4/23/20 Clinician Office COVID Guideline

(Optional items italicized)

Effective Date:  In place on re-opening or expanding clinical services
Duration: Until public health emergency lifted
Version 1.0 Date:  April 23, 2020

 

Disclaimer:  There are little or no controlled studies underlying these recommendations.  They are based on CDC recommendations, local health department orders, and expert consensus of PHC medical directors.  They should be considered a starting point for evaluation of office systems, and may be modified by the clinical leadership at a practice.  Any directive by a local health officer which is more stringent than these guidelines would take precedence.

Send comments or suggestions for improvements to: rmoore@partnershiphp.org

Patient Care in Office:
  1. Staff and clinicians will wear face masks at all times, as will patients. This should be explained to patients before they arrive at the office.
  2. Patients without their own masks will be given one on entry to the office. The mask should completely cover over the nose to below the chin and fit snugly along the sides.
  3. Staff and clinicians will wear gloves for any patient contact, disposing gloves between patients and washing hands before entering and upon leaving each exam room.
  4. Stethoscopes, blood pressure cuffs and other non-disposable equipment touching patients should be cleansed before and after each use.
  5. When rapid, point of care PCR tests become available for office use, perform a rapid test on asymptomatic individuals prior to performing procedure that will generate significant aerosol (e.g. dental extractions, dental cleanings, office spirometry)
Virtual Visits: (all patients should be contacted by phone before coming to the office)
  1. Patients with contact with a person who tested positive for COVID 19 or who are experiencing fever, chest congestion, flu-like symptoms or symptoms of milder respiratory infection will be asked not to visit the office but rather to consult with the physician via phone or video conferencing.
  2. Patients who are immunosuppressed or are at higher risk for COVID 19 related complications, will be offered phone or video conferencing. If they must be seen, have a plan that minimizes their risk, such as seeing them in the first few hours of the day, or conducting a detailed history over video/phone first, before a brief office visit.
  3. Develop workflows and best practices for visits to be addressed by video/phone as much as possible.  Use these guidelines to limit exposure of patients and staff to potential  infection when in person visits are needed for routine visits ( well child, women’s physicals for example) and as indicated for face to face visits for chronic disease management or other necessary exams. Consider:

a. If a person is coming in for a face to face visit for one reason, ensure all            related reasons for a face to face visit are done at the same time.

b. Methods of optimizing obtaining history and doing a partial physical exam          by virtual visit to make the physical visit short and efficient with minimum          chance of infection transmission.

c. Finding alternatives to more hazardous examinations/procedures, such as       coaching parents on application of fluoride varnish over phone or                       application of silver diamine fluoride to caries instead of tooth extraction or       filling. 

4If patients with symptoms listed below need to be seen in the office, they will be      scheduled at a time and in a manner to prevent potential infection of other                patients. This may include

a. Examining the patient in their car.

b. If the patient may not be examined in their car, they would be scheduled at        a time and location where other patients would not be using the same room      until decontamination is possible.

c. Moving them directly to an examining room with no waiting room time               (potentially through an alternative entrance), followed by thorough                     decontamination/aeration of the exam room.

 Operational Aspects:
5. Patients will be scheduled in such a manner to maintain six foot spacing in the
            waiting area.  This may require patients to wait in their cars until called in to the
            office, or moving the patient directly to an examination room from the waiting
            room upon arrival.
6. Patients should be seen in the office alone unless they need a caregiver, or they
    are a minor needing an adult.

 

Staffing Aspects: 
1. Temperatures and symptom review (see below) of staff will be done each day.
2. Any staff member with symptoms potentially caused by SARS-CoV2 will be
    referred for testing as a healthcare worker with face-to-face patient contact.
3. Staff members with exposure to a person who tested positive for the virus will be
    asked to remain home under paid sick leave for 14 days, only returning after
    consultation with clinician in charge. In circumstances of significant staff 
    shortage, if rapid PCR testing is widely available, an asymptomatic exposed 
    staff member who tests negative for coronavirus may be considered for return
    to work with continuous mask use for a day or two (they would need to be
    retested every couple days to be sure they do not develop viral shedding).
4. If scribes are used by a practice, consider changes to support infection control.        Examples may include having them support virtual visits or virtual pre-visits              where the history is gathered.

 

Maintenance and Facilities: 
1. Hand sanitizers as well as soap and hot water for hand-washing are readily
    available throughout the office and waiting areas.
2. Cross contamination will be minimized by frequent sanitizing (wiping down) of
    surfaces, doorknobs, light handles, keyboards, phones, etc. with isopropyl
    alcohol or chlorine-based cleansers.
3. Scrubs and lab coats should be laundered daily. Neckties or other loose clothing
    that could contact patients should be avoided.
4. In the setting of an office where patients may walk in for care without a mask or
    where no screening for respiratory infections before visits can be done, adding a
    Plexiglas barrier for reception staff may need to be added.
5. Any break room should be arranged and use scheduled to allow at least 6 feet of
    distance between individuals who are eating and drinking. Discourage
    conversation while eating.
6. Shared restrooms should have surfaces decontaminated with increased
    frequency, depending on how much it is used.
7. Review decontamination procedures done by maintenance staff to ensure they
    are conducting duties in a way that protects them and thoroughly
    decontaminates the office.
8. Develop a procedure for educating staff on these infection transmission
    prevention measures and monitoring their adherence.

 

Symptom Review:
  • Fever
  • Cough
  • Sore throat
  • Shortness of breath
  • Chills
  • Severe fatigue
  • Unusual headache
  • Runny nose in the absence of known allergies
  • Gastro-intestinal symptoms such as diarrhea or stomach cramps
  • Loss of sense of smell (anosmia) or taste or suddenly all food tastes bad (dysgeusia)

Temperature Guidelines:

 Temperature of 100 degrees F or greater or with any symptoms above should be            isolated.

Definition of Higher Risk for Serious COVID infection  (CDC guidelines)

  • Age over 65
  • Residents of congregate living facility (skilled nursing facility, homeless shelter)
  • Chronic Lung Disease, including COPD
  • Chronic Lung Disease, including CHF
  • Kidney failure of advanced kidney disease
  • Cirrhosis or other chronic liver disease
  • Diabetes
  • Other condition impairing immune system
  • Taking medication impairing immune system (includes most on current cancer treatment)
  • Severe obesity (BMI over 40)

Definition of Exposure requiring Quarantine (recommendations vary; CDC guidelines complex)

  • Direct contact with person known to be infected with COVID
  • Less than 6 feet distance for at least 5 minutes with a person known to be infected with COVID who was coughing (regardless of wearing of a mask) or who was not coughing but not wearing a facial covering.
  • Living in same dwelling as a person with COVID, regardless of mask use
  • Recent travel from area more highly impacted by COVID than “home” area, especially if by crowded public transportation.

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