{"id":2171,"date":"2020-04-28T14:49:07","date_gmt":"2020-04-28T21:49:07","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2171"},"modified":"2020-04-28T14:49:07","modified_gmt":"2020-04-28T21:49:07","slug":"42320-clinician-office-covid-guideline","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2171","title":{"rendered":"4\/23\/20 Clinician Office COVID Guideline"},"content":{"rendered":"

(Optional items italicized<\/em>)<\/p>\n

Effective Date:\u00a0 <\/strong>In place on re-opening or expanding clinical services<\/h5>\n
Duration: <\/strong>Until public health emergency lifted<\/h5>\n
Version 1.0 Date:\u00a0 <\/strong>April 23, 2020<\/h5>\n

 <\/p>\n

Disclaimer:\u00a0 <\/strong>There are little or no controlled studies underlying these recommendations.\u00a0 They are based on CDC recommendations, local health department orders, and expert consensus of PHC medical directors.\u00a0 They should be considered a starting point for evaluation of office systems, and may be modified by the clinical leadership at a practice.\u00a0 Any directive by a local health officer which is more stringent than these guidelines would take precedence.<\/p>\n

Send comments or suggestions<\/strong> for improvements to: rmoore@partnershiphp.org<\/a><\/p>\n

Patient Care in Office: <\/strong><\/h5>\n
    \n
  1. \n
    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.<\/h5>\n<\/li>\n
  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.<\/li>\n
  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.<\/li>\n
  4. Stethoscopes, blood pressure cuffs and other non-disposable equipment touching patients should be cleansed before and after each use.<\/li>\n
  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)<\/em><\/li>\n<\/ol>\n
    Virtual Visits: (all patients should be contacted by phone before coming to the office)<\/strong><\/h5>\n
      \n
    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.<\/li>\n
    2. Patients who are immunosuppressed or are at higher risk for COVID 19 related complications, will be offered phone or video conferencing.\u00a0If 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.<\/li>\n
    3. Develop workflows and best practices for visits to be addressed by video\/phone as much as possible.\u00a0 Use these guidelines to limit exposure of patients and staff to potential \u00a0infection when in person visits are needed for routine visits ( well child, women\u2019s physicals for example) and as indicated for face to face visits for chronic disease management or other necessary exams. Consider:<\/em><\/li>\n<\/ol>\n

      a.\u00a0If a person is coming in for a face to face visit for one reason, ensure all\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 related reasons for a face to face visit are done at the same time.<\/em><\/p>\n

      b. Methods of optimizing obtaining history and doing a partial physical exam\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 by virtual visit to make the physical visit short and efficient with minimum\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 chance of infection transmission.<\/em><\/p>\n

      c. Finding alternatives to more hazardous examinations\/procedures, such as\u00a0 \u00a0 \u00a0 \u00a0coaching parents on application of fluoride varnish over phone or\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0application of silver diamine fluoride to caries instead of tooth extraction or\u00a0 \u00a0 \u00a0 \u00a0filling.\u00a0 <\/em><\/p>\n

      4.\u00a0<\/em>If patients with symptoms listed below need to be seen in the office, they will be\u00a0 \u00a0 \u00a0 scheduled at a time and in a manner to prevent potential infection of other\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 patients. This may include<\/p>\n

      a. Examining the patient in their car. <\/em><\/p>\n

      b. If the patient may not be examined in their car, they would be scheduled at\u00a0 \u00a0 \u00a0 \u00a0 a time and location where other patients would not be using the same room\u00a0 \u00a0 \u00a0 until decontamination is possible. <\/em><\/p>\n

      c. Moving them directly to an examining room with no waiting room time\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0(potentially through an alternative entrance), followed by thorough\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0decontamination\/aeration of the exam room. <\/em><\/p>\n

