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Doing TMS Safely in a COVID World, a Paradigm Shift

Source: 
Clinical TMS Society

By Kevin Kinback MD, Director of Advanced TMS Center

Overview: to help fellow Society members, I collated information on the impact of pandemic on medical practices, some virus considerations, telehealth operations, considerations for resuming "normal" operations in the near future, and nearly 500 references. I've spent up to 1 hour daily reading reports from hospital networks, the CA Medical Association, CDC, Medical Economics and news links. There are interesting and useful considerations related to TMS. NOTE: I haven't fully researched all listed services, references and options and I therefore don't endorse or certify their suitability, it's all "just FYI."

Impact of Pandemic on Medical Practices:

A quick internet search showed that 43 states and DC implemented "stay at home" orders in an effort to contain the pandemic caused by the SARS-CoV-2 virus. This has likely impacted TMS providers, causing a dilemma, whether it's "safe" to continue TMS treatment, while balancing exposure isks to patients, staff, doctors and indirectly all of our families, with the need to maintain practice income and meet patient needs. Many providers reduced TMS services, stopped taking new TMS patients, continued TMS as usual with personal protective equipment (PPE) and decontamination, while others have temporarily stopped TMS totally. These are all individual decisions and there is no absolute right or wrong answer on how to proceed. However, most would agree, including the CDC, that continuing TMS treatment "as usual" without at least using masks, gloves, possibly face shields, decontamination, and screening patients for personal and family symptoms or exposure risks (temperatures?) is clearly wrong and extremely irresponsible. So the tricky problem is how to continue to treating TMS patients and exactly what should be done, and then how "safe" are these measures as we restore "business as usual"?

This COVID pandemic has devastated most general businesses which have closed across the country. At least in our area, many medical & dental practices have closed to all but the most emergent cases, and the use of telehealth has literally exploded under temporary state and insurance authorization. Outgoing messages I hear from some medical and dental practices is that "we've been ordered to close to non-emergency care." This raises a discussion whether TMS is considered essential or elective. Because TMS is not indicated on actively suicidal patients for whom hospitalization or ECT is the appropriate, some may argue that all TMS is elective. If so inclined, some practices are "holding off" on new starts, but screening new TMS patients, working on authorizations for TMS, with a plan to restart once the first virus wave passes, using new safety measures and PPE. Other TMS practices, especially those treating more severely depressed patients, would deem their TMS services as essential and not elective. This may be especially true in areas where ECT or inpatient treatment is even more "risky" for virus exposure than outpatient. State and local health departments have the right to investigate medical practices and intervene if they offer "nonessential" treatment against a Governor's order, for example, cosmetic botox or spider vein removal. It does seem that for very hopeless, severely depressed patients who may worsen despite close medication management and psychotherapy, TMS would clearly not be considered elective treatment. The decision to begin TMS treatment during this crisis seems best made on a case-by-case basis between patient and doctor, after a careful assessment and open discussion of risks, benefits, and safety precautions considering the local virus prevalence. The key is how to keep TMS technicians, patients and other office staff safe during this crisis.

There are potential liability concerns for TMS practice during the pandemic. One concern is that if a TMS patient with COVID comes in daily, there is high risk of staff & other patients becoming infected. Decontamination is very difficult. Perhaps a young TMS tech thusly exposed may have mild or no symptoms, but their parent or grandparent may be in mortal danger if they contract the virus. (check the age-adjusted mortality rates, as high as 15% or more in the oldest decades). Is there liability to our practices if patients and/or staff can trace their infections to our workplaces? If we are not exactly following CDC and OSHA guidelines (a moving target in the past 2 months) can we be sued by employees for death of a family member through workplace exposure?

A recent Medical Economics article found medical practice patient volume, procedures and income to be down between 50 and 80%. Just today one local hospital system announced gross revenue reduced by 40%, while costs of extra labor, medications and PPE are skyrocketing. Just like all the parked cruise ships and grounded airplanes, we can't delay our in-person TMS treatment much longer and expect to stay in business. There is also a tremendous unmet patient need if TMS availability is limited. Even if TMS practices remain open for essential treatment, many are reporting substantial drops in the number of patients who are willing to undergo in-person TMS treatment, as well as a lot of other medical procedures and office visits. In the coming weeks, the economy will try to "restart," and has already indeed started in California, allowing some "elective" surgeries to begin, albeit with very heavy testing, guidelines, monitoring and use of PPE. There remain more questions than answers at this time on how to be safe and patients seem to be quite skittish about risks.

