Get the Latest COVID-19 Updates

 

COVID-19 and Patient Safety in the Medical and Dental Office

Debra Kane Hill, MBA, RN, Senior Patient Safety Risk Manager, The Doctors Company, Part of TDC Group

Updated April 21, 2022: The BA.2 Omicron subvariant, currently the dominant strain of COVID-19 circulating in the United States, is responsible for 72 percent of new infections (versus 25 percent for BA.1 and 2.5 percent for B.1.1.529), according to recent data from the CDC.

With the sizeable wave of BA.2 infections in Europe in early 2022, health officials in the U.S. anticipate a similar upsurge of cases here due to BA.2’s increased transmissibility, particularly as COVID-19 restrictions are lifted across the country and vaccination efficacy declines. While BA.2 cases are significantly milder than those caused by the Delta variant and Omicron subvariant BA.1, practices must remain mindful that they may continue to see both BA.1 and BA.2 Omicron infections, as well as the flu, within their office settings. Once again, medical and dental offices must remain on guard.

According to the CDC’s “COVID Data Tracker,” vaccination rates across the U.S. have slowed over the past months as restrictions have been lifted. As of April 8, 77.1 percent of the U.S. population had received at least one dose of the COVID-19 vaccine, with 65.7 percent (218.1 million) being fully vaccinated (with vaccinated defined as being at least two weeks out from receiving a second dose of the two-part Moderna or Pfizer vaccine or two weeks after Johnson & Johnson’s single-dose Janssen vaccine). For those age 65 and over, 95 percent have received one dose, while 89.3 percent of Americans in that demographic have completed the series. For boosters, 45.1 percent of those fully vaccinated have received boosters (98.4 million), and 67.6 percent of those age 65 and older have received boosters since August 13, 2021. To help the U.S. attain higher rates of vaccination, healthcare providers must continue to have meaningful discussions with patients about vaccines and to provide them with fact-based information.

CDC Safety Guidelines and Provider Liability

On February 2, 2022, the CDC updated its recommendations for infection prevention and control for healthcare personnel. The CDC made these updates as the Omicron variant continued to escalate around the globe.

Currently, the CDC shows that the rate of hospital admissions in the U.S. is trending downward from January’s peak by a noteworthy 93.6 percent. With a potential surge in BA.2, however, hospital beds may again be in short supply in certain jurisdictions. Liability becomes a concern for healthcare providers if treatment of non–COVID-19 patients is delayed due to affected hospitals and emergency rooms. Invariably, the question becomes: Did the hospital comply with community standards regarding access and delivery of services? Following an adverse event—when plaintiff’s counsel would attempt to prove that the facility failed to follow what other similarly situated medical centers did in the same or similar situations—much would depend on whether the hospital complied with CDC guidelines and executive orders then in effect.

As communities around the country face the new subvariant while simultaneously lifting restrictions for public health, what are the latest considerations for keeping patients and staff safe within the medical and dental office settings? Consider the following suggested guidelines.

Managing the Unvaccinated

Many practices continue to ask, “How do we handle our unvaccinated patients?” While some read “unvaccinated” as shorthand for “antivaccine” or “against the COVID-19 vaccine,” in fact, the unvaccinated population includes adults and children with certain medical conditions, as well as young children not yet eligible for a COVID-19 vaccine. Admittedly, however, most provider questions about unvaccinated patients pertain to those who are eligible for a COVID-19 vaccine but have declined it for various reasons. Many parents with young children and adolescents, for example, are reluctant to seek the vaccine due to its novelty.

Consider why a patient is not vaccinated. Some patients who are members of Christian Scientist, Jehovah’s Witness, Seventh-Day Adventist, Orthodox Jewish, or other religious communities may decline a vaccine on those grounds. Others may decline the vaccine due to concerns about its efficacy and potential side effects and adverse events.

In January, the U.S. Supreme Court blocked the Biden administration’s COVID-19 vaccine-or-test mandate for large private businesses of 100 or more employees while allowing the mandate to stand for healthcare facilities that accept Medicare or Medicaid reimbursement.

