The coronavirus disease 2019 (COVID-19) pandemic has expanded rapidly in the United
States and around the globe, much faster than anticipated. Hundreds of thousands are
infected and unfortunately plenty of patients have died. As an academic allergy and
immunology division in a large city, our clinical, educational, research, and community
responsibilities have been tremendously impacted. Patients needed us more than ever,
but mitigation efforts prevented us from seeing them routinely in person. Three weeks
ago, as the first severe case of COVID-19 in Chicago was diagnosed and admitted to
our intensive care unit, we understood we needed immediate plans. The change happened
in multiple categories: clinical operation, training programs, and research (Table
I
). Although in the past decade we have witnessed a tremendously rapid progress in
communication technology, these changes pale in comparison to the speed of change
within the last 3 weeks. It was the time to harness this technology to be used for
educational activities and patient care. Here, we report on the changes to our clinical
and educational activities in response to the COVID-19 pandemic.
Table I
Challenges and solutions in the urban academic allergy and immunology division in
response to the COVID-19 pandemic
Domains
Challenges
Solutions
Clinical
•
Social distancing (including reducing exposure in outpatient clinic and reducing need
to round on inpatient consults with large team of fellows, residents, and students)
•
Converted all nonurgent in-person clinic visits to virtual (with video) or telephone
visit
•
All inpatient consults triaged for need for physical examination and risk of exposure
to coronavirus; physical examination was not done if unnecessary. Discussion rounds
were done virtually. Group rounds at patient rooms were avoided
•
New virtual/telephone visit model
•
Rapid training of faculty and fellows on virtual/telephone visits
•
Increased telephone calls from patients concerned about possible COVID-19
•
Nurses and fellows created phone call pools through a new triaged algorithm
•
Faculty volunteered at special COVID-19 virtual visits at hospital level
•
Staffing and nursing shortage due to surge
•
Stopped all visits at central clinic
•
Moved any urgent visit to 1 satellite location
•
Need for coronavirus-specific patient communication (eg, letters, work-from-home excuse,
coronavirus symptoms, and risk stratification)
•
Standardized letters describing symptoms and when patients should call the COVID-19
hotline
•
Generated COVID-19–specific letters
•
Biologic medications administration
•
Except omalizumab and few cases with disabilities, all other biologics were given
at home. Moved all biological injections to 1 satellite location
•
Allergen immunotherapy (IT)
•
Halted all IT in accordance with AAAAI guidelines for 4 wk
•
Created IT restart plans for interested individuals, with lowest possible frequency.
Plans were discussed with patients over the phone
Educational
•
Minimizing fellow exposure
•
Converted all educational meetings to Web-based meetings
•
Staying current on COVID-19 literature
•
Expanded journal club and staff meetings
•
Expanded case conference
•
Added complexity of fellows schedule in response to increased educational activities
and redeployment
•
Shared calendar
•
Anticipating future COVID-19 challenges
•
Frequent discussions with program directors of Allergy/Immunology
Research
•
Patient recruitment
•
Temporary suspension of all research recruitments
•
Efforts were focused on completing information and chart reviews
•
Expedited IRB amendments to switch consenting and follow-up visits to virtual and
Web-based questionnaires
•
Basic science research
•
Temporary halt of previous experiments
•
Research lab members who were interested got involved in new studies related to COVID-19
experiments by other labs or volunteered in the clinical laboratory
Hospital and community
•
Need for volunteers on the COVID-19 hotline
•
Increased need for inpatient coverage for COVID-19 surge
•
Faculty volunteered to screen concerned patients for COVID-19
•
Nurses volunteers in various COVID-19 testing areas
•
All providers were added to hospital surge lists for COVID-19
AAAAI, American Academy of Allergy, Asthma & Immunology; IRB, institutional review
board; lab, laboratory.
Changes to allergy and immunology clinical practice
With the exception of urgent visits and biologic medication administration, outpatient
clinical operations were transitioned to telemedicine. All faculty and fellows were
trained emergently to perform virtual medicine through video and phone visits. Our
inpatient consult service changed shape as well; the requested consults ran through
an algorithm based on the need for physical examination, and the risk to COVID-19.
Faculty volunteered in COVID-19 telemedicine clinics, which provided a unique opportunity
to augment our typical curriculum evolving COVID-19 guidelines. The insight gained
was tremendously helpful, not only for referring potential COVID-19 cases but also
for understanding the impact of this infection on allergic conditions. The changes
and strategies implemented by our division are summarized in Table I.
Challenges and changes to clinical educational program
The training program was faced with difficult decisions on how to maintain clinical
training. Previous reviews have found that supervision using telehealth can be an
effective method of clinical training.
1
,
2
Both faculty and fellows were trained and provided with adequate information technology
support. Faculty, who had previous experience with telemedicine visits, supervised
the fellow’s telehealth training. Fellows were instructed via university-provided
Web-based sessions, through both prerecorded and live interactive sessions, on virtual
visits. After these tutorials, fellows were directed to use the virtual hospital desktop.