Meanwhile, there have been some relief options for medical caregivers, including:

    • Paycheck Protection Program-- 1% loan, forgivable if you follow guidelines and retain employees. However competition is stiff and funding is very tight and limited. 
    • Economic Injury Disaster Loan (EIDL) at 3.75% up to $2 million from SBA, $10K advance
    • SBA express bridge loan up to $25,000 with less paperwork
    • Relief for SBA 7(a), 504 or microloan waiving interest and payments for 6 mos
    • Student loans and residential mortgage forbearance for 3-6 mos (apply via servicer)
    • Professional Liability (Malpractice) discounts-- if you cut to part time, seek discount
    • Extended unemployment benefits, some allowance even for 1099 in some states
    • Extended tax filing and payment deadline to 7-15-2020, & some states
    • Employer Retention Tax Credit for first $10K paid per employee (if no PPP loan)
    • Payroll Tax delay (Social security), modifying for net operating losses, interest expense
    • Waived 10% penalty on IRA withdrawals
    • Medicare advance loans (on hold now), pause on 2% sequestration, HHS relief payments
    • Mainstreet Business Lending program, 2% loan, 6 mos deferred payments
    • For Healthcare Workers: Free hotel rooms, discounts at Walgeens (4-25-20), free food at McDonalds, free donuts Mondays at Krispy Kreme, early admission to Costco, etc.
    • Numerous other state programs--check your state med association for information

Some General Virus Considerations:

The problem comes from the high rate of asymptomatic transmission of the virus, thought to have a Ro value (basic reproduction number or the # of new infections caused by each positive case) ranging from 1.4 to 3.9, however due to lack of available widespread testing the true infection and transmission rates may be much higher. There are even "superspreaders" who have been traced to have infected dozens or more! (Stein RA. Super-spreaders in infectious diseases. Int J Infect Dis. 2011 Aug;15(8):e510-3.). This virus has an overall mortality rate between 2 and 10 times that of seasonal flu. The flu alone in the US alone kills 25,000 to 50,000 per year with over 500,000 hospitalizations and millions infected, but has a much shorter incubation and infectious period, and tends to burn out naturally each season. There is too much we still don't know about the new Coronavirus, but we can expect at least twice as many deaths compared to flu. There is talk of a 2nd wave this winter, when the COVID virus will run concurrent with annual flu. The coronaviruses are not new, first discovered by virologist June Almeida in the 1960's, and usually responsible for the common cold, but in some forms cause Sudden Acute Respiratory Syndrome (SARS) and MERS. Those words in most of us trigger memories of outbreaks with very high mortality rates of 9.2 to 37%, infecting thousands, and killing hundreds between 8 and 18 years ago. Any virus called SARS needs to be taken very seriously.

Due to lack of testing availability (we even have a shortage of swabs) as well as inaccurate testing procedures ( just last week we changed from NP to OP swabbing due to high false negatives), most infections disease experts agree that we are likely underestimating exposure by at least a factor of 10. Our current count of 2.8M infected and nearly 200,000 deaths is likely closer to 28 M already. Just this week testing in New York showed asymptomatic infection rates in the 15% range. (Centre for Evidence-Based Medicine; Heneghan C, Brassey J, Jefferson T. COVID-19: What proportion are asymptomatic? 2020 [internet publication]., Day M. Covid-19: identifying and isolating asymptomatic people helped eliminate virus in Italian village. BMJ. 2020 Mar 23;368:m1165.). We won't have the full picture until either widespread virus or antibody testing. There is one city without any distancing which will be interesting to watch, as they try to build local "herd immunity," the threshold for COVID-19 being somewhere from 29 to 74% infection rate. (the formula is Pc or critical population = 1 - 1/Ro). However, while this city may eventually be safe, it is currently a nidus of contagion if residents stray outside city limits! They are also putting their own elderly population at disproportionally higher mortality risk.

From what we know, populations in close and frequent contact, such as prisons, cruise and military ships, and nursing homes, have astronomically high infection and death rates. This raises the question for TMS technician safety, having to be within inches of patient faces during setup and takedown of TMS. While not prolonged contact, it is certainly close, frequent and repeated.

It seems that for unknown reasons, people of all ages, but mostly older people, as high as 20% are sick enough to be hospitalized. Of those, about 10% seem to require ventilators and of those, as the death rate despite heroic efforts can be in the 80% range. The infection rate for front-line health care workers, especially doing intubation and CPR is staggering, in some cases up to 30% even with full PPE. There has been talk of universal DNR's, deadly delays in CPR by minutes while staff dons PPE, and the need to "flatten the curve," by social distancing and stay at home orders. These measures ARE clearly working well and we haven't had to resort to "Y" or "T" adapters for patients to share respirators. Many companies such as Tesla are stepping up and making large numbers of low cost, emergency respirators, and BIPAP is also being used whenever possible. So far, the death rates have been DESPITE these heroic efforts in the US, and not because we have run short of ventilators. However without people staying home the infection rate is expected to flare up again, at least locally. 

Little known & COVID complications (aside from ARDS) from a great article with over 450 references: 
(https://bestpractice.bmj.com/topics/en-gb/3000168/complications#referencePop434):  

    1. Emotional & mental: hospitals have banned visitors, so the toll on families who can't visit those sick and dying is staggering.  Caregiver and staff burnout is also high.
    2. Financial: Insurance seems to have waived copays for care related to COVID.  However does this mean someone hospitalized as a PUI (person under investigation) for suspected infection that is not given the formal diagnosis or having a positive test, will be stuck with copays on bills in the tens of thousands?  We would hope not.  There are already over 22 million unemployment applications and even medical practices have contracted and lost revenue.  Phones once busy are simply not ringing at this time and many medical practices including psychiatry have furloughed, cut hours or laid off staff and doctors.
    3. Cardiac: There have been reports of 7-20% of patients with acute myocardial injury.  Just this week new announcements about pediatric cardiac risk, even in mild cases of COVID.
    4. Acute liver injury: up to 76% of patients had abnormal LFT's, with 14-53% acute liver injury rate.  Some antivirals increase the risk.
    5. Coagulopathy:  as emboli, DIC, venous thromboemboli, etc.
    6. Acute kidney injury:  in 3-8% of patients, with 26-40% having proneinuria or hematuria.
    7. Pancreatic injury:  mild, but in up to 17% of patients.
    8. Neurological complications: reports of Guillain-Barre, meningitis, encephalitis, enceopalopathy, thought to be direct infection found in brain and CSF.  Neurological symptoms occur in 36% of patients, more common with severe illness.  Recent reports showed cases of widespread brain swelling, inflammation and irreversible acute necrotizing encephalopathy. 