      \u00a0<\/strong>Operational Aspects:<\/strong><\/h5>\n
      5. Patients will be scheduled in such a manner to maintain six foot spacing in the<\/h5>\n
      \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 waiting area.\u00a0 This may require patients to wait in their cars until called in to the<\/h5>\n
      \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 office, or moving the patient directly to an examination room from the waiting<\/h5>\n
      \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 room upon arrival.<\/h5>\n
      6. Patients should be seen in the office\u00a0alone\u00a0unless they need a caregiver, or they<\/h5>\n
      \u00a0 \u00a0 are a minor needing an adult.<\/h5>\n

       <\/p>\n

      Staffing Aspects:\u00a0<\/strong><\/h5>\n
      1. Temperatures and symptom review (see below) of staff will be done each day.<\/h5>\n
      2. Any staff member with symptoms potentially caused by SARS-CoV2 will be<\/h5>\n
      \u00a0 \u00a0 referred for testing as a healthcare worker with face-to-face patient contact.<\/h5>\n
      3. Staff members with exposure to a person who tested positive for the virus will be<\/h5>\n
      \u00a0 \u00a0 asked to remain home under paid sick leave for 14 days, only returning after<\/h5>\n
      \u00a0 \u00a0 consultation with clinician in charge. In circumstances of significant staff\u00a0<\/em><\/h5>\n
      \u00a0 \u00a0 shortage,\u00a0<\/em>if rapid PCR testing is widely available, an asymptomatic exposed\u00a0<\/em><\/h5>\n
      \u00a0 \u00a0 staff member\u00a0<\/em>who tests negative for coronavirus may be considered for return<\/em><\/h5>\n
      \u00a0 \u00a0 to work with\u00a0<\/em>continuous mask use for a day or two (they would need to be<\/em><\/h5>\n
      \u00a0 \u00a0 retested every\u00a0<\/em>couple days to be sure they do not develop viral shedding).<\/em><\/h5>\n
      4. If scribes are used by a practice, consider changes to support infection control.\u00a0 \u00a0 \u00a0 \u00a0 Examples may include having them support virtual visits or virtual pre-visits\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 where the history is gathered.<\/em><\/h5>\n

       <\/p>\n

      Maintenance and Facilities:\u00a0 <\/strong><\/h5>\n
      1. Hand sanitizers as well as soap and hot water for hand-washing are readily<\/h5>\n
      \u00a0 \u00a0 available throughout the office and waiting areas.<\/h5>\n
      2. Cross contamination will be minimized by frequent sanitizing (wiping down) of<\/h5>\n
      \u00a0 \u00a0 surfaces, doorknobs, light handles, keyboards, phones, etc. with isopropyl<\/h5>\n
      \u00a0 \u00a0 alcohol or chlorine-based cleansers.<\/h5>\n
      3. Scrubs and lab coats should be laundered daily. Neckties or other loose clothing<\/h5>\n
      \u00a0 \u00a0 that could contact patients should be avoided.<\/h5>\n
      4. In the setting of an office where patients may walk in for care without a mask or<\/h5>\n
      \u00a0 \u00a0 where no screening for respiratory infections before visits can be done, adding a<\/h5>\n
      \u00a0 \u00a0 Plexiglas barrier for reception staff may need to be added.<\/h5>\n
      5. Any break room should be arranged and use scheduled to allow at least 6 feet of<\/h5>\n
      \u00a0 \u00a0 distance between individuals who are eating and drinking. Discourage<\/h5>\n
      \u00a0 \u00a0 conversation while eating.<\/h5>\n
      6. Shared restrooms should have surfaces decontaminated with increased<\/h5>\n
      \u00a0 \u00a0 frequency, depending on how much it is used.<\/h5>\n
      7. Review decontamination procedures done by maintenance staff to ensure they<\/h5>\n
      \u00a0 \u00a0 are\u00a0conducting duties in a way that protects them and thoroughly<\/h5>\n
      \u00a0 \u00a0 decontaminates\u00a0the office.<\/h5>\n
      8. Develop a procedure for educating staff on these infection transmission<\/h5>\n
      \u00a0 \u00a0 prevention measures and monitoring their adherence.<\/h5>\n

       <\/p>\n

      Symptom Review:<\/strong><\/h5>\n