Navigating the Unexpected

How Duke Eye Center Responds to COVID-19 Pandemic

In January 2020, the world naively watched on as the city of Wuhan, China locked down to stop the spread of an unidentified virus, now universally known as COVID-19. Uncertain of the potential impact on the United States population and the medical community at-large, Duke Eye Center formed the COVID-Response Executive Task Force. Led by Eric Postel, MD, professor of ophthalmology and vice chair for clinical affairs, this team was composed of key cross-functional leaders from Duke Eye Center including Edward Buckley, MD, chair for the department of ophthalmology, Heidi Campbell, clinical operations director,  Scott Cousins, MD, Robert Machemer Professor of Ophthalmology and vice chair for strategy, Elizabeth Hunter, MHA interim chief administrator and director of finance,  and Adrienne Lloyd,  MHA, former chief department administrator .   
Together, the team proactively examined and mapped out scenarios to manage all aspects of clinical and research operations as the pandemic crisis grew in intensity, and as rapidly changing events necessitated.  They had to adapt to ever changing state mandates and responses, help lead the Health System response to the crisis, and be prepared for many worst-case scenarios, from severe illness throughout the department to redistribution of staff to a nationwide shutdown of ambulatory care.  Robin Vann, MD associate professor of ophthalmology and operating room director and Sarah-Jane Miller, RN, BSN, CRNA, MSN were key partners, helping develop strategy, policy, and tactics to manage the surgical practice. 
Frequent meetings were held with faculty leaders, the faculty at large and staff to share information making sure that everyone was kept up-to-date with the ever-changing landscape early in the COVID crisis.   The clincal operations team lead by Postel and Campbell worked with faculty and staff to coordinate and implement complex process changes that assured the safety of all employees while also continuing to deliver care to patients.  All-in-all, this was a massive and “all-hands-on-deck” team effort. 
“It was essential to put a plan in place to manage the various functions of the department. While preparing for the most drastic scenarios was complex, our priorities were clear — care for our patients who require treatment; continue our robust research operation; maintain Duke’s world-class education program and, protect staff, faculty and their families,” said Edward Buckley, MD, Gills Professor of Ophthalmology and chair, department of ophthalmology. 
Thanks to the foresight of our administration team, staff across the board were equipped with the necessary resources to enable them to effectively work from home.   
As the pandemic persisted, it introduced unexpected and unfamiliar challenges; teams within each functional area of Duke Eye Center were forced to pivot and identify workable solutions.  
Patient Care 
Duke Eye Center is a regional and national referral facility for medical practices across North Carolina and throughout the country – more than 18,000 clinical patients and over 1,200 surgeries scheduled every month – individuals with severe eye disease rely on our timely response to help prevent the possibility of permanent vision loss.  
“Though some medical specialties can rely on telemedicine, that approach is not as effective in ophthalmology because treatment is often contingent on obtaining images of the eye. Therefore, reopening of clinical space was a top priority, which meant for three months in early 2020, the team worked seven days a week with daily 6 a.m. planning calls,” said Postel. 
As stay-at-home orders were implemented and the seriousness of the pandemic gripped the country, a transformation in how patient care was delivered at Duke Eye Center was underway. The task force started by examining the footprint of each clinic to determine which could effectively accommodate our most urgent patient cases while maintaining necessary safety precautions and social distancing. Fortunately, an adequate number of clinical sites were able to accommodate these patients and perform surgeries on those individuals whose vision was at-risk without immediate care.  
A system was established with alternating teams of caregivers and staff to protect individuals to the degree possible and minimize the risk of COVID transmission.  A COVID outbreak would completely shut down the ability to deliver care. These teams consisted of attendings, fellows, residents and staff. Each team worked at only one site, alternating for one week at a time, then spent the next week working remotely, creating a mini-quarantine period for each group. 
“I am so proud of our clinical team, who understood the importance of taking care of our patients even during some of the hardest times in our careers.  They were amazing with the COVID-19 protocols, they were flexible and willing to do what was necessary to make sure our patients could be seen safely,” said Campbell.  