This last one is truly scary, since we don't know why so many people are asymptomatic or have only mild URI-like symptoms while others end up with neurological damage.

What will be the solution going forward? Clearly the ultimate prevention is some combination or herd immunity or universal use of an effective COVID-19 vaccine. Currently there are up to 70 various vaccines being tested, and right now 5 are in clinical trials. Competition is a good thing here, and the FDA seems to be allowing acceleration of approval, but we expect them to not compromise safety of efficacy. Clearly the winner of the vaccine race stands to profit in the tens of billions, so motivation for success is very high! Hopefully the anti-vax crowd will come to their senses when the vaccine comes out. I've been sort of prepping my patients by asking if they plan to take the COVID-19 vaccine once available, and a surprising number of patients hesitate or express doubt, so I give reassurance of safety, efficacy and the need for herd immunity. Since some projection models without current social distancing show up to a 90% infection rate, there are only two likely outcomes for most of the world: get the vaccine or get the disease. They have just developed new, rapid tests for acute infection in the past 2 weeks, with OP swabbing, with sensitivity and specificity in the 90+ % range, much better than a few weeks ago when our test had a 30% false negative rate!

Another solution is antibody testing. Currently there are MANY scams to be avoided. Just today our local health department put out a notice that there is NO specific antibody test for COVID-19. It seems that all the common cold coronaviruses cause IGG spikes which are hard to distinguish from actual COVID-19, so there are lot of false positives. It is also unknown if the IGG is actually protective against COVID, or how long this protection lasts. Hopefully the folks working on this will very quickly come up with a highly accurate and sensitive antibody test. The current recommendation as of today, is to ignore a positive coronavirus IGG test and continue protecting yourself as if it were negative. Hopefully the general public who don't read daily COVID updates as most of us do, will not be hoodwinked by these unproven and misleading virus or "home antibody" test kits hitting the market! To complicate matters this week, the WHO announced that re-infections are possible, so even those infected need to maintain full preventive measures (https://www.cnn.com/2020/04/25/us/who-immunity-antibodies-covid-19/index.html)

Finally, social distancing will be the norm until a vaccine has been widely given. Restaurants will remove at least half their tables, servers will wear mask, as should the general public. We're not even sure that confirmed cases can't be reinfected or carriers, so it seems that universal masking would be prudent. Fortunately many washable cloth masks are coming available, and we can see them being widely used by wise citizens. Medical practices will hopefully continue telehealth, but it won't be "business as usual" with in-person treatment until the vaccine arrives, so hopefully we will get permission to continue telemedicine until then.

Telehealth Operations for Psychiatry:

All insurance payors, federal and it seems nearly all states have temporarily removed all restrictions on telehealth services. Previously, specific secure technology was required, with limitations on where the doctors could be (in offices, not home) or where patients could be (in a specific clinic, not home). There are still licensing restrictions, so doctors must be licensed in states where they work and sometimes also where they live, as well as where their patients live or are located. Some emergency provisions exist but they vary by state and seem to be extremely complicated. In general, psychiatrists and psychologists seem to be way behind the curve compared to other specialists and hospitals in adopting highly advanced EMR systems. The majority of my colleagues are using "free" systems or using some electronic forms of scheduling or eRx, without an integrated practice management or telemedicine option.

Over the early and middle weeks of the COVID-19 outbreak, payors one by one relaxed guidelines, first allowing less secure, non-HIPAA compliant platforms like Zoom basic and facetime, then finally phone calls. However this is only temporary and not expected to last in it's present form past sometime in June. There have also been proclamations of payments to be equal for telemedicine to in-person care, and some payors plan to waive copayments for telehealth (i.e. pay at 100% of contracted rate). Other payors are paying out of network providers at network rates, so the telehealth industry has grown up explosively within a matter of weeks. It should be noted that public-facing products such as public shat rooms, TikTok, Facebook Live, or Twitch are still prohibited and violate HIPAA. Also note that aside from the telehealth dispensation, all other aspects of HIPAA remain in place and should be followed. NOTE: This allowance of broad telehealth platforms could END any day with short notice, so watch your email carefully.

Currently allowed non-public facing remote communication products (per HHS- medicare) are:

    • Apple FaceTime
    • Facebook Messenger viceo chat
    • Google Hangouts viceo
    • Whatsapp video chat
    • Zoom
    • Skype

Text allowed apps include (note:  texting is asynchronous communication): Signal, Jabber, Facebook Messenger, Google Hangouts,Whatsapp, and iMessage. 

End-to-end encryption is recommended with individual user accounts, logins, and passcodes to limit access and verify participants. Here is a great HHS reference for Telehealth: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf.

