Katherine (Kate) L. Walsh, MPAS, P.A.-C., M.P.H., and her team at Mayo Clinic in Florida created a virtual clinic for patients with COVID-19 to keep beds available at the hospital. Walsh explains how the clinic was implemented and the best practices for virtual patient care during this pandemic. She also discusses the benefits and hurdles to creating a virtual clinic.
Click here to claim credit and view faculty disclosures. Select Register to begin the credit claim process. Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Hi. So my name is Kate Walsh, and I'm a physician assistant at Mayo Clinic in Jacksonville, Florida I've been in pulmonary medicine here, Um, and I'm going to talk to you about a co vid 19 virtual clinic that we set up here at Mayo Clinic, Florida. So we set up a Kobe 19 virtual clinic. It's also known as the CBC. So if I refer to CBC throughout this presentation, you'll know what I'm speaking about. And this is the Mayo Clinic experience of setting this up, so I have no relevant financial disclosures or off label or investigation you investigational uses. The objectives of this presentation are to summarize the establishment of our cove in 19 virtual clinic, the CBC, to discuss when to discontinue isolation from Cove in 19 patients and then to explain strategies for outpatient Kogan 19. Monitoring The best way I thought to discuss this topic is to give a timeline of events from the pandemic. Start So as of March 13th, our first cove in 19 Positive patient presented to Mayo Clinic, Florida By March 20th, we had seven in patients at that point with Kobe 19. So with the unknown extent of this disease coming, we didn't know what resource is would be affected by this pandemic. So we needed to look at staffing hospital beds. PPE, Andi come up with a better model so that we weren't putting burden on several Resource is so initially we were utilizing the Department of Health testing that was available, that testing tended to be delayed so you would get the test one day and several days later you would get a result that led to a burden on multiple different resource is. So it increased staff exposure because we did not. No, if the patient was positive, what we were waiting for results, and we had to assume that they were positive. And then, um, we were utilizing much more peopie by doing it that way as well. So then Mayo Clinic Laboratories announced that it would be coming up with his own testing and making it available to us, which made it so that we could get results faster and therefore minimize exposures and burdens on resource is as well. So with the Mayo Clinic Laboratories coming out with that testing, we just started to look at a drive thru model of testing, and that drive through model of testing was then instituted. So March 23rd, Dr Francis recruited a couple of us to establish a covert virtual clinic to care for the cove in 19 positive patients that were testing positive through the outpatient drive through. What we were looking at was whether or not we could establish a virtual clinic to see them via video, and that would minimize the burden on our emergency department as well as impatient as well. If we could help the patients with their symptom ontology, give them education via virtual visits, we could then potentially prevent them presenting to the emergency department with anxiety and fear and not knowing what to do in the situation of having this diagnosis. So as of March 24th, the drive thru started conducting drills, and while the drive thru is conducting drills, Dr Spiker and I were creating protocols, defining roles and setting up scripts, dot phrases for notes and we had some residents on board with us that we're helping us with a lot of the electronic medical record. Thanks, Onda. We were setting up a patient registry as well so that we could follow the patients in real time. And we could also all be in putting data that we could follow on these patients. So the residents set up a triage for the patients. So the patients that were going through the drive through that didn't have an order. So we knew that once Mayo Clinic announced that it was having drive through testing available and that word got out that there would be male clinic patients that arrived at the drive thru without orders. Um, so what we did at that point in time was the residents would, um, be available for calls and triage the patients to get them order so they could get through the drive through if they fit criteria. And then the providers is the part of the virtual clinic. We started out patient clinical care for Kobe, 19 positive patients. On March 25th, the CBC began notification calls, and we started calling the patients with positive results as soon as the drive there was officially open, so this is a diagram of the drive through. There were several stations set up throughout the drive through. There was a station set up so that we could establish what what window the patient was in because you had to have the right and correct window. We had to establish that it was the correct patient and the patient did have an order. We also had Thio provide information to them so that the CDC information would be given to them because they had to assume that they were positive until they had their results. So they had to have that information about quarantine and self isolation. And then we had three pots set up so that we could test three patients at a time, and that allowed us to test multiple people and get more people through the drive through at one point in time. So there were several staff that were needed. We needed staff at each checkpoint, and then we needed people in PPE to do this swapping. So then we looked at how the drive thru was conserving PPE. So the first seven days the number of patients that were tested were 1153 the average patients per day, or 192. So there was a big range when we