At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Disease Control and Prevention (CDC) “recommended that healthcare systems prioritize urgent visits and delay elective care to mitigate the spread of COVID-19 in healthcare settings.”1
However, an unfortunate consequence of this guidance “has been the under-utilization of important medical services for patients with non-COVID-19-related urgent and emergent health needs.”1 For this reason, the CDC recommends that healthcare systems “balance the need to provide necessary services while minimizing risk to patients and healthcare personnel.”1 This focus on “reopening” is part of a broader drive to reopen the country, with specific guidelines being developed both federally and on a state-by-state basis.2 And as more states ease restrictions, medical practices hitherto closed or operating on a telemedicine basis only for non-urgent visits face increasing pressure to reopen.3 However, “conflicting information is causing confusion as practices carefully weigh resuming in-person visits.”3
To shed light on the complex and often delicate process of reopening, we spoke to Ada D. Stewart, MD, a family physician with Cooperative Health in Columbia, South Carolina, and president-elect of the American Academy of Family Physicians (AAFP).
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“The overarching guiding principle, before you even start implementing the reopening process, is to make sure you have a safe environment, not only for your patients but also for your staff,” according to Dr Stewart. “All of the steps you take need to be undertaken and put into place with this in mind before you can reopen your doors to patients.”
1. Educate Your Staff
The AAFP recommends educating all staff about COVID-19. Even though most will be aware of the major aspects of the illness and its impact on patient care, a “refresher” training is useful.
Included in the review are explaining your policies and practices for minimizing exposure to the virus that causes COVID-19, including changes in how appointments are scheduled, patient flow, cleaning procedures, COVID-19 testing, and addressing patients’ concerns.
It is helpful to regularly go over the procedures and review any changes that may arise during this new process.
2. Implement Thorough Cleaning and Sanitizing Procedures
“We make sure that our office is constantly, constantly, cleaned,” Dr Stewart reported. Prior to COVID-19, nightly cleaning was sufficient, but now Dr Stewart and her staff have 2 or 3 midday cleanings, in which they disinfect the waiting room, wiping chairs and doorknobs, and also disinfect all surfaces of the examination room between patients.
“Hand sanitizing is an important part of our protocol. Not only do we constantly practice handwashing for at least 20 seconds, but we also encourage our patients to do the same. And we give out small hand sanitizer sample bottles to patients, especially if they don’t have sanitizer at home or in their cars,” she added.
The AAFP advises discontinuing the use of toys, magazines and similar items in waiting areas, as well as office items that patients usually share, such as pens, clipboards, and phones and providing no-touch waste containers with disposable liners in all areas of the office. As much as possible, limit surfaces that might be touched—for example, keep doors propped open or use sensors. Equipment such as stethoscopes and thermometers should be cleaned with appropriate cleansing solutions before each patient, and—if possible—disposable equipment should be used when possible.
“As much as possible, we are using disposable items, so laundry is not necessary,” Dr Stewart said. She advised following CDC guidelines for linen and laundry management, if relevant.
Ensure adherence to standard precautions, including airborne precautions and use of eye protection. Assume that every patient is potentially infected and could transmit the virus, Dr Stewart emphasized.
3. Ascertain Whether Your Patients Are Ill
One day prior to a patient’s appointment, Dr Stewart’s staff call the patient to make sure they are not sick with fever or cough or other symptoms that might suggest COVID-19. “That way they won’t make an extra visit to our office if they are sick with symptoms consistent with COVID-19, because we are asking patients with suspected COVID-19 to do a televisit or phone visit rather than come to the office in person,” she said.
Patients who come in person have their temperature checked as soon as they enter the office and also fill out a questionnaire asking about cough, fever, chills, and shortness of breath. If they are having these symptoms, they are asked to return home and have their appointment by phone if possible.
However, some of these patients may need to be tested for COVID-19. Dr Stewart’s practice does not have the capacity to do COVID-19 testing, but she refers patients to other local facilities that do testing. The AAFP has issued guidance for physicians regarding who should be tested and what types of tests are available. The office of the US Department of Health and Human Services offers a guide to locating local community-based testing sites. Additional information can be obtained from state and local health departments.
If you do see a patient who has symptoms suggestive of COVID-19, try to restrict them to a special time so that they don’t intersect with patients who are having well visits, sanitize and disinfect areas where they have been and consider having a separate dedicated entrance for them if possible. In general, it is advisable to stagger patient appointments and to see patients who are ill at a different time than those who are well or to offer telehealth visits.
4. Make Personal Protective Equipment (PPE) Available for Everyone
All patients should wear masks, Dr Stewart stated. The Centers for Disease Control and Prevention (CDC) provides instructions how to make a cloth face covering or mask from household items.
“Our practice is a federally qualified health center where we have many uninsured people, some of whom are homeless and unable to make their own masks or obtain masks, so we give masks out to anyone coming into our office who might need them,” Dr Stewart recounted.