The virtual desktop can be accessed remotely by their office or home computer, in
conjunction with a smartphone- or tablet-based video-conferencing application to perform
visits. After Web-based tutorial training was completed, the fellow’s first virtual
visit occurred in a cleaned patient room while the patient was at home. These ad-hoc
offices improved social distancing for the fellows. After the review, the supervising
attending allergist joined the patient and fellow in a concluding group virtual visit.
The first virtual visits allowed the supervising allergist to help the fellow navigate
the electronic medical record, trouble shoot, and fix any problem in person. Once
the fellow was comfortable, we allowed fellows to work from home.
The electronic medical record provided various methods for real-time conversation
between the fellow and faculty during the virtual visit. Fellows and faculty created
several new letter and documentation templates specific for the COVID-19 crisis. New
modules for electronic patient education and coordination of care were created as
well.
Regulations surrounding telehealth services were modified during this time of national
emergency. The federal government instituted waivers for originating site requirements
and other previous restrictions to allow for greater provision of telehealth services.
3
The billing and coding procedures for telehealth services changed as well. Staying
current on the latest provisions at the local and national levels, communicating with
the coding auditors, and educating fellows were essential because of the changing
nature of this pandemic. The division held a virtual conference guided by hospital
coding experts to go over new regulations, codes, and modifiers. Furthermore, training
program directors discussed any new changes with fellows through group emails and
separate short conferences.
Virtual shared calendar for academic and educational activities
Allergy fellowship educational activities were complicated by a multitude of factors.
These factors include overloading of the daily clinic schedule with telemedicine training,
the rapid publication of key COVID-19 articles, and social distancing. To address
these challenges, the weekly calendar was revised. The training program created a
new detailed, shared calendar to follow and document all the fellows’ educational
and clinical activities. The new calendar reduced scheduling conflicts. Given the
rapidly developing crisis and publication of important findings, journal club required
an expansion. An online, expanded journal club schedule was embedded in the above
schedule. Faculty and fellows were assigned to cover allergy- and immunology-related
articles with focus on COVID-19. Example was a 90-minute journal club through which
5 fellows thoroughly discussed the new practice parameters guidelines on COVID-19
pandemic contingency planning published by the American College of Allergy, Asthma
& Immunology/American Academy of Allergy, Asthma & Immunology.
4
This journal club was followed by a divisional meeting to reinforce some of the changes
that needed to be implemented in our clinical practice according to this publication.
Similarly, social distancing required the in-person discussing of interesting or challenging
cases be transformed to conference calls, with emphasis on cases related to COVID-19
infection.
Support systems
The pandemic and fear of infections aside, going through this significant amount of
change in a short period of time has been very stressful. As schools and daycares
closed, those with young children faced difficulties to coordinate their personal
lives. Unfortunately, grandparents were the high-risk population and not suitable
babysitters in the COVID-19 pandemic. Performing telehealth visits, or participating
in remote journal club, immunology lectures, and training sessions from home was not
always easy. We addressed these issues with provisional planning and changing schedules
whenever needed. The fear and uncertainty of the unfolding pandemic was particularly
unsettling for fellows in training. An open dialog was essential to allow trainees
to voice concerns regarding how this national emergency may impact their individual
experience. The availability of program directors and their rapport with fellows to
address their concerns and provide reassurance on an almost daily basis were essential
and helpful to address some of these challenges. Some other changes were made in response
to fellows’ concerns. For example, the traditional call schedules were reordered to
share the responsibilities, and messages and phone calls were placed in clinical pools
as the volume of patient questions increased in the face of the pandemic.
We also identified a need for future emergency planning, given the likelihood of the
crisis worsening. There would be more difficulties, such as COVID-19 infection among
faculty, fellows, and support staff, and increased inpatient responsibilities for
all physicians including allergists. Contingency plans and schedules were placed for
both inpatient and outpatient responsibilities, with 2 lines of backup for faculty,
fellows, and other staff. Furthermore, we shared detailed information on the available
resources by university for stress management, employee and family health, and contingency
child care.
Although we are pressed with immediacy of the COVID-19 pandemic, we also need to keep
a long-term view for the future of our specialty. The COVID-19 pandemic has impacted
all parts of the world. Given the recent history of other epidemics (eg, severe acute
respiratory syndrome, H1N1, ebola, and Middle East respiratory syndrome), it is unlikely
that this will be the last epidemic/pandemic crisis. This type of crisis requires
allergy divisions and training programs communicate by virtual global assemblies.
Communication between program directors and fellows across different programs can
provide support and solutions, which can be adapted at each division on the basis
of their needs and resources. The entire specialty should unite with the societies
such as the World Allergy Organization, the American Academy of Allergy, Asthma &
Immunology, and the American College of Allergy, Asthma & Immunology in these difficult
times to share experiences and knowledge to overcome present and future difficulties.