first opened the drive thru anywhere from 50 to patients that went through the drive through all the way up to 598. So the PPE that we used to drive through testing were a day were 42 masks, 24 gowns and 504 pairs of gloves. So if you think about the way that patients were being tested through the emergency department when a patient presented to the emergency department, five sets of PPE had to be used per patient. That was to accommodate for rooming staff, nursing providers, registration teams, cleaning staff and the estimated reduction in PPE was 96% for masks, 97% per gowns and a 47% reduction for gloves. So overall we were conserving Ah, lot of PPE using this model. So this is a picture that Dr Speicher took of us setting up the clinic. So Theo Executive Suite had been closed down as the pandemic had been ramping up and we utilize that space to meet together as a team to discuss protocols and create work flows and have discussions about Kobe 19 and how to best manage these patients that were testing positive. And that's the team within the first couple of weeks. So the workflow for notification calls we would get a result notifying us to our in basket that the patient was positive that positive patient would then be triaged to unavailable provider. And they would. Their information would be put into a SharePoint documents so that the provider would know that that notification call was their responsibility. The provider that would then call verify the name and the date of birth and discuss the positive results with the patients. One thing we noticed right off the bat was these patients were anxious. They had a lot of questions. They'd watched a lot of news programs. They thought they had a lot of answers. Um, so these notification calls varied in time. They buried anywhere from the shortest one would be potentially 10 minutes all the way upto well over an hour for some patients. We would also assess the symptom severity and go over CDC guidelines. CDC guidelines were constantly changing, and they were getting more information and up to date information. So we had to be up to date on the information as well, so that we could provide them the most adequate, accurate information so we would go over the self isolation and quarantine and what that meant. Most of these patients had family members, so they were concerned about their family members exposure. So we had to go over things like You are not to be outside your room. You should quarantine yourself to a room, have a bedroom to yourself, a bathroom to yourself. Don't share towels, and all high touch surfaces in the house should be wiped down like door knobs, light switches, countertops. And that way we could minimize exposure within the household. We talked to them about the severity of their symptoms. If there were clinically stable, um, then we could keep them on the phone and discuss what symptoms they were experiencing and how to best manage those symptoms. And then we continued emphasize that self isolation and quarantine, as outlined by the CBC. We would also discuss whether or not they would want video visits with us so that we could follow them through their diagnosis and make sure that they hopefully didn't worsen on. We could keep them out of the hospital. And we could, based on that severity kind of gauge how often they would need video visits. So all this information was documented in our HR and then nursing staff would also provide the information into our SharePoint website that we were able to extract from the patient. And then we also had stuff that we're notifying each county health department of the positive results. If the patient in our notification call, um had severe symptoms, they had worsening dysthymia chest pain, something that was concerning then we could also refer them to the emergency department. At that point in time, we could refer them if we felt they were stable enough via personal vehicle. If somebody were able to drive them or we would encourage them to call 911 we also were able to notify our emergency department ahead of time to let them know that they were coming, which also minimize exposure to staff A swell and in our notification cause. We also notified the patients that should their symptoms worsen, that there were staff available for them as well. So what we would do at when the patients had that notification call, we would get them set up with these video visits. So the workflow that we created for the positive patients was we would schedule their appointment. Um, depending on the severity of their symptoms, we could schedule the same day next day. Onda. We could see them every 24 to 48 hours if we needed to. If they were stable enough, we could see them every 72 hours to a week, so we would give them information. We have attempted letter that we would send them that had a link to the C. D. C, as well as information about E check in. So what they would do is they would checking through their portal and connect with this care connect group. And they would. That care connect group would ensure the provider and the patient were connected and able to hear each other and connect in real time video. Um, so we would dio clinical course and progression with the patient. We would look at their symptoms and how their symptoms were progressing. Um, if their symptoms were worsening, we could talk to them about symptom management. So if they were coughing and having difficulty clearing music mucus, we could talk to them about Musa necks. We could talk to them about rest and fluid intake. Um, several of them were losing taste and appetite. So, um, taste and smell, which led toa decrease in appetite. And when that happened, they weren't drinking. So, um, at several appointments, we would go over how they could increase their fluid intake ways in which they could do that. We could talk to them about certain diets that can