key: cord-289266-4830qw10
authors: Borchert, Alex; Baumgarten, Lee; Dalela, Deepansh; Jamil, Marcus; Budzyn, Jeffrey; Kovacevic, Natalija; Yaguchi, Grace; Palma-Zamora, Isaac; Perkins, Sara; Bazzi, Mahdi; Wong, Phil; Sood, Akshay; Peabody, James; Rogers, Craig G; Dabaja, Ali; Atiemo, Humphrey
title: Managing Urology Consultations during COVID-19 Pandemic: Application of a Structured Care Pathway
date: 2020-04-21
journal: Urology
DOI: 10.1016/j.urology.2020.04.059
sha: 
doc_id: 289266
cord_uid: 4830qw10

OBJECTIVES: To describe and evaluate a risk-stratified triage pathway for inpatient urology consultations during the SARS-CoV-2 (COVID-19) pandemic. This pathway seeks to outline a urology patient care strategy that reduces the transmission risk to both healthcare providers and patients, reduces the healthcare burden, and maintains appropriate patient care. METHODS: Consultations to the urology service during a three-week period (March 16 to April 2, 2020) were triaged and managed via one of three pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non- COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A p-value <0.05 was considered significant. RESULTS: Between March 16 and April 2, 2020, 53 inpatient consultations were performed. By following our triage pathway, a total of 19/53 consultations (35.8%) were performed via Telemedicine with no in-person exposure, 10/53 consultations (18.9%) were High-Risk, in which we strictly controlled the urology team member in-person contact, and the remainder, 24/53 consultations (45.2%), were performed as Standard in-person encounters. COVID-19 associated consultations represented 18/53 (34.0%) of all consultations during this period, and of these, 8/18 (44.4%) were managed successfully via Telemedicine alone. No team member developed COVID-19 infection. CONCLUSIONS: During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway.

Consultations to the urology service during a three-week period (March 16 to April 2, 2020) were triaged and managed via one of three pathways: Standard, Telemedicine, or High-Risk. Standard consults were in-person consults with non-COVID-19 patients, High-Risk consults were in-person consults with COVID-19 positive/suspected patients, and Telemedicine consults were telephonic consults for low-acuity urologic issues in either group of patients. Patient demographics, consultation parameters and consultation outcomes were compared to consultations from the month of March 2019. Categorical variables were compared using Chi-square test and continuous variables using Mann-Whitney U test. A p-value <0.05 was considered significant. Conclusions: During the COVID-19 pandemic, most urology consultations can be managed in a patient and physician safety-conscious manner, by implementing a novel triage pathway.

As of April 9, 2020, the World Health Organization reported nearly 400,000 cases of and 12,740 deaths attributed to COVID-19 in the United States (US) alone (1). In the state of Michigan, over 80% of cases and deaths are occurring in metropolitan Detroit, making it the third largest epicenter per population in the US (2)(3), causing unprecedented changes to the healthcare environment. In the context of rapidly evolving guidelines for personal protective equipment (PPE) and diagnostic testing for healthcare workers (4), as well as the internal reassignment of clinical team members to other patient care teams, implementation of new departmental protocols were needed.

The present report details the efforts of the Urology Department (Henry Ford Hospital, Detroit, MI) to develop and implement an inpatient consultation triage pathway to minimize unnecessary exposure for providers and patients, while providing safe and effective care during the COVID-19 pandemic.

This study was conducted as a part of necessary transition of care delivery at a 3) High-risk: Patients with urgent/emergent inpatient needs who were suspected/proven COVID-19 positive were deemed High-risk urology consultations (seen by only one urology resident and/or attending, especially if a bedside procedure or operative intervention was necessary). PPE were donned, including N95 masks, per CDC and hospital policy. Of note, while 34.0% of consultations in the 2020 study period were for COVID-19 status positive or COVID-19 status pending patients, our hospital has quickly become a majority COVID-19 facility, and we expect the majority of urology consultations moving forward during this pandemic to be classified as either Telemedicine or High-risk, and managed accordingly.

Contemporaneously, and in conjunction with development of this pathway, we restructured our urology service into two teams to optimize patient care and minimize unnecessary exposures, described similarly at other institutions. (6) Each week, "Team A" covers urologic care across our covered hospitals, including additional satellite facilities, while "Team B" covers COVID-19 and non-COVID-19 units as needed. These teams switch responsibilities each week. This system has allowed us to help in other hospital departments and units, while ensuring adequate coverage for any needed urologic care.

Limitations of the study include the following. There are a relatively small number of consultations tracked over a short period of time. The control group, while it appeared well-matched in our analysis, may represent a different cohort of consultations than our study group. The pathway we utilized is non-validated. Lastly, we have no follow-up to identify outcomes associated with the consultations performed during the study. 

Implementing a urology consultation triage pathway allowed for appropriate inpatient urologic consultation management while minimizing the risk of exposure for both patients and urology team members during the COVID-19 pandemic. Given the fluidity of the current circumstances, we acknowledge the need to continue to adapt to any new and unforeseen circumstances, but we hope that this pathway may provide a useful framework for other urology departments. 

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