Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemic
Authors: Kyla N. Price, Rebecca Thiede, Vivian Y. Shi, Clara Curiel-Lewandrowski
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: We were very pleased to read Chen et al's commentary1Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar presenting practical methods for reducing the spread of coronavirus disease 2019 (COVID-19) in the dermatologic setting. Health care teams around the world are working diligently to limit the spread of COVID-19 despite unprecedented challenges. In this letter, we provide additional strategies and a potential framework for maintaining successful patient care while limiting risks for faculty, residents, staff, and the community during the COVID-19 outbreak. The first goal in the COVID-19 pandemic is to limit the spread of the virus. To prevent infection of an entire specialty group, departments should consider adopting a team-based practice model to limit cross-contamination. Each team consists of a ratio of providers based on the individual institution's workforce. For example, 1 team in our department consists of 1 attending physician, 2 resident physicians, 2 nurses or medical assistants, and 1 supportive staff member. Individuals are in the clinic only if their team is conducting in-person visits that day. They are not allowed to have in-person contact with members outside of their designated team. In the event that a team member is exposed to or tests positive for COVID-19, only individuals within their team are required to self-quarantine for 14 days and/or be subsequently tested. By using this approach, cross-contamination is limited; thus, the department can continue to operate and deliver in-person care despite COVID-19 exposure. To continue effective patient care while limiting exposure, we have implemented a coded triaging system that allows us to prioritize and provide the appropriate care for each patient (Fig 1 and Table I). A key step is to implement this model as early as possible in combination with teledermatology, as other practices have already suggested.2Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19 [Epub ahead of print].N Engl J Med. 2020; (Accessed March 26, 2020)https://doi.org/10.1056/NEJMp2003539Crossref PubMed Scopus (2086) Google Scholar,3Smith A.C. Thomas E. Snoswell C.L. et al.Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19).J Telemed Telecare. 2020; (Accessed March 26, 2020)https://doi.org/10.1177/1357633X20916567Crossref PubMed Scopus (1166) Google Scholar As depicted in the diagram, patients with high acuity, such as individuals with concerning lesions and potentially life-threatening eruptions, have priority for in-person visits. Simultaneously, continuity of care for existing patients can be achieved through teledermatology. With this system, patients can continue long-term management while decreasing the risk of exposure.Table IVisit types and associated visit categoriesVisit typeVisit categoriesIn-person visitBlistering skin conditionDiffuse rash (BSA >80%); acute onset within 1-2 weeksErythrodermicMucosal involvementRapidly enlarging non-healing lesion (including bleeding) that has been present for at least 4 weeksPainful lesion(s)/rashPatients with high number of skin cancers and diffuse actinic damageAny rash in immunocompromised patient or patient on chemotherapy that requires a skin biopsyConcerning lesion for melanoma diagnosis or other high-risk skin cancerTelemedicineCondition worsening; need to make changes to therapeutic plan< 3-month follow-up scheduled at last visitLesion for monitoring in patient with history of melanoma or high-risk skin cancerNew lesion of concern present for > 4 weeksAcne vulgaris and rosacea (active disease)New patient visit with chief complaint other than specified "in-person visit" categoryHidradenitis suppurativa (active)Cyst (inflamed, painful)Provider phone callFollow-up on chronic rashes (psoriasis, etc.)Isotretinoin monthly discussion (RN/MA visit for urine in female patients)High-risk medication monitoring (including biologics and immunomodulators)Diagnosis of melanoma or other high-risk skin cancer in the last yearHidradenitis suppurativa (controlled)RN/MA callsPath results informationLaboratory tests – notification of normal/abnormal resultsRN/MA visitIsotretinoin refill (female urine test)∗With associated provider phone call.Nonurgent/reschedule6-12 month follow-up without concerning lesionsLesion for monitoring in patient with no personal or family history of melanoma. Lesion stable per patient.Lesion of concern present < 4 weeksAcne vulgaris and rosacea (controlled)Seborrheic dermatitisSkin tag/seborrheic keratosesLipoma/cystHair lossIrritating lesionPatch testingCyst (not inflamed)BSA, Body surface area; MA, medical assistant; RN, registered nurse.∗ With associated provider phone call. Open table in a new tab BSA, Body surface area; MA, medical assistant; RN, registered nurse. Because in-patient visits are unavoidable, Chen et al1Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar detailed additional precautions that can be implemented to reduce COVID-19 spread. Recommendations included allowing only 1 accompanying person per patient, mask usage and temperature reading for people entering both inpatient and outpatient buildings, and the use of personal protective equipment (PPE) by team members working with patients with suspected or confirmed COVID-19. We agree with these recommendations, although PPE has been in short supply, restricting successful implementation. Alternatively, sterilization of PPE equipment can help mitigate this limitation. The COVID-19 outbreak has been challenging, and the medical community has united together to halt the spread. As the COVID-19 outbreak continues to evolve, we hope to develop and implement procedures that limit the spread of COVID-19 while ensuring that optimal patient care is achieved in dermatology. Once again, we thank Chen et al1Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar for their contribution to improving patient care and safety during this unprecedented time. The authors thank Dr Sancy Leachman and Dr Julie Bauman for their support and inspiration during the design and implementation of the proposed clinical model. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?Journal of the American Academy of DermatologyVol. 82Issue 4PreviewIn late December 2019, several individuals with unexplained pneumonia were reported in Wuhan, China. A novel coronavirus was subsequently identified as the causative pathogen and provisionally designated 2019 novel coronavirus (2019-nCoV).1 As of February 10, 2020, 42,638 cases of 2019-nCoV infection have been confirmed in China, with 21,675 suspected cases and 1016 deaths. There are still more than 3000 confirmed cases every day, involving people living in or visiting Wuhan, as a subsequent characteristic of human-to-human transmission. Full-Text PDF Hidradenitis suppurativa: The importance of virtual outpatient care during COVID-19 pandemicJournal of the American Academy of DermatologyVol. 83Issue 1PreviewTo the Editor: We read with interest "Strategic dermatology clinical operations during COVID-19 pandemic" by Price et al1 and greatly appreciate their approach to maintaining successful patient care while limiting risks. In addition to preventing the spread of infection, the role of the dermatologist is also to provide appropriate care to patients with skin disease to prevent complications and to lower the burden on the health care system through emergency department (ED) visits and admissions. Full-Text PDF