize cell phones has made it a lot easier, and some of the disparities are much less of a problem as they were … But the rural communities are facing broadband issues,” he says. “There’s a lot of money being pumped into getting broadband across the country, but for now, there have to be other means — whether it is in person or the use of a telephone — to reach care.”


Anticipate a boom in treating chronic diseases via telehealth. Dr. Feldman sees great potential for ”some of the asynchronous ways of communicating, such as having patients with diabetes send you a list of their daily blood sugars that you can review during a subsequent visit.” In-person visits for physical exams will still occur, but more consultative visits can be completed while reducing infection risk, travel time, and overall hassle for patients — which may enable more frequent consultations. “Even should some of these rules (that make telemedicine easier during the pandemic) go back, it’s opened our eyes to these possibilities

to really help, especially patients with chronic conditions for whom an in-person visit may not be so necessary,” Dr. Feldman notes.


Envision a future where your annual physical kit arrives in a box. Dr. Hernandez describes a futuristicsounding invention that already is being produced by an Israeli company: “an entire physical examination kit that’s attached to an iPad. They drop it off at your house in a box.” Via video visit, the patient participates in, for instance, a cardiovascular exam. The visit is recorded, and the kit is then returned to the provider company for analysis. Similarly, Gastro Health partners with a company that remotely monitors patients with inflammatory bowel disease — for intervention before symptoms worsen and patients land in the emergency department (ED). As Anguilm points out, technology that links patients to physicians is more cost-effective and risk-preventive than patients missing visits.


Expect malpractice claims to increase — know what to document and transfer risk. John E. Hall Jr., Esq., of Hall Booth Smith, P.C., predicts filing of COVID19-related cases will peak in 18 months to two years. Mr. Hall encourages physicians and practices to document daily life now, because juries

will forget. He recommends documentation of daily infection control measures, as well as noting who is working hard to procure personal protective equipment (PPE), coordinate with labs, and so on. This will make it easier later to contact staff members who can attest as witnesses that providers made their best effort to reduce risks. Awareness of risk transfer opportunities may also be protective. Jacob Zissu, Esq., of Clausen Miller, P.C., points out: “It may be that the injury alleged is attributable to the acts or omissions of your vender or an independent contractor,” he says. “Think about risk transfer as if it’s a Swiss army knife with multiple tools. … The best position to be in is to have multiple risk transfer options available.” The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. David L. Feldman is the chief medical officer and Laura Kline is senior vice president, business development at The Doctors Company.



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