How do you document telehealth? I've reviewed emails from various payors as well as attended Webinars from the California Medical Association, as well as my own experienced billing and coding team and we have good news!

This emergency declaration allows wide use of various platforms, locations for doctors and patients (at home) and even phone sessions to be done and paid at customary rates. This must all of course be documented in notes. We have had most of our claims paid even quicker than usual for telehealth. 

Telehealth Documentation requirements in progress notes: 

    1. Document that the visit was in telehealth and not in person.
    2. List the specific platform using, and whether synchronous audio and/or video (phone) or asynchronous (delayed) transmission such as secure email or text.
    3. Document the patient consented to a telehealth visit (temporarily can be verbal but previously written consent was mandatory, and will shortly be mandatory again).
    4. Document the location (city, state) of both patient and clinician, and specify each is at home, office, or car, work, etc.
    5. Document whether the patient is alone, and if not, who else is present and can hear the call on either end, and that the patient is both aware and consents to the other parties. Speakerphones should be avoided if possible.  Patients should be asked if they can be overheard and given opportunity to move away from others or use earphones before starting.
    6. Document the exact start and stop time of the televisit. Optional documentation of total time of televisit may be acceptable under the emergency for now, but apparently in 2021 the start and stop times will be mandatory.
    7. If screenshots are possible, you could capture these and save to patient documents for private reference in case of any future disputes about whether the visit took place.  These can always be deleted later but must be saved and stored securely per HIPAA. 

(NOTE: be aware that patients can also record or screen-grab your image, so keep your comportment in mind. In some states consent of both parties is required for recording (like CA), so your consent form should notify patients if you want to forbid recording). 

Telehealth Billing and Coding: 

  1. Change the POS (place of service) code from 11 (outpatient) to 2 (telehealth). This triggers the telehealth payment during the emergency to be the same as the original POS code would have been. It seems like nearly ALL payors are now requiring or at least allowing POS 2 to be used on all telehealth claims, combined with a modifier below.
  2. Use Modifier GT for a synchronous telehealth platform, either video, audio, both or phone.
  3. Use Modifier GO for asynchronous telehealth platform (email, text). However this is NOT the preferred mode of communication and could result in reduced reimbursement. These may be considered e-visits or virtual check in and may have different CPT codes.
  4. Modifier 95 can also be used and indicates synchronous telemedicine. Some providers want POS code 11 (outpatient) used with MOD 95. If your Medicare MAC is reducing your payments to facility rates because of POS 2, submit corrected claims using POS 11/MOD 95 instead.   Auditing of payments is necessary to correct any coding/payment issues compared to those with the prior in-person coding.
  5. CPT T1014: this is a per-minute allowance for telehealth technology cost reimbursement. Some insurance contracts DO allow billing a per minute fee, & may specify other codes for this charge. This code can be used once, with the number of units equal to the number of minutes on the audio/video link. For example a 27 minute telehealth visit would be coded as T1014, with 27 units, POS 2 (no modifier necessary). We were just advised today that Noridian Medicare is NOT paying for T1014. It won't hurt to send this code and if payment is denied, simply adjust if off the claim.  If the entire claim is denied due to T1014, then drop the T1014 CPT and resubmit the claim.
  6. General visit CPT coding: During this emergency, providers are supposed to use typical office CPT codes for medication management (90791, 90792, 99213-215, psychotherapy codes, etc). NOTE that telehealth codes are NOT appropriate for TMS, ECT or other office or hospital based procedures.

NOTE: right now it seems that many payors will pay for POS 11 + MOD 95, however POS 2 + MOD GT is perhaps the most common combination. If claims are denied for incorrect POS/modifier combinations, they should be promptly rebilled with a corrected claim by adding the appropriate resubmission code in box 22 on the HCFA 1500 form. (one common resubmission code is 7, indicating replacement of prior claim submission).

However, there are an entirely different set of telehealth billing codes including codes for facilities, originating sites, etc. that would apply in the absence of this COVID emergency allowance. All those factors will come back into play once the emergency blanket authorization of telehealth ends. 

Telehealth Contracting Issues: Some psychiatric contracts allow and others prohibit telemedicine. This would be a good time for your billing and/or credentialing staff to reach out to each payor to sign any additional contracting agreement(s) to allow permanent ongoing telehealth services. They should also clarify NON-emergency codes which should be used. I t is my sincere hope that nearly all insurance will continue to allow telehealth in the future, as many patients find it convenient, and effective, especially if they have a long drive to provider offices, or limited time during work hours. For example, with telehealth, a 10-15 minute appointment for a patient at work could be done over a lunch or rest break, but a round-trip travel time of 30-45 minutes would be impossible. However, you can expect more restrictions on where the patients and doctors must be located.  Also, be sure to NOT treat patients across state lines unless you are properly licensed and insured. If you are non-contracted, be advised that while telehealth may reimburse you and/or patients during this emergency, there may be zero reimbursement for patients seeing out of network telehealth providers in the future. 