minimize, um, the stomach bothering them. So there were several things that we could do over the phone. We talked to them about fever management and how to best manage their fever. If there, um, symptoms were worsening at any video visit, we always had the capability of referring them to the emergency department and again notifying the staff. I had a time to minimize that exposure. Um, as we follow them through their course of illness, um, we could talk to them about when they meet that criteria for release from self isolation and quarantine. So we would ask them several symptoms, and if they fit that criteria at that point in time, we could release them. So initially that would be three days without fever. And that's without use of any anti pirate ICS a za, long as they were showing symptom improvement in regards to their respiratory symptoms. And it had been at least seven days from their symptom onset. What we had decided was Thio encourage the retesting model. There's a there was, ah, testing base clearance from quarantine. And then there was a non test based clearance from quarantine at the time when we set up this clinic and we had the capability to run a lot of tests and get same day results, Andi, we felt that it was doing a community good if we could retest the patients to show that they weren't shedding virus, and that could minimize community exposure. So we encourage patients if they had the capability to come and do the retesting model to do so. So the retesting model of clearance was that they had to fit that criteria of the three days fever free without any anti pirate ICS. The symptom improvement of the respiratory symptoms as well as seven days from symptom onset. If they did that, we got them set up with retesting through our drive through, and they had to have two negative tests that were greater than 24 hours apart. There were several times when somebody would have a re test that was positive, and then we would have to talk to them about recommendations at that point in time. And based on the fact that we were retesting patients regularly, we knew the time at which it took them to potentially get their negative so that we could give them better guidance in regards to retesting without having to do multiple retests and getting the same results. So at that point, once they went through the retesting model and got those two negatives, then at that point we could clear them to return to work or their activities of their regular activities. So at any point in time, if they didn't fit that criteria, then we would get them set up with follow up visits. If they wanted Thio, and then we would continue to talk to them about symptom management and when potential release from quarantine could happen. So March 28th was the day that we all went virtual at that point in time. So we stopped meeting in that space that we had been utilizing, and we all went to our separate offices homes on did these virtual visits from there. So at that point in time, we went to virtual huddles. So every morning we had ah facetime call where we discussed whether or not, um, how are patients were doing If there were any new treatment advances as regard in regards to Kobe 19 we would discuss our panels size to see whether or not somebody had too many patients that they had on their panel and needed assistance. We discuss remote monitoring. So we had a system set up where we could set these patients up with a tablet at home, a blood pressure cuff and a pulse oximeter and a thermometer so that we could get vital signs two times a day to four times a day, as well as a nurse management as well. And they could reach out to us if there was any concerning, um, things that were noticed on a patient survey that the patients were filling out Elektronik Lee or vehicle so we could get real time information on those patients that we could follow. We would also talk about convalescent plasma donation and how to best get patients in because we had patients in the I. C U that we're getting sicker that we were utilizing convalescent plasma on. So we wanted to make sure that we had out patients that were recovered and feeding in to plasma donation if they were willing and able Thio. And then we also talked about research protocols. So could we get these patients into any research protocols that they could potentially benefit from? So that picture is one that I took him when the Doctor Speicher took of our virtual huddle calls that were occurring on every morning basis. So this is, ah, diagram of the total cases per day you can see in March we were having a steady amount of cases that were coming in, and then in April, it started to trend down, and then in May, we had hardly any really in May, so we had a lot of providers at first that we trained and got up and running, and then we minimize the amount of providers in May as we were not seeing as many cases. So some of those providers went back to their prior specialties at that point in time. So this is a diagram of the patient characteristics of the 1st 118 patients. So we were stealing, seeing pretty equal in regards to gender, equal, male, equal female. Um, we're seeing more patients in the age demographic, 40 to about 70 and not as many patients below 40 or above 70. Um, and then the referral source we were looking at. So we were documenting all this on our SharePoint website, whether or not we received that patient information from the emergency department had they been tested in the E D and then sent home and then we picked up management of them had they been tested in patient and then were discharged, and we picked up management of them. At that point in time, we had several patients that have been tested outside of Mayo in the community at either their community centers or other hospital systems, and they wanted to seek carrot mayo. So, um, we had several patients from outside testing