Updated March 26, 2020: The 2019 novel coronavirus (COVID-19), declared a global pandemic by the World Health Organization (WHO), continues to spread across multiple continents, infecting hundreds of thousands worldwide, with thousands of deaths. Many municipalities and some states across the U.S. have begun mandating shelter-in-place. With outbreaks clustered in multiple states, medical offices are experiencing an influx of patients seeking assistance.
Most medical offices have, for the most part, learned from experience and are paying closer attention to widespread outbreaks of disease. One lesson learned from Ebola, measles, and other recent outbreaks—when many healthcare organizations were unprepared—is that all medical offices should have an infection control and emergency preparedness plan in place.
The Centers for Disease Control and Prevention (CDC) has been responsive in its role to gather data and advise clinicians on COVID-19; however, it is up to physicians and all healthcare facilities to take necessary steps to provide effective screening for the public, followed by recommended protocols and patient management.
A well-constructed infection control preparedness plan for COVID-19 is essential for facilities where patients receive care, such as physician offices, dental offices, long-term care facilities, and ambulatory care centers. Leading into the Ebola crisis, nearly 80 percent of hospitals in the U.S. acknowledged that they were unprepared to deal with patients who might present with Ebola symptoms. That led to avoidable early mistakes when clinicians encountered cases they had not anticipated seeing. Unlike Ebola, patients with a COVID-19 infection may look a lot like patients with fairly routine cold and flu symptoms or seasonal allergies, or they may be infectious without any presenting symptoms at all. But by following best practices, facilities where patients receive care can make great strides in identifying, testing, and treating COVID-19 early. Careful screening with a bias for suspicion that a patient might have COVID-19 will serve healthcare providers well in this situation.
The following are some recommendations in the event a patient with suspected COVID-19 seeks care:
- 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. We recommend that you check this CDC website daily 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, or via another 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.
- For diagnostic and therapeutic interventions, the CDC advises: “Patients should receive any interventions they would normally receive as standard of care. Patients with suspected or confirmed COVID-19 should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed.” The CDC recommends postponing all nonessential or elective healthcare visits and group-related activities, and some states with widespread disease are mandating the provision of emergency services only.
- 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 regarding new office policies for appointments, telephone assessment/telemedicine, and visitors on the practice website. Also post COVID-19 resources for patients (e.g., the CDC’s Coronavirus (COVID-19) page) with a reminder 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 apart. Ask patients to wait in their cars 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 preparations for accommodation. If 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 (segregate them from other patients in the facility) in a designated exam room with dedicated patient care equipment. A back entrance should be utilized, if available. 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 the CDC guidelines for environmental infection control in healthcare facilities. Be aware that according to the CDC and the National Institutes of Health (NIH), 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 provides tips to submit a report on a PUI, presumptive positive case, or laboratory-confirmed case.
- 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 staff continues to wear personal protective equipment (PPE).
- 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).
Suspected cases must be reported to applicable local and state health departments. The CDC provides tips to submit a report on a PUI, presumptive positive case, or laboratory-confirmed case. (Many jurisdictions now have the capability for local testing.) Also, screen healthcare personnel daily for symptoms/travel/contacts for 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).
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 delay 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.
We recommend that 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.
- American Academy of Family Physicians (AAFP): Checklist to Prepare Offices for COVID-19
- CDC: Information for Healthcare Professionals
- CDC: Healthcare Professionals: Frequently Asked Questions
- WHO: Coronavirus Disease (COVID-19) Outbreak
- Johns Hopkins Global Case Map: Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.