Documents and forms for Telehealth: While our office was fortunate to activate secure telehealth inside our EMR and train staff/providers within days inside of our EMR, others had more struggles, especially those without hospital-grade EMR's. Even advanced EMRs don't often include secure email for attachments or document management. Many, including us, without a document management platform, are now seeking HIPAA-compliant solutions. These would allow patients to securely receive forms and documents to fill out, digitally sign as needed, and submit to a secure portal. Office staff then drag these documents and images (such as pic of insurance card) into the EMR for permanent storage. These forms/documents can also be linked to websites for easy access, as well as pushed to patient cell phones, laptops or other devices to capture signatures contact-free in the next 1-2 years.  This also saves mountains of staff time instead of printing, clipboards, scanning, reviewing and shredding documents!

Some examples of document management platforms include: Docusign, Adobe Forms, Formstack, pdfFiller, etc.  Costs can be several hundreds of dollars a month and contracts can be required. NOTE: you MUST use a HIPAA-compliant document service, especially if they use email and cloud storage, and they MUST provide you with a Business Associate Agreement (BAA) just like any vendor you may use. 

 Telehealth Platforms, perks and Costs: 

There ARE some telehealth alternatives. It seems that most insurance payors, such as the Blue plans, Aetna, and other big names, offer FREE telehealth platforms, at least for their own patients.  However after the emergency passes, they may restrict these to use for only their own insureds. You would not need a special BAA since they are the actual insurance company's platform. However, it would be quite difficult for most providers to keep track of which platforms must be used with which certain patients going forward. I certainly wouldn't want to do it. 

Some telehealth platforms are listed and costs are likely PER provider. Note that most have various simple and free, or better and pay options.  Some have waived fees or cut costs during the emergency, so as a rule, you can expect costs to increase in the future. Hopefully maybe the T1014 or other CPT codes per minute from some insurance payors, even if paid at pennies per minute, will help offset telehealth technology costs. NOTE: Be SURE you have a HIPAA-compliant written agreement AND a BAA if you are using these vendors, especially after the emergency waivers expire.      

Doxy.me.  Free base, with other perks a la carte cost.

eVisit:  may cost $50-150/mo.

SimpleVisit:  maybe in $150/mo range.

VSee:  can cost up to $250/mo

Mend (MendFamily):  reported at $250-500 but higher end option includes some forms/questionnaire pushing to patients (may be limited to certain geographic areas).

Spruce Health:  unclear pricing or options.

Zoom Professional:  in $200/mo range

Updox:  details and pricing unknown, includes email, text, fax and appt. reminders, may integrate with EMR

A great telehealth reference from AAFP:  https://www.aafp.org/patient-care/emergency/2019-coronavirus/telehealth.html

Considerations for resuming "normal" TMS operations:

We can hopefully all agree that simply resuming or continuing TMS "as usual" without regard to the COVID-19 risks is no longer an option. There will be either new outbreaks or pockets of infection all over the country. Despite our current million US infections and > 50,000 deaths in the past 2 months, in at least some areas new case #'s are leveling off. It does seem clear that until we have widespread immunity via vaccine, a series of changes are needed in TMS practices. I'll give the list of all the possible mitigations I can imagine, with some commentary and caveats, then leave it to your readers which to apply to your practice.

Liability issues and duty to staff and patients: 

    • Keep checking med society, hospital and CDC guidelines for best practices and PPE use, post & follow them. 
    • Be aware daily of the number of new infections in your County/city, and where your patients live. Be prepared to pause TMS if there is a flare-up in your immediate area. 
    • Post a written policy & procedure for staff distancing, and modified patient flow procedures. Check compliance.
    • Consider doing 100% telehealth for TMS evals, new patients and follow-ups as long as permitted (hopefully 2021)
    • Conduct and document training for staff use of PPE & monitor compliance
    • Update your policies for paid time off and have a policy for symptomatic staff/household exposures, quarantine staff members showing symptoms or with known exposures
    • Create work-from-home job descriptions for staff use as needed
    • Remember that HIPAA regulations require a signed BYOD (Bring Your Own Device) policy for clinicians using home computers or laptops outside the office. Spammers and ransomware abound, so do extra security training and be sure antivirus and firewalls are updated on all devices. Home networks lack protections of corporate platforms. 
    • Prohibit flash drives and saving data on non-secure computers or home devices
    • Consider using Doximity Dialer or other phone emulator--be sure clinicians/staff broadcast only the office # and not their personal cell numbers or emails to patients. You can be sure this will be quickly abused by some patients, and poses a risk to staff!  Avoid texting patients (it shows your phone number unless using an emulator).
    • In nearly all states it's improper to prescribe experimental meds or treat yourself or family without proper exams, documentation and medical necessity. Some states have already disciplined doctors for writing prescriptions for each other "just in case." Be safe and if someone has symptoms, have a colleague do a "real" evaluation and rely on their expert treatment. 

NOTES:  PPE is currently nearly impossible to obtain. Local stores, Amazon, etc. are overwhelmed, out of stock. If you have a medical supplier account (Schein, McKesson, etc) then NOW is the time to "kiss up" and bribe your personal sales rep (Starbucks or other gift card?). They use "allocation" which means if you haven't had consistently high levels of prior orders, they will not let you buy even small quantities of items like gloves, masks, gowns, face shields, sanitizer, wipes, etc. We are fortunate to have accounts, but even for a small quantities of PPE we are told it's 2-4 weeks for delivery. If anyone learns of a good supplier of PPE, please share on the CTMSS forum or listserv!