For staff, masks and gloves are essential, and—depending on the nature of the practice and specialty—clinicians and others interacting with patients might need full-face coverings or other protective clothing.
Prior to reopening, it is important to assess what PPE supplies you have available and, if possible, have them delivered in advance so that they are on hand as needed. Also, know what your mechanism will be for reordering when they start to run low.
5. Reopen in Stages
Do not throw your doors open and return to “business as usual,” Dr Stewart advised. Instead implement a step-by-step process, beginning with opening part-time, slowly starting to conduct in-person visits.
“Some recommendations suggest having one-third of the practice open for in-person visits and conducting the remaining appointments remotely via telehealth, and then gradually and incrementally increasing the in-person visits,” Dr Stewart said.
The AAFP recommends evaluating the necessity of in-person care “based on clinical needs and individualized care for each patient” and suggests “prioritizing high-complexity chronic condition management and patients with illness” and determining the necessity of preventive services on each individual patient’s needs.
6. Consider Shifts for Office Staff
“Some of my colleagues divided their office team into shifts, with one group of staff working in the morning and the other in the afternoon, and possibly a third group working in the evening,” Dr Stewart said. This minimizes the number of hours that a given staff member is exposed to patients, so if a patient who enters the office turns out to test positive for the virus, the entire staff has not been exposed.
“Unfortunately, we had that problem at the beginning of the COVID-19 pandemic in our office,” Dr Stewart reported. “We had 3 positive patients and had to close down our entire office and be quarantined for 14 days, followed by a thorough cleaning following OSHA guidelines. So making sure that fewer staff members are in the office at a given time reduces that risk.”
If a staff member has to be quarantined, the practice tries to assign as many televisits as possible to him or her so that they are still considered to be working, even while not in the office, Dr Stewart added.
The issue regarding paid sick leave for employees who may have been furloughed is complex and it is important for practices to consider the implications of quarantining staff. Further information is available here.
7. Limit Non-Patient Visitors
The American Medical Association (AMA) recommends limiting individuals who are not patients from visiting the office (eg, vendors, educators, service providers) and instead utilizing virtual methods to communicate with them. If a non-patient (such as a repair-person) must enter the office, a window of time outside of normal patient hours should be designated.
8. Notify Patients, Staff and Other Relevant Individuals About Your Policies
Make sure that all of your practice policies are posted and known to both patients and staff through signage and through digital methods (eg, on your website and/or through a newsletter).
Notifying patients of your policies will also allay their fears about in-person appointments, Dr Stewart noted.
“We have seen many reports4,5,6 of people who have had strokes or heart attacks or increased symptoms of chronic illnesses but have been reluctant to get medical care because they are afraid of contracting COVID-19,” Dr Stewart said. “We are trying to encourage them and reassure them regarding measures we are taking to ensure their safety and explaining how their visit will be different from what it was prior to the pandemic.”
9. Remain Cognizant of Confidentiality and Privacy Regulations
Many of the usual HIPAA requirements related to telemedicine have been relaxed during the pandemic because it is a public health emergency.
However, this does not mean that all privacy regulations have been suspended. General HIPAA regulations, security, and breach notifications and precautions remain in effect.
10. Remain Updated About New Developments and Updated Guidance Regarding COVID-19
Physicians should remain cognizant that this is a rapidly and continually evolving situation and that, although some regulations are being relaxed as the country reopens, there might be an increase in cases. Patients should be reminded that social distancing, hand sanitizing, and face covering are still important and that they must continue to take adequate precautions during this uncertain time.
Resources for physicians to consult include:
American Academy of Family Physicians
Association of State and Territorial Health Officials
Centers for Disease Control and Prevention
References
1. Centers for Disease Control and Prevention (CDC). CDC Releases Framework for Health Care Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic. May 12, 2020. Available at: https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html. Accessed: May 16, 2020.
2. American Medical Association (AMA). COVID-19: A Physician Practice Guide to Reopening. May 1, 2020. Available at: https://www.ama-assn.org/delivering-care/public-health/covid-19-physician-practice-guide-reopening. Accessed: May 14, 2020.
3. American Academy of Family Practice (AAFP). Considerations for Re-opening Your Practice. Available at: https://www.aafp.org/dam/AAFP/documents/practice_management/COVID-19/resuming-care.pdf. Accessed: May 12, 2020.
4. Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic [published online ahead of print, 2020 Apr 9]. J Am Coll Cardiol. 2020;S0735-1097(20)34913-5.
5. American College of Emergency Physicians (ACEP). COVID-19. Available at: https://www.emergencyphysicians.org/globalassets/emphysicians/all-pdfs/acep-mc-covid19-april-poll-analysis.pdf. Accessed: May 25, 2020.
6. Masroor S. Collateral damage of COVID-19 pandemic: Delayed medical care [published online ahead of print, 2020 May 17]. J Card Surg. 2020;10.1111/jocs.14638.
This article originally appeared on MPR