that were referred into Mayo how many patients were drive thru tested, and then we did capture some and preoperative evaluation. So we were screening everybody prior to high aerosol generating procedures as well as operations. So some of those patients, um, would go through that preoperative testing and test positive, and then you would have to follow them through management at that point in time. But the majority of our patients did come through the drive through testing, and then the pie chart on the right shows theme amount of patients that were in each county at the time of testing for the 1st 118 patients. So you can tell the majority was Duval and the next county that we saw a lot of patients from was Saint Johns County. So other information about patient characteristics that we were able to capture. So 24 of those initial patients were health care workers, 21 of which were male employees. We had six first responders. We had a number of households with only one positive index Case index case. That was 75 households, and then we had 30 households where there was more than one case, and then we had three households that had multiple positive family members. And then we're also looking at exposures. So we saw cruises. We saw, um, domestic travel in international travel, we saw work exposures, family member exposures on Ben. We're tracking all that so that we could have up to date information on that to be able to provide our and for our patients as well. This is a diagram of what we were looking at. So we were looking at what was going on in regards store community and the level of positives that we were getting. So we looked at. On June 5th, there was a phase two reopening, which meant in Florida that 50% in your capacity was allowed in bars, restaurants, movie theaters and full capacity outside. So, as you can see, once that happened, we started to see a trend up, and we typically saw that when things opened up, we saw positive results around 10 to 14 days as early as seven days after that change. So on 6 26 the state then put a ban on alcohol sales and bars again because they were seeing such a high spike in regards to cases at that point in time aan den. We looked at July 4th, the holiday weekend, and we had a spike following that. So we're continuing to follow this. We've got Baker County schools that opened. Now we've had all other counties that have opened, um, to students. So at this point in time, we're following whether or not that increase, um, will happen with any school, um, openings or college openings, things like that as well as holidays coming up. So now I'm going to talk about discontinuing of isolation for the cove in 19 patients. So the C. D. C. S initial guidelines were two ways of clearance. There was a test based clearance, which you needed two consecutive tests that were greater than 24 hours apart, and then a non test based clearance, which was? They had to be a febrile for 72 hours with no anti pirating medications and have symptom improvement and seven days, um, symptom onset. So if they met that non test base clearance criteria, then we would, at that point in time, get them in for tests based clearance. A patient could always opt out if they didn't want to go through retesting But most often the patients wanted to utilize the test based clearance because they had the capability to do so through Mayo. So later on that discontinuation of isolation increased to 10 days. So and it included a time based strategy because we had several patients that were asymptomatic. So what do you do with your asymptomatic patients if you can't follow that symptom based criteria? Um, when do you retest those patients? Or do you even offer retesting for those patients? So, um, there was a time based clearance that was recommended for asymptomatic patients, and there was a nup date where they changed it from offering those two based clearance to encouraging just the symptom based clearance. We had enough tests and lab capacity as well as PP eat. And that is why we initially recommended the test space clearance. And patients wanted to know whether or not they could potentially be exposing other family members. So we felt like it offered several patients peace of mind in order. Thio not continue to spread this illness. If they had that test base and had that test in their hand that showed that they weren't potentially spreading the virus So from a retesting data, we were able to extrapolate how long it could potentially take a patient to get resolution from a positive results and symptoms as well. So and this is showing that the retesting over time and the time it took for patients to get those two negative tests some patients, it took longer than others, and we couldn't correlate it with whether or not, like a severe patient tested positive longer. That wasn't the case. We had several mild cases and even asymptomatic cases that were persistently testing positive and some sicker patients that went negative pretty quickly. So, um, we're following this information to see if we could offer better guidance in regards to this. A swell. So, um, from a retesting data, we were able to determine that The meantime, from symptom onset to the undetectable results was 21 a half days. In the meantime, for from the first detectable result to obtain the undetectable results was about 15 days, and we were able to find that 53% of patients that we studied had met CBC criteria and guidelines for released from isolation, and we're still testing positive so that at that point in time was alarming for us. So though they were re testing positive, what did this mean? Um, where was this detecting dead virus? Was it detecting live virus? Um, there was a journal article in Nature Journal that came out, Um, that talked about, um, viral cultures that they were doing on sputum. And they found that potentially after eight