Check your Medical Association guidelines for reopening practices: Here is a link to the California (CMA) guidelines just published:  https://www.cmadocs.org/Portals/CMA/files/public/CMA%20COVID%20Guidelines%20for%20Reopening.pdf

Distancing in medical offices: 

    • Remove magazines and common items (i.e. coffee bar, fridge, toys, clipboards) from waiting rooms
    • Remove most of the waiting room chairs
    • Install plastic shields or sheeting between staff and patients (like grocery stores did)
    • Put 6' marker tape on the floor to remind distance
    • Don't let patients linger or congregate in waiting or check in-out areas (post signs or use barriers)
    • Put physical barriers (like plastic folding tables) in front of check-in counters to keep distance
    • Go to touchless check-in--keep patients in cars until you text them to come in
    • MOVE your TMS room to a room with a separate entrance, don't walk patients through entire office (may require electrician for new circuits). A TMS room in deep in the bowels of the back office is the highest risk, so relocate it.
    • Separate staff and move workstations apart, locate them in unused rooms if possible
    • Collect credit card payments by phone, apple pay or other touchless system
    • Get document management to digitally import images of ID and ins cards, NOT by hand, avoid all paper
    • Train staff to maintain 6' distance from each other and patients
    • Stagger staff lunch breaks to avoid congregation
    • Close the break room for eating and have staff enjoy the Spring weather eating outside
    • Ban family members and tag-alongs for TMS patients and others
    • Stop giving injections in the office--pharmacies will do these or use home healthcare
    • Put away office based tablets and devices, push documents to patient devices or portals
    • Post a policy about all these factors and document ongoing staff training and reminders, update your website
    • Limit vitals unless absolutely necessary, maybe every 2-3 visits, or get notes from PCP and record those recent VS
    • Avoid blood draws and EKG's in offices, send patients to labs or seek other recent records instead
    • Consider using an empty room as supplemental waiting room, or better yet, space patients out if possible to avoid more than one in the waiting room. If possible use a separate exit. 

Using PPE in psychiatric offices: 

Disclaimer: psychiatrists, staff and TMS techs in primarily outpatient offices are NOT typically trained in proper PPE use. There have been healthcare worker infection rates as high as 25-30% in some areas, despite full and proper PPE use. Our local hospital requires a monitor person watching every staff member don and doff PPE, to alert the need to decontaminate if perfect procedure isn't followed. Reusing masks requires hospital grade decontamination (a very expensive vaporized hydrogen peroxide system), so do-it-yourself tricks will not work, do NOT try this. Soiled masks must be discarded. Even N95 masks per OSHA and other regulations require very extensive fit testing or they are worthless-- any leak is the same as not having a mask. There are many USDL and other great Youtube videos on respiratory and other PPE protection. Check out a "real" fit test and you will be shocked at the complexity if you haven't done it as part of hospital staff testing.  https://www.youtube.com/watch?v=D38BjgUdL5Uhttps://www.youtube.com/watch?v=6qkXV4kmp7c 

There have been counterfeit N95 masks on the market, so be sure they are NOISH certified and properly marked. If you  want to use N95 masks properly, use a fit test kit and document periodic training of all staff ($200-300 initial cost for 100 uses, extra solution is available, as is kit use training). There are also many Phishing sites offering PPE which actually put viruses on your devices. Don't click on these sites. Be aware that PPE can give staff a false sense of security, so make them aware that gloves and the outsides of masks are always contaminated. Adjustment of masks once donned is not allowed. Improper use of PPE, especially donning and doffing, is very high risk and prone to contamination. Conduct and document repeated training on proper PPE use (youtube has many good videos, see reference--a specific order must be used). Fight the urge to over-reuse PPE, and finally, be aware that proper use of PPE is very inconvenient and expensive. Train, do more training, and then train your staff again!

PPE & disinfection Tips for TMS Practices (staff & patients) until vaccine is available: 

