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'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals lure patients back in COVID-19 era

BOSTON –  Before he could cross the soaring lobby of the Dana-Farber Cancer Institute, James Nauen had to answer a litany of questions. 

No, he hadn’t run a fever or felt sick lately. No, he hadn’t been tested for COVID-19 in the last two weeks. Yes, he lived in a private home and hadn’t spent any time in a nursing facility.

Then Nauen, 53, traded his black cloth mask for a hospital-issued one, took the elevator to the second floor and answered the same questions again. He'd have to answer them four times that recent Wednesday morning.

As health care facilities try to convince patients that it’s safe to return for scheduled procedures, many, like Dana-Farber, have dramatically stepped up safety precautions.

A plexiglass window separates Jim Nauen of Newton, Mass. and clinic coordinator Nick Lucido during screening for incoming patients at Dana Farber Cancer Institute in Boston on Wednesday, May 20, 2020. Nauen, 53, is battling colon cancer and was in for chemotherapy treatment.

Cancer centers have been particularly affected by the coronavirus outbreak because their care is so time-sensitive. Many cancer patients also may be at higher-than-normal risk due to disease, treatment and patient age.

At Dana-Farber, employees now enter patients’ information from behind plexiglass. Footprints in elevators indicate where people should stand – as far from others as possible, in limited numbers. Fewer chairs in waiting rooms force visitors to sit further apart.

The hardest change for Nauen, and others in those waiting rooms: They can no longer bring a family member with them for moral support as they get poked, prodded and are given life-changing news.

Luckily for Nauen, the recent news was good. Nauen's tumor continues to shrink, and he was told surgery that ­– fingers crossed – could cure his colorectal cancer would happen in less than a month

“Wow,” he said as he realized that day’s chemotherapy session was likely his last ever, “woah." Pointing at his face mask, he told his doctor, “I’m smiling under here."

Infusion nurse Melissa Perna administers chemotherapy treatment to Jim Nauen of Newton at Dana Farber Cancer Institute in Boston, May 20, 2020. Because of COVID-19 restrictions, visitors are not allowed to be with patients receiving chemotherapy.

At Dana-Farber, the patient load dropped by one-third during the second half of March and April out of concern for COVID-19, the disease caused by the new virus, said Dr. Andrew Wagner, the cancer center’s associate chief medical officer.

When possible, doctors switched patients to oral chemotherapies that could be taken at home. Appointments were deferred or transformed into telemedicine visits – which now constitute more than half of exams – and surgeries like Nauen’s were put off as hospitals turned away all but the most urgent patients to focus on COVID-19 care.

For cancer patients, a delay of even a few months can worsen a prognosis.

“Cancer really doesn’t wait for COVID to go away,” Wagner said. And delaying care certainly ratchets up fear, Nauen confirmed with a shudder.

COVID and cancer:New study shows more cancer patients die from COVID-19, but not necessarily for the reasons you'd expect.

The pandemic's impact on hospitals 

In a tragic twist, many people were so afraid of catching COVID-19 that they stayed away from the hospital even when they desperately needed one, and died at home of a heart attack or stroke. Nationally, hospital admissions for a particularly serious form of heart attack known as STEMI fell 38% after March 1, according to research published in the Journal of the American College of Cardiology.

Chairs spaced apart and a sign asking for social distancing in a waiting room at Dana Farber Cancer Institute in Boston, Wednesday, May 20, 2020

Emergency department visits in the US fell 42% during March and April compared to a year earlier, according to a study released Wednesday by the Centers for Disease Control and Prevention

And in a preliminary study published last month, researchers from Beth Israel Deaconess Medical Center in Boston found the number of patients who came to the hospital with heart attack symptoms in March and April was a third lower than a year earlier. The number of patients who sought care for stroke dropped by 58%.

Overall, health care spending fell 18% in the first quarter of 2020, according to federal data, and the American Hospital Association estimates hospitals and health systems nationwide have lost more than $200 billion since February.

Dr. David Asch, an internist and medical and business professor at the University of Pennsylvania, feels strongly that American health care providers are doing their best to provide a safe environment for patients.

"What I worry about is not that it actually won’t be safe," said Asch, also executive director of Penn's Center for Health Care Innovation. "What I worry about is that people won’t think it’s safe and they will delay the care that they need."

He's concerned both about people not getting care for medical crises like a stroke, in which the faster someone gets to the hospital the more brain tissue may be saved, and for conditions such as colon cancer that seem less urgent but can become lethal if ignored for too long. This, he said, could magnify existing disparities of care. 

To convince people it’s safe to come back for emergency care, a number of medical organizations have jointly launched a video campaign to encourage people to call 911 when they have signs of a stroke or heart attack.

(Common warning signs of heart attack may include discomfort in the chest, pain in the arms or back, shortness of breath, nausea or dizziness. Stroke symptoms may include a drooping face, arm weakness and speech difficulties.)

In Seattle, cancer care has shifted to telemedicine where possible, including wellness high risk and survivorship programs, according to Terry McDonnell, the chief nurse and vice president of clinical operations for the Seattle Cancer Care Alliance.

“Nationwide, we’ve all been trying to bring more telehealth forward,” she said. “This crisis afforded us the opportunity to do work that has taken us years to stand up … it forced the shift of a paradigm.”