The practice substantialy reduced patient  volume in the early months of COVID, but as soon as CDC recommendations and state mandates allowed, clinical and surgical operations were rapidly reopened and providers and staff were redeployed to deliver care to all in need.   
“Across the country, ophthalmology experienced more than an 80 percent decrease in patient visits — one of the hardest hit specialties in medicine,” said Postel. There are still ophthalmic caregivers in the community who have not reopened offices.  Duke Eye Center managed to reopen very quickly and most importantly, safely, to care for the huge number of patients that rely on us to maintain, restore and improve vision.   
Continuing patient care during the pandemic drove innovation and introduced improvements that will continue into the future. For example, the crisis clarified the need for technological innovation and process development that will make remote diagnosis in ophthalmology a common reality. 
The strength and resilience of the ophthalmology team was evident and impacted Duke Eye Center’s ability to respond to the evolving pandemic.  Operational improvements made over the previous five years helped to prepare the department for unprecedented time. “Alignment on improved processes and systems allowed the group to implement adjustments to our clinical operations and communicate effectively during this time of crisis,”  said Buckely.  
Duke Eye Center is proud to have robust basic, translational and clinical research programs.  In anticipation that significant measures would be taken to combat the spread of COVID-19, the research response team prepared to adjust all research operations.   
The team identified essential basic research experiments — analyzing administrative activities that could be temporarily halted, while also confirming those that could not stop because of the years of work already invested.   
“We worked efficiently and effectively to conserve research operations, pausing approximately 40 research studies temporarily during the initial shut down,” said Daniel Stamer, PhD, Joseph A.C. Wadsworth Professor of Ophthalmology and member of the COVID-19 research response team.  
The research labs at Duke ophthalmology employ dozens of people, from students and senior fellows to technical staff. However, between March and June, many of the Duke Eye Center labs were empty, with the exception of necessary visits to feed cells or to care for animals.  
The challenges were especially significant for technical staff who typically spend the day conducting experiments and analysis. There was some work that could continue at home but that was finite, so the burden was on Stamer to make sure everyone stayed busy while at home. 
Reopening the lab was a careful process. To complete the necessary work, research staff split each day into two shifts — early morning and late day — in order to limit the number of people in the lab at any given time.  
Teaching within the labs remained a critical component. In the lab, you may need to teach a student your technique or review data together, both are challenging from six feet away. Fortunately, Duke provided face shields which allowed for closer interaction and more effective instruction. 
“I feel tremendously lucky to be a Duke faculty member during the pandemic,” Stamer said. “I’ve communicated with numerous of colleagues in the U.S. and around the world, and I’ve found that Duke has done an excellent job at keeping us safe and creating a work environment that is productive,” he continued. 
Many of the Duke Eye Center labs have an open floor plan, this ultimately made it easier to reconfigure the space for the safety of our staff.  
The clinical research operation also suffered during the initial months of COVID, having to temporarily halt clinical research. To optimize the ability to safely restart clinical research and many other processes, like other reopening processes, there was a gradual phased approach to the resumption of in-person research activities.  The progression from one phase to the next was contingent on stable conditions in the health system and the local and state-wide community.  Clinical resrach is similar to patient care.  Often the clinical research coordinator or provider will need to be in close proximity to the patient in order to obtain eye images and perform evaluations.  
“We held as many virtual research visits as possible and initially reopened only essential interventional studies following strict infection prevention procedures and revised patient flow.  We gradually opened the clinical research unit to the rest of the studies such as natural history studies, this approach protected our clinical research staff and paitents to the best of our ability,” said Eleonora Lad, MD, PhD, associate director of the clinical research unit.  
Clinical research is essential to the development of new treatments, imaging ans surgical techniques.   Duke Eye Center successfully resumed research activites in a timely manner with minimal impact on the projects that were in process.  
Duke Eye Center has a long history of offering a vigorous education program including medical student, residency and fellowship training, as well as a robust continuing medical education (CME) program.  