days, there was no live virus detected. Um, so did that correlate with our patient population? Um, there's a 30% false negative rate amongst some PCR testing aan den. We saw several patients that got there two negatives and then presented for their preoperative surgical clearances. And they ended up testing positive again. So they got their two negatives and then re tested positive. So, um, we were looking a lot of the testing data and and trying to delineate what it meant for a patient population. So this is about the most common symptoms. So at each video visit or telephone visit that we had with the patient, we had smart phrases made so that we were asking consistent symptoms that they were having so we could monitor potentially how their symptoms were progressing as as the disease progressed, so the most common reported symptoms are on that diagram my Callejas chose chest congestion were some cough and fatigue. We have patients that we're losing tastes and losing smell or noticing changes in taste and smell, headaches and, of course, fever. So we were monitoring all those symptoms. Um, and then, unfortunately, there continued to be throughout. There's no evidence based treatment available. So we were getting these patients into research trials, if possible, on Ben again helping them with their symptom management and just being there, Um, virtually for them. We did notice that several patients, their anxiety levels, were going down just in the fact that they knew that they had somebody to reach out to and somebody available to them. Um, we also we're seeing them via video, so we kept it consistent. So the provider that did the notification called was also the provider that followed them. So you got really close to these patients as you followed them for 14 plus days, um, and really got to know them. And they really seem to benefit from that relationship that you're developing with them. So if the patients were immuno compromised. You were concerned that they were going to decline. You could order remote monitoring so they may not have symptoms are very many symptoms now, but they have that background that makes you concerned that they're going to decline. You can order that remote monitoring where nurses can check in on them. You have vital signs monitoring so that if something changes, then you are the first to know so that you could potentially reach out to that patient. So the monitoring outcomes. So the initial wave of patients we found waited about a week from symptom onset to be tested. That seems like a lot of time. Eso The median was about seven days from symptom onset to testing. And some of that was, um the testing wasn't readily available. They had gone to several other revenues to potentially or avenues sorry avenues to be tested, and they weren't able to get tested. Um, so it took him about seven days. Teoh be able to get that final test. And then we were able to find out that most patients recovered on an outpatient basis. So and this again is the first wave of patients. So the number of patients that went to the emergency room after discharge, um, was two and one was post CBC release. The number of patients that were hospitalized after being established with the covert virtual clinic was seven, and one of those was not Kobe. 19 related. And then the number of patients that were hospitalized after released from the CBC at that point in time was one. So that was for a cytokine storm that happened a month after the patient's exposure. Um, and we had also the availability of a clinic that Mayo had set up where if we wanted chest X rays or outpatient imaging lab work on these patients, um, we could send them to that facility, and they were able to get them tested with minimizing staff exposure and other patient exposure. So we had that whole way to get them tested if we needed to get them tested. If we were concerned for something and then we also had that clinic set up so that say, somebody goes through the drive through their having symptoms, they're not doing well, but it's not Cove in 19. What do you do with those patients? You can't just let them potentially get sicker out of the hospital. We had that other place that we could send them for evaluation as well. So the updated CDC release guidelines as of August 10th were the mild to moderate severity of symptoms. Patients had to be at least 10 days from their symptom onset and now 24 hours fever for eight without medications. And they had to show that respiratory symptom improvement as well if a patient is severe to critically ill, um, it has to be at least 10 days all the way up to 20 days, depending on the severity of that patient's illness and then meeting that other criteria as well. So are clinicians that were part of our clinic were using their clinical judgment to determine if they fit that 10 day criteria or 20 day criteria, Um, as they may not fit that, um, standard model and then the asymptomatic patients. At that point in time, it was 10 days from their first test, as long as they didn't develop symptoms. I had a patient recently that was asymptomatic and tested due to an exposure and then five days after her test, then became symptomatic so that time frame starts over. At that point in time, it would be 10 days from her symptom onset, not her testing date. And if the patient is severely immuno compromised, that timeframe again changes to 20 days as well. And then now we're rarely utilizing the tests based strategy. So we had a surge in cases. Um, are Dr that was already burdened. We didn't want to send patients through the test based strategy at that point in time. Um, and we also had the c. D. C. At the time that was saying that the test based strategy they weren't even recommending at that point in time. So at that point in time, we stopped recommending the test based clearance and went by that symptom based clearance. But we need testing available in rare cases where a consultation with an I. D expert they potentially wanted that retesting or if a patient needed it to return to work, so we would always get them expedited through the drive through. If they needed that, testing were asymptomatic and needed to get back to their jobs. So what I'm gonna do now is I'm going to talk about one specific case to give you an idea of what it was like to go through our Kogan virtual clinic and and the care that was received through this clinic S O. I had a 32 year old male patient that tested positive via our drive thru. Um, he had a known contact. He had been with his mother over a holiday weekend and his mother had just tested positive. So I did the notification called with this patient on 4. 