The Seattle Cancer Care Alliance, which includes several hospitals as well as cancer clinics, also has been trying to relieve pressure on its hospital collaborators by keeping patients out of emergency rooms, if possible. Patients who previously might have been sent to an ER are instead receiving pain management, hydration and other approaches as outpatients, McDonnell said. 

It's an approach she hopes will continue after the COVID-19 threat has passed.

“A lot of that work has been meaningful, and it won’t go away,” McDonnell said.

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Are hospitals safe?

It’s not possible to know for sure whether a hospital is safe, because there’s no national or local data about how many people have caught COVID-19 at a medical facility. Many aren’t even keeping count.

But some are trying. At Johns Hopkins Hospital in Baltimore, in addition to wearing proper masks and gowns and separating COVID-19 patients from those without the virus, Dr. Aaron Milstone has been tracking patients and health care workers who become ill with the virus. Milstone, a professor of pediatrics and associate hospital epidemiologist, wants to figure out whether they were infected inside the hospital or in the community.

“Those investigations have been very reassuring to us that our measures are doing a great job at keeping both our patients and our staff safe,” he said.

Doctors and nurses in COVID-19 wards often say they feel safer in the hospital than in the community at large, he said.

A maintenance worker disinfects the buttons on an elevator at Dana Farber Cancer Institute in Boston, Wednesday, May 20, 2020. Signs on the floor tell people where to stand with a limit of six passengers on most elevators.

“At least they know what they’re getting into and they’re protected,” he said. “It’s the known versus the unknown.”

Still, Milstone conceded, there can be no certainty. If someone went to New York City and then spent a few days working or being cared for in the hospital, “it’s really hard with that long window to identify what the actual exposure was,” he said.

Amid the pandemic, the federal government has allowed hospitals to stop tabulating so-called hospital-acquired infections, dangerous pathogens that infect roughly 3% of patients during normal times.

Dr. Mark Rupp, a professor and medical director of infection control and epidemiology at Nebraska Medical Center, said he understands, but is concerned by the move. The care COVID-19 patients receive, which include catheters and central lines, put them at extra risk for such infections, he said. And, if someone laid low by COVID-19 caught one of these antibiotic-resistant bugs, he said, they might not survive.

"Although we’ve had to direct most of our infection prevention resources to control of COVID-19, we shouldn’t neglect our other patients or let our routine prevention efforts lapse," he said.

Rupp hopes extra hand-washing and other safety precautions instituted during the pandemic are keeping down dangerous infections but he cautions against complacency.

“This doesn’t mean that we’re in the clear and that we shouldn’t maintain our scrutiny on hospital-acquired infections and antibiotic resistance, Rupp said. “If we’re not careful, we will see outbreaks of antibiotic resistance or other problems emerge, just because we don’t have enough bandwidth to maintain our attention on everything.”

Treating patients in the COVID-19 era

Both Dana-Farber and the Seattle Cancer Care Alliance have been tracking infections carefully, and haven’t seen any cases of COVID-19 likely caught in their outpatient facilities, Wagner and McDonnell said.  

Though cancer patients and their caregivers take extra precautions to avoid COVID-19, they can still catch the virus. Nearly 90% of cancer patients and survivors say their health care has been affected by the pandemic, according to a new poll by the American Cancer Society Cancer Action Network, with 79% of those in active treatment saying it's delayed their care.

Dr. Kimmie Ng, a physician at Dana-Farber who specializes in colorectal cancer, said she’s had a few patients who caught COVID-19 in the community. All but one had a mild case, she said, but that one patient has been off her treatment regimen for six weeks so far. 

Dr. Kimmie Ng, right, stays several feet away from her patient,  Jim Nauen of Newton,  in an exam room at Dana Farber Cancer Institute in Boston, May 20, 2020. Nauen, 53, is battling colon cancer and was in for chemotherapy treatment.

Ng’s patient Nauen, said he feels very safe at Dana-Farber. Even his 15-year-old younger daughter, who is always urging him to be cautious – and would have been upset if she’d known he’d stopped at Dunkin’ Donuts that morning – is OK with him coming for care at the Boston facility.

Nauen understands why his surgery was delayed, first from March to May, then July, before settling on June. He was happy to avoid the hospital when COVID-19 nearly overwhelmed the region’s health care system.

Now, he’s eager to get it over with. The new date in two weeks means he’ll hopefully be able to return to his favorite hobby – golfing – before the summer ends.

Even without chemotherapy, Nauen, who works in the software industry, faces a long, unpleasant season. His doctors predict he’ll need one to two weeks in the hospital and another six to recuperate on his screened-in porch in nearby Newton, Massachusetts.

As he settled in for his last chemo session recently, he chatted as always with his favorite infusion nurse, Melissa Perna. Over three years of regular chemo infusions, she's become like a third daughter to him.

“You’re going to come visit me over at the Brigham, right?” Nauen asked, hoping she’ll be allowed to cross one of the center’s long corridors to the adjacent Brigham and Women’s Hospital. His wife and two teenagers may be kept out because of COVID-19.

For now, though, he's focused on squeezing in as many rounds of golf and family movie nights as he can. And hoping his cancer – and COVID-19 – will soon just be a bad memory.

Contact Weintraub at kweintraub@usatoday.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.

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