    • Procedure masks and cloth masks help keep the virus IN but aren't good keeping the virus away from staff.
    • All patients BEFORE coming into the office could be required to have at least a tightly fitting cloth mask at all times
    • Consider a portable handwashing station at office entrance to have staff, patients wash on entering
    • Have hand sanitizer available in treatment areas
    • Wipe down doorknobs and other surfaces, BP cuffs, often
    • Buy touchless thermal scanners and check temperature of staff and all patients (currently these are $40-80 or more each from China with $60 shipping fees, and in the $100-300 range from US medical supply).
    • Have patients tap on doors, so gloved staff can open, don't let patients touch doorknobs, light switches, etc.
    • Keep 6 distance from everyone, avoid even fist bumps, never shake hands
    • Consider giving TMS techs a fit-tested n95 mask. This can be doffed a certain # of times before contamination, but should last a full shift. Proper donning and doffing requires clean gloves which are hard to get now.
    • Assign only one TMS tech per day, to avoid having multiple people using more advanced PPE (N95, gowns, gloves)
    • Disinfect TMS and other office equipment often (CTMSS has posted guidelines on website)
    • Require or supply cloth masks for all persons & staff in your office. While not tested or perfect, everything helps.
    • If a patient or staff member who has visited your office becomes infected, you may need to bite the bullet and hire a PROFESSIONAL decontamination company such as ATI to clean your office. WARNING: time consuming and expensive, but very effective, however be aware that peroxide can damage TMS electrical components. See https://www.naahq.org/sites/default/files/naa-documents/disaster/guideli...
    • If a patient or staff member becomes infected, you may get a call from County Health contact tracing and then be forced to quarantine exposed staff members, so have a good backup plan with multiple TMS techs/staff on call. This week the CO Health Department closed a walmart after complaints of inadequate distancing, people without masks, leading to 3 deaths, to "control the outbreak." Could the County close your TMS practice if there are infections and complaints?
      (https://www.bing.com/search?q=Colorado+Aurora+Walmart+shut&filters=tnTID... 9AC00B731EBF%22+tnVersion%3a%223496995%22+segment%3a%22popularnow.carousel%22+tnCol%3a%222%22+tn Order%3a%229b95cc7d-4974-4c1e-acb0-70a4720c3293%22&FORM=BSPN01&crslsl=0)
    • It is safe-ER to treat TMS patients or other patients who recovered from a documented case of COVID-19, however you should still consider them as potentially re-infected or a carrier and require your standard masks/distancing. We still don't know the reinfection risks, or exactly how long to quarantine after exposures--some suggest at least 7 days after symptom resolution for negative tests (consider the 30% false negative rate), and 2 weeks or more for confirmed positive cases.
    • Resist the urge during active outbreaks to do any NP or OP swabs, or other COVID testing on staff, patients or family members. This is extremely high risk, and many parameters must be followed for adequate specimens and technique. Refer them to official testing stations where this can be done safely and correctly, with reliable followup if positive.
    • Testing parameters may change during reopening of medical clinics. One local hospital is starting some elective surgery next week, but they are evaluating with a committee first, then actually rapid testing EVERY surgery patient for COVID prior to entering the hospital. This underscores the risks of asymptomatic transmission.
    • Don't let staff share workstations and devices. Clean often with wipes all keyboards, mice, monitors, power buttons, phones, doorknobs, switches, credit card machine, printer buttons, etc. Wipes are very hard to get now.
    • Update your website with guidelines for patients and post signs, update phone messages to educate patients & staff on revised safety measures and patient flow

A Special Word about Air systems (HVAC) and UV decontamination: Disclaimer: some items in this section are untested and can be very expensive, but again this whole article is FYI and food for thought, so do your homework!

    • NOW is a great time to have your office air systems cleaned and serviced, ducts cleaned, new filters, etc. If your office is already musty or stuffy to begin with, the risks are higher with heavy patient flow during the pandemic  
    • Consider changing air filters monthly instead of quarterly or upgrading them
    • Air filters have MERV ratings, higher is better, and 8-10 is typical. MERV 13 for example filters 0.3 microns, including some viruses, can last 90 days, but can restrict air flow.  Your A/C contractor can adjust air flow to compensate for a higher MERV filter.   One filter reference:  https://filterbuy.com/merv-13-air-filters/?msclkid=d9e3fe83e4101e425857a0201fd32283&utm_source=bing&utm_medium=cpc&utm_campaign=Generic%20Air%20Exact&utm_term=merv%20air%20filter&utm_content=MERV%20Air%20Filter
    • Many commercial air systems require 20% or more outside air. Find your outside air ducts and check airflow and filters there as well, and clean the intakes, cut away any foliage or spider webs, etc.  Your contractor during service should verify the % of outside fresh air.  Open dampers and maximize outside fresh air if possible.   If you're blessed with office windows, keep them open for business hours and consider a window fan for ventilation.
    • If you are in a large commercial building and sharing fresh air with other offices, be sure you are actually getting fresh OUTSIDE air and not pulling air from other offices, especially those with heavy patient or visitor flow (peds, urgent care)
    • Consider upgrading your office air filters from 1" to 2-4", and be aware that hospital grade filtration media are available for offices, and not much more expensive once installed.  Your contractor may need to enlarge filter slots.
    • There are ultraviolet (UVC) devices available to install in office air systems to keep coils clean and stronger ones to decontaminate moving air. These need to be of specific energy/distance to actually kill viruses and are strong enough to harm humans, degrade plastics, rubber and even metal and may discolor objects.  Ask your contractor about installing UV cleaners in your air systems, which also prevent mold and other buildup. 
    • UVC is being used in OR's and other areas for germicidal decontamination. There are many large portable units with wheels, ceiling mounts, handheld and tabletop units, many with remote control and motion sensors to protect humans.  These range from a few hundred for handheld to many thousands for larger units.  Some are pulsed to minimize damage to room décor.
    • Be aware that UVC is line of sight, so a "downlight" on the ceiling for example, won't decontaminate the underneath parts of TMS devices. A low belt level device in the center of a room may do better.  Check carefully for energy, distance and time required to help minimize virus contamination.   Most good systems come with UV sensor cards to put around the room in some cases up to 10 or more feet away.  They turn color to indicate adequate energy has been deposited in that area by the device.  These look like about the size of a tall office chair or higher, on wheels and can be moved to various rooms to decontaminate as needed (with proper safety).  NOTE:  specific dosing in mW/square inch, at specific distance for specific time should be specified and the UVC range is 250 nm ish, but not all UV light is germicidal.  Review all specs carefully and get expert advice from people NOT trying to sell you one. 
    • Also be aware that there are no absolute standards and many devices have good track records but are not necessarily tested or certified specifically against SARS-coV-2. It is a red flag is a device PROMISES to kill COVID, as it is too early for that claim. 
    • Any UVC cleaning system does NOT take the place of other cleaning and wiping of surfaces and can't be used on organic organisms (humans, pets, nannies, etc). Many can go on timers or remote to turn on at night.
    • Here is one example of the many UV education and suppliers: https://insights.regencylighting.com/can-uv-light-kill-viruses-like-COVID
    • Be aware that availability is very low, and costs are skyrocketing for UV disinfection systems of all types, and the prices will definitely scare you. These are increasingly hard to get and as yet not proven.  Do some homework and maybe call a disinfection company or compare vendors to learn about options.
    • UVC devices have limited number of hours, and degrade the more often they are cycled. Be sure you know the cycle life and replacement bulb/service costs.  A 10,000 hour unit sounds like a long time, but if running 24/7, will burn out in about 13 months.

