Strategic dermatology clinical operations during the coronavirus disease 2019 (COVID-19) pandemic

To the Editor: We were very pleased to read Chen et al's commentary¹ 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.^{2 , 3} 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.

Fig 1.

Color-coded scheme of triaging patient visits in dermatologic care during the coronavirus disease 2019 pandemic. MA, Medical assistant; RN, registered nurse. Created with Biorender.com.

Table I.

Visit types and associated visit categories

Visit type	Visit categories
In-person visit	Blistering skin condition
	Diffuse rash (BSA >80%); acute onset within 1-2 weeks
	Erythrodermic
	Mucosal involvement
	Rapidly enlarging non-healing lesion (including bleeding) that has been present for at least 4 weeks
	Painful lesion(s)/rash
	Patients with high number of skin cancers and diffuse actinic damage
	Any rash in immunocompromised patient or patient on chemotherapy that requires a skin biopsy
	Concerning lesion for melanoma diagnosis or other high-risk skin cancer
Telemedicine	Condition worsening; need to make changes to therapeutic plan
	< 3-month follow-up scheduled at last visit
	Lesion for monitoring in patient with history of melanoma or high-risk skin cancer
	New lesion of concern present for > 4 weeks
	Acne vulgaris and rosacea (active disease)
	New patient visit with chief complaint other than specified “in-person visit” category
	Hidradenitis suppurativa (active)
	Cyst (inflamed, painful)
Provider phone call	Follow-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 year
	Hidradenitis suppurativa (controlled)
RN/MA calls	Path results information
	Laboratory tests – notification of normal/abnormal results
RN/MA visit	Isotretinoin refill (female urine test)∗
Nonurgent/reschedule	6-12 month follow-up without concerning lesions
	Lesion for monitoring in patient with no personal or family history of melanoma. Lesion stable per patient.
	Lesion of concern present < 4 weeks
	Acne vulgaris and rosacea (controlled)
	Seborrheic dermatitis
	Skin tag/seborrheic keratoses
	Lipoma/cyst
	Hair loss
	Irritating lesion
	Patch testing
	Cyst (not inflamed)

BSA, Body surface area; MA, medical assistant; RN, registered nurse.

^∗With associated provider phone call.

Because in-patient visits are unavoidable, Chen et al¹ 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 al¹ for their contribution to improving patient care and safety during this unprecedented time.