There was concern that the educational programming was going to be severely impacted by COVID-19, especially the medical student and CME events. The team successfully pivoted to virtual learning for our external learners – previously uncharted territory for the programs.  
The CME team and faculty learned how to successfully deliver virtual events.  “I could not be prouder of Renee Wynne, CME director and her staff. They created powerful educational content that was well received, generated unprecedented attendance and will be accessible online long-term,” said Lejla Vajzovic, MD, associate professor of ophthalmology and medical director for CME.  
Medical student education was briefly halted, however Jullia Rosdahl, MD, PhD, assistant professor of ophthalmology and medical student education director, had a vision that turned into a solution that met several needs. For medical students who were unable to rotate at our institution, virtual electives allowed them to continue learning during COVID, while simultaneously addressing the needs of underrepresented minority (URM) students at universities without an ophthalmology specialty.  
“I could not allow medical students to miss out or have to wait on the ophthalmology elective.  We previously identified a need for some sort of virtual platform to teach students at other universities, COVID just pushed us forward and launch the program sooner than expected,” said Rosdahl. 
Managing Costs and Taking Care of our People 
The pandemic generated a significant loss of revenue and unplanned expenses. This ultimately required a balanced approach between monitoring necessary expenses and identifying ways to conserve cash flow, while ensuring safe delivery of patient care, and allowing administrative staff to work remotely. 
“Rearranging priorities and reallocating funds allowed the team to secure resources such as monitors and laptops for the anticipated work-from-home arrangement, facilitating a fairly seamless transition from on-campus to remote,” said Elizabeth Hunter, interim chief administrator and director of finance. 
For example, staff assistants historically did not have laptops, yet those became critical tools to help them remotely schedule appointments and support faculty.  “Our staff that support the faculty and assist with patient appointments were instrumental in organizing schedules, communicating with patients, and helping faculty identify which patients required urgent care.  Without the proper equipment to work from home, we would have never been as successful as we have been” Campbell said. 
Many medical centers experienced layoffs. To avoid this, our team worked to eliminate unnecessary expenses and avoid a deficit. Overtime hours were eliminated for employees, reimbursements were put on hold, and capital equipment purchases were delayed, all to ensure that clinics were properly staffed.   
“We heard how many people were being furloughed across the country,” Campbell said. “For us to keep everyone employed was a huge success.”  
“The goal was something everyone could agree on, continue to pay staff and avoid a major deficit,” said Hunter.  
The pandemic caused us to take a fresh look at finance operations and examine our expenses, and it’s expected that some short-term changes will become permanent.  
“When you step back and look at the past year, we did very well.  The administrative team pulled together in a difficult situation and worked around the clock to deliver solutions,” said Buckley.  “I am so proud of the tireless dedication of the group for their exceptional job throughout this crisis.” 
Hope in Sight 
For months, medical research experts worldwide worked round-the-clock to expedite the development of vaccines that will help create immunity to the virus that causes COVID-19. In December 2020, the U.S. Food and Drug Administration authorized the distribution of two vaccines – one produced by Pfizer; the other by Moderna Therapeutics – creating a light at the end of the tunnel for countless millions.  
At the end of 2020, in compliance with federal, state and local guidelines, Duke Health began vaccinating health care workers deemed high risk for COVID-19. 
“Our providers and trainees see a tremendous number of patients and must be in close proximity of them for their examination, which puts them at high risk for COVID exposure. Vaccinating our providers, trainees and clinical care team was top priority to help safeguard them from contracting coronavirus.   There is hope in sight,” said Postel. 
Navigating the unimaginable, the COVID-19 pandemic has not been an easy experience for anyone, but there is always good and new wisdom that comes from a bad situation.  “For Duke Ophthalmology, we have learned that we can continue our missions of research, education and patient care with a new innovative approach. We’ve developed a different level of trust for one another, made process improvements that will last and know that we can be resilient in the most difficult of times,” said Buckley.