For most providers, patient visits and income are down significantly since the onset of the coronavirus. However, now that most states have started easing restrictions, clinics need to be able to reach out to their patients to assure them that their offices are a safe and patients should no longer fear to come into their doctors’ office. This patient outreach, assuring the safety of your clinic can be accomplished by phone, adding a message on your website, and adding signage to your office. But how do you make your clinic a safe place?
The following are some recommendations from the CDC for the screening and management of patients in your practice, which is a key to making your practice safe, and suggested standard operating procedures for your clinic moving forward.
- Follow the CDC’s patient assessment protocol for early disease detection for patients presenting to your practice. Patients should be screened using the Criteria to Guide Evaluation and Laboratory Testing for COVID-19. It is recommend that clinic management check this CDC website often for any updates in screening criteria. Essential visitors to your facility should also be assessed using these criteria and redirected to remain outside if suspect.
- It is strongly recommended that practices do not turn patients away simply because a patient calls with acute respiratory symptoms. All patients should be triaged over the phone or via telemedicine and managed according to CDC recommendations. Refusing assessment/care may lead to concerns of patient abandonment.
- With community spread, the CDC recommends alternatives to face-to-face triage and visits if screening can take place over the phone, via telemedicine, through patient portals or online self-assessment tools, or through a designated external triage station. Licensed staff should be trained in triage protocol to determine which patients can be managed safely at home vs. those who need to be seen either at the office or at a properly designated community facility. See Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States. The CDC provides Phone Advice Line Tools, which include a sample phone script, a clinical decision-making algorithm, and advice messages. Resources on telemedicine can be found at COVID-19 Telehealth Resource Center.
- For diagnostic and therapeutic interventions, including surgery, the CDC provides considerations for specific settings, including outpatient and inpatient facilities. Also, the American College of Surgeons provides guidance on triage and management of surgical cases, including specialty guidelines. Many states have now eased restrictions on the provision of nonurgent, elective surgeries and procedures. Check with state and local regulatory agencies for any related mandates.
- Practices should post front-door signage requiring patients and visitors who are exhibiting any of the “person under investigation” (PUI) evaluation criteria (e.g., presenting symptoms, recent contacts, and/or travel history) to immediately notify facility personnel via telephone for instructions on accessing care. Include information on the practice website regarding new office policies for appointments, telephone assessment/telemedicine, and visitors. Also, post COVID-19 resources for patients (e.g., the CDC’s Coronavirus (COVID-19) page) with a reminder to maintain social distance and to stay at home to lessen community spread. If the office is closed, update voicemail messages to address telephone assessment, telemedicine, and how to reach the physician in the event of an emergency.
- To maintain social distancing within your facility, require that patients sit at least six feet or more apart. Patients should be asked to wait in their car if that option is available. Remove magazines and toys from the waiting room. Routinely disinfect the waiting room throughout the day.
- Evaluate patients on a case-by-case basis. If presenting symptoms, travel history, and/or contacts are suspicious, and it is determined that the patient must be seen, have the patient call prior to their arrival to make preparation for accommodation. When possible, conduct the patient evaluation outside your facility at a designated triage location. If that is not possible, immediately isolate the patient coming into the office (segregating them from other patients in the facility) in a designated exam room with dedicated patient care equipment. A back entrance should be utilized. Since most medical offices don’t have negative pressure airflow, a spare bathroom with negative exhaust fans may be an option in the medical office setting instead of a regular exam room. Review and follow the CDC guidelines for environmental infection control in healthcare facilities. Be aware that according to the CDC and research published in the New England Journal of Medicine, it is unknown exactly how long the virus remains active once a room is vacated, and there are currently no CDC instructions on length of time before the room may be used again.
- Once suspected patients are inside the facility, instruct them to put on a face mask, utilize tissues, practice good hand hygiene, and dispose properly of any contaminated protective equipment/tissues in a designated waste receptacle. Educational resources, including posters for use in the medical office, are available from the WHO and for healthcare workers from the Centers for Disease Control (Contact Precautions, Droplet Precautions, and Airborne Precautions). Again, reference the CDC’s Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States for patient management guidance.
- Follow Standard Precautions and transmission-based Precautions, including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit-tested. This applies to all healthcare staff interacting with PUI. If there is a shortage of N95 respirators in your facility, access current CDC respirator recommendations.
- Limit staff exposure to suspected patients, with the exam room door, kept closed. Ideally, the designated exam room should be at the back of the office, far away from other staff and patients.
- Physicians should determine which patients require testing based on presenting symptoms, history, and community transmission of disease. When there is a reasonable presumption that a patient may have been exposed to COVID-19, contact the local or state health department to coordinate testing using available community resources. (See the CDC’s Priorities for Testing Patients with Suspected COVID-19 Infection.) The CDC advises, “Healthcare providers should immediately notify their local or state health department in the event of the identification of a PUI for COVID-19.”
- Maintain records of staff-patient contact, i.e., who was assigned to work with the patient, either in a log or in the medical record.
- Once the patient exits the room, conduct surface disinfection while the staff continues to wear personal protective equipment (PPE). For general guidance, see COVID-19 Infection Prevention and Control in Healthcare Settings: Questions and Answers.
- Provide up-to-date, factual information on the virus to the patient and close contacts, including how to follow infection-control practices at home, such as in-home isolation, hand hygiene, cough etiquette, waste disposal, and the use of face masks.
- Remind patients and their families to access information about the virus through reputable sources such as the CDC, not social media.
- Check with your local public health authorities for locations designated to triage suspected patients, so exposure is limited in general medical offices. Community emergency preparedness plans have been activated so that parties are coordinating efforts to deliver effective public health intervention.
- Screen healthcare personnel daily for symptoms/travel/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed and monitored. See Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19).
- Reference the CDC, your state medical board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation. This continues to be a fluid situation with ongoing publication of new regulations and guidance. It is crucial that physicians stay on top of these important changes to protect your patients and your practice.
Consider Legal Risks
When the Ebola virus was new to the U.S., there was one well-reported case where a patient who came to the hospital with Ebola was sent home without treatment. Due to delays in testing and misdiagnosis, patients have also been turned away with COVID-19. Such situations not only put the patients and others at risk but also put healthcare providers and hospitals at risk for litigation.
When in doubt, healthcare providers should adopt a clinical suspicion of COVID-19 to protect the patient and others. The dynamics surrounding the virus will continue to change in the days and weeks ahead. What must not change is that physicians and care teams should remain vigilant and careful. They should be exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as they become available from the CDC.