References:

    1. CMA COVID financial toolkit:  https://www.cmadocs.org/Portals/CMA/files/public/CMA%20COVID%20Financial%20Toolkit%20for%20Medical%20Practices.pdf
    2. Mask Effectiveness:  https://www.cmadocs.org/Portals/CMA/files/public/CMA%20COVID%20Financial%20Toolkit%20for%20Medical%20Practices.pdf
    3. A bad week for NYC:  https://www.wsj.com/articles/seven-days-hundreds-of-deaths-new-yorks-worst-week-yet-tests-its-coronavirus-response-11586308180
    4. Doctors Company guide to temporarily close practice:  https://www.thedoctors.com/articles/COVID-how-to-temporarily-close-your-practice-while-minimizing-risks/?utm_source=communications+from+The+Doctors+Company&utm_campaign=d5e3d27cb8-E-194+COVID+Temp+Office+Closure+%28Members%29&utm_medium=email&utm_term=0_238c55ecb6-d5e3d27cb8-449036577
    5. Tesla making ventilators:  https://www.forbes.com/sites/alanohnsman/2020/04/06/tesla-touts-a-prototype-ventilator-for-COVID-patients-made-out-of-electric-car-parts/#2dacf6f1235b
    6. 102 year old survives COVID:  https://apple.news/AHnmM_Fs2S3WQoZsVSOEY-Q
    7. How virus kills some and hardly affects others:  https://apple.news/AhJ1HNTbOQ1y6_d_SXSxBEQ
    8. Sharing ventilators:  http://newjersey.news12.com/story/41968785/can-coventing-solve-new-jerseys-ventilator-shortage-problem
    9. CDC recommends cloth masks in public:  https://www.vox.com/2020/4/3/21202792/coronavirus-masks-n95-trump-white-house-cdc-ppe-shortage
    10. Risks of states NOT closing down:  https://www.usatoday.com/story/news/nation/2020/04/02/states-without-stay-home-orders-residents-celebrate-freedoms/5105303002/
    11. Asymptomatic spreaders:  https://www.nytimes.com/2020/03/31/health/coronavirus-asymptomatic-transmission.html
    12. N95 hospital fit testing (pictures, details):  https://mobile.twitter.com/leorahorwitzmd/status/1235018922023440385
    13. CDC says virus will persist:  https://www.npr.org/sections/health-shots/2020/03/31/824155179/cdc-director-on-models-for-the-months-to-come-this-virus-is-going-to-be-with-us
    14. Study about airborne COVID:  https://www.npr.org/sections/health-shots/2020/03/31/824155179/cdc-director-on-models-for-the-months-to-come-this-virus-is-going-to-be-with-us
    15. Convalescent plasma as treatment:  https://dgalerts.docguide.com/convalescent-plasma-possibly-helpful-treatment-5-critically-ill-patients-COVID?nl_ref=newsletter&pk_campaign=newsletter&nl_eventid=34731&ncov_site=COVID&nl_campaignid=3641
    16. Nearly 10,000 medical workers infected in Spain:  https://www.nbcnews.com/news/world/medical-workers-spain-italy-overloaded-more-them-catch-coronavirus-n1170721
    17. A chilling account from Doctor at center of crisis:  https://www.buzzfeednews.com/article/josephbernstein/elmhurst-hospital-coronavirus-ventilator-ppe-crisis
    18. Medical worker descries terrifying lung failure:  https://www.propublica.org/article/a-medical-worker-describes--terrifying-lung-failure-from-covid19-even-in-his-young-patients
    19. CDC poster for sequence of applying PPE:  https://www.cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf
    20. Hack to double patients up on ventilators:  https://www.vice.com/en_us/article/qjdm53/this-risky-hack-could-double-access-to-ventilators-as-coronavirus-peaks
    21. California Med Assoc guidelines to restart practices:  https://www.cmadocs.org/Portals/CMA/files/public/CMA%20COVID%20Guidelines%20for%20Reopening.pdf
    22. Coronavirus Lingers in Air of Crowded spaces:  https://apple.news/AEJviy4CrRJee8XkL4oyfrA

Here is an excellent overview from BMJ best practice on COVID: https://bestpractice.bmj.com/topics/en-gb/3000168/pdf/3000168/Coronavirus%20disease%202019%20%28COVID%29.pdf

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      *This article represents the individuals opinion and work of the author not the Clinical TMS Society.