14. His initial symptoms were scratchy throat, head congestion and diarrhea. So at that first notification call, I discussed CDC guidelines for self isolation and quarantine as well. A supportive care. Him and his mother lived separately as well, and both were sick. Onda lived alone. So at that point in time, his mother actually came over and they quarantined together so that they could keep a closer eye on each other. Um, the initial video visit with this patient was 4 17 2020. The patient was having a fever. Still his team max of 100.5. He was having headaches, fatigue, lack of taste and smell, and a cough that was productive at the time with clear toe, light yellow, We'll kiss. So I continued at that point in time to recommend supportive care. So we talked about Musa. Next. We talked about Tylenol for fever. We talked about increasing fluid and takes and getting plenty of rest. Um, And then we arranged a second video visit to make sure the symptoms weren't progressing. At the second video visit, the patient had a new complaints. So the second video visit took place on 4. 2020 20. He had a new symptom of him opt Asus. He had mucus with blood streaks in it that had just started. At that point in time, I sent him to that location at the beaches s so that he could get a chest X ray done. This is his chest X ray that he had, Um, as you can see, it shows ill defined by Bassler airspace disease, and that's reflective of pneumonia, including a typical viral infections given the cove in 19 detection. So our radiologist here we're looking at the chest X rays already at this point in time and seeing whether or not they thought that the changes were related to co vid as well as the patient had that chest X ray that was abnormal and had the hypothesis. Patient was then started on his it through Meyssan azithromycin. We were utilizing in our clinic not for its antibacterial properties but for its immune modulation properties. We were using it to hopefully decrease some of the inflammatory response that Corbyn was bringing about. Um, I was concerned for this patient assed he was developing, Um, the same opt assists. I set him up with remote monitoring. At that point in time, at the third video visit for 22 patient had a new complaint of shortness of breath with persistent cough and him opt assists. He was on day three of five of his azithromycin, and at that visit, his remote monitoring had been set up. So, um, the welcome call had been completed, but he hadn't plugged in his first vital signs. So what I did with him at that visit was we had to put on the pulse ox. I checked his pulse oximeter, um, resting. So he sat there for a while on DWI, checked it, check it pulse and his oxygen saturation. And then I actually had him get up on ambulance around the house and get his heart rate up, um, to see what happened with his, um, oxygen saturation. It remained well above 95. So in that instance, with his new complaint of shortness of breath and, um, the fact that he was able to speak in full sentences and didn't appear short of breath when he was ambulance. And I did not feel at that point in time and he did not feel a swell that he needed to seek emergency services. But we did talk if that visit, that if the symptoms did progress at any point in time, he was developing plastic paying with breathing that he should seek emergency services on Ben. We talked about as well. I went over oxygen saturation parameters with him so that he could know when to be concerned and went to seek emergency services. Um, with this persistent complaint of shortness of breath to, I set him up with a follow up chest X ray just to make sure things weren't progressing on his chest X ray as well as some blood work, because I wanted to see if he had any inflammatory markers that were elevated. So on 4. 24. the results were that there was no change in regards to the chest X ray, but he did have some elevation in his a l t. At 1. 43 has a S t at 1. 83 his ALC fast was 57. So during that phone call, where I was discussing the results with him, I found out that he was duplicating, dozing. So he had gone to the pharmacy and had gotten Musa next, which I had discussed with him but couldn't find the one that was on legal, if innocent. And he found the one with acetaminophen added to it. And then he was taking Tylenol on top of it, not realizing acetaminophen and Tylenol were the same. So he was duplicating dozing of his Tylenol. So we discussed at that point in time to get the Musa next with Onley, got venison, and then to minimize his use of Tylenol to this point as needed, because he was regularly taking it, trying to keep his fever down as well as he didn't want any body aches that he had been experiencing. So we discussed all that, and we were able to figure that out via phone call as well. So during the fourth video visit, at that point in time, it was 4 27 and patient was now a from Brown without the use of acetaminophen. For more than 24 hours, his mopped Asus and his shortness of breath had resolved, and his cough was finally improving. So I ordered a follow chest X ray because I wanted to make sure that his changes related to his co vid 19 infection were improving or resolving. So in 4 28 there was interval resolution of the prank mullah passages of the basis, although his lab's still showed that his, um, liver function tests were abnormal. So it's lt was 61 his ass. He was 28 his alphas was 69. Um, I ordered follow up lab testing on five Fine, just because I wanted to make sure that his LFTs normalized, which they did on 55 And then he was cleared the a P. C. R. On 5 12 2020 via the test based clearance. He got his two negatives that were greater than 24 hours apart, and we were able to discuss that over the phone, and he at that point was very thankful, Um, that he was able to do all this on an outpatient basis and get those two negative results so that he could return toe work in school as well. So the lessons that we learned through this cove in 19 remote monitoring and virtual care clinic was that remote monitoring can help these patients. They found that these patients can take a turn very quickly. They may seem like they're doing fine one day. You see them via video the next day, and they're ill appearing. So, um, they can take turns very quickly and vital signs. Monitoring can be an important indicator of their progression as well. So if we can monitor their symptoms and see them and lay eyes on them virtually to make sure that they're doing okay, um, then vital science can also help us manage and follow these patients a lot more closely on this allowed the patients to have a safe place for patients and staff to do, um, lab work and imaging. So because we had that beaches clinic, we were able to, um, do chest imaging and lab work toe. Make sure that the patients were not worsening, and this capability also minimize our burden on the E. D. So we didn't have to send these patients to the E. D for routine chest X ray, which they were doing in other areas. So we were able to send them to this clinic and potentially manage their course on an outpatient outpatient basis. Aan den. Regular virtual follow ups helped better manage these patients thes r e d. Um, we're seeing less of these patients are Hospital was seeing less of these patients. Onda. We were able to manage these patients and get them through illness. Onda receive quality care all via virtual visits. So the changes since the initial wave. So now our covert virtual clinic has brought on emeritus providers, so retired providers that are all over the country, they are now capable of working virtually. So We've brought some of them back because a lot of them, um, the retired have wanted to help with care. So they been able to jump right back in. And we are, of course, there training them. Ah, lot of them. This whole virtual visit is new to them. So it does take a lot of training to get them up and running. Um, but now they're capable of providing care to these patients. And this helped us with our search that we had a swell We're bringing on these providers as well as I'm a PPS. So nurse practitioners and pus from other specialties. So we brought those on during our surgeon. Now the emeritus providers are helping. And so we've been able to send those patients those A PPS back to their prior specialties so that they can continue to care for their everyday patients. Um, so we've established new provider training, work flows, so we have a training model for these providers so that we can make sure that they have the up to date information they know which studies are available. We're having huddle meetings with them. We've also created a registry and epic. So our Elektronik medical records. So no longer do we have to keep this self spreadsheet that was getting really cumbersome and really hard to navigate. Um, now we have a registry within our electronico medical records that we can plug in information, and now we can pull that data directly out of our electronico medical records and get more up to date information on these patients. So we also have an interactive model for helping patients cope with the stress associated with being diagnosed with cova. 19. I think that's huge. Um, one thing that I've noticed through caring for these patients is they're highly anxious. They're watching the news. They're getting information from all sorts of different sources. Um, they're being bombarded by information, and they're highly anxious. Um, their concerns are are very valid, and they need ways to help cope with the stress and these concerns So they have this virtual clinic to voice those concerns with. But we also have these interactive models so they can go in and watch videos, um, and do these, um, information gathering things so that they know how to cope with this stressful part in their life. Um, we are also doing policy adjustments. So the CDC again is always updating criteria and changing recommendations and coming up with new recommendations. So, um, based on those changes, we needed to change our pre surgical management, we needed to change how we handle asymptomatic patients, so we always have to be up to date on that CDC recommendation s so that we can make sure that we're changing policies as they need to be changed at our facility. And then we're looking to add more innovative, innovative outreaches, such as sending text messages for real time results so that patients have quick access to care. We're looking at potentially getting a message to the phone where they can, um, click an option to be linked to a provider a soon as possible because we've noticed that once they've received that result in our electronic system, anxiety starts at that point in time. So we need to make sure that they have quick access to health care providers and information. And these are all the people that I'd like to thank that took part in helping set up this clinic. And, um, all the information provided from this presentation Thank you for listening to it