Therefore, in addition to conducting patient visits via telemedicine when appropriate, practices might consider other options for seeing unvaccinated patients. One option is maintaining the office policies and practices for infection control that were in effect before vaccinations became available. These include the use of drive-through visits, pre-examination questions and screening, masking by patients and staff, social distancing, and disinfecting patient care areas frequently. Another option is designating one exam room only for the treatment of unvaccinated patients by fully vaccinated clinicians wearing PPE, while maintaining rigorous screening for patients entering the facility. Alternately, unvaccinated patients might be seen only during certain hours, such as at the beginning or end of the day. of refusing to see unvaccinated patients. (For more on this topic, see the suggested recommendations in the “Staying Diligent” section below, or read our article “FAQs About COVID-19 Vaccinations.”) Evaluate individual patients for risk, acuity, and treatment options.

Managing the Unmasked

Some patients have refused to wear masks during the pandemic, but the CDC continues to support masking in healthcare settings for both patients and healthcare workers. It is also mandated in most jurisdictions for healthcare facilities. Practice staff who are responsible for making in-office patient appointments should continue to set patient expectations for established infection control protocols prior to the patient’s arrival in the office. Inform patients that continued adherence to masking protocol is required. Also, remind patients that individuals in healthcare settings are often sick, immunocompromised, and in close proximity to one another, which creates the potential for more exposure. Including signage on the practice website, on the front door, and at the reception area will help alert patients that infection control protocols are still in effect.

If, on arrival, the patient is uncooperative, a healthcare provider should ask the patient to step aside to a private area, then acknowledge the patient’s concerns. Remind any angry patients that the practice is obligated to follow guidelines from the CDC, as well as other government mandates, and that all infection control policies remain in place to ensure everyone’s safety. If a patient remains emotionally volatile and uncooperative, a healthcare provider can suggest that the patient seek care from another healthcare provider. (For more information on this topic, see our article “Terminating Patient Relationships.”)

Per the CDC, face masks should not be used by those who are unable to remove the masks themselves, who have trouble breathing, or children under age two. Further, when requiring masking, patients protected by the Americans With Disabilities Act (ADA) must be carefully evaluated to avoid a claim of discrimination to the Office for Civil Rights. The National Disability Institute provides examples and explanations of why some patients may legitimately decline to wear a mask.

Vital Pandemic Recordkeeping

Continue to maintain records of staff-patient contact (i.e., who was assigned to work with the patient), either in a log or in the EHR. Document so that you can track and notify contacts in case of a COVID-19 diagnosis or probable exposure of the patient or provider.

To further protect your practice, document administrative records with staff screenings and screenings of those entering your facility, and maintain records of all protocols and updated policies followed by your office throughout the pandemic. Keep records of PPE supplies/shortages, cleaning protocols followed, communications with patients, case incidence, and available medical and dental resources within your community. Documentation that you have taken steps to follow recommended infection control protocols may be your best defense should COVID-19–related litigation occur in the future. For more details, see our article “COVID-19 Administrative and Medical Record Documentation: Prepare for Future Lawsuits.”

OSHA Weighs In

On June 10, 2021, more than a year after the start of the pandemic, the Occupational Safety and Health Administration (OSHA) released its Emergency Temporary Standard (ETS) for COVID-19, with an effective date of June 21, 2021. Affected healthcare employers were expected to comply with most requirements within 14 days of publication and within 30 days for the remainder of the requirements (e.g., employee training). The agency withdrew the vaccination and ETS standard on November 5, 2021. The withdrawal,  , went into effect on January 26, 2022. To learn more, see OSHA’s “Statement on the Status of the OSHA COVID-19 Healthcare ETS.”

Planning for a Vaccine

  • Vaccine Distribution: With vaccines more readily available within most communities (e.g., from local pharmacies and grocery chains), evaluate your patients’ access to the vaccine and make plans to determine how your practice would handle administering vaccines, should this be a consideration. Many medical practices are partnering with state and local governments to provide vaccine clinics within the community, particularly in rural areas. For those interested, the Office of the Assistant Secretary for Preparedness and Response provides information for  to become a vaccine provider.
  • Informed Decision Making: As the COVID-19 vaccine rollout continues across the U.S., medical and dental practices should implement plans to educate patients and guide them to an informed decision about the vaccines available within their community. Vaccine fact sheets are available through the Food and Drug Administration (FDA) website: Pfizer-BioNTech—Fact Sheet for Recipients and CaregiversModerna—Fact Sheet for Recipients and Caregivers, and Janssen (Johnson & Johnson)—Fact Sheet for Recipients and Caregivers. The CDC also provides easy-to-understand fact sheets for patients on its website: “Benefits of Getting a COVID-19 Vaccine and “Myths and Facts about COVID-19 Vaccines.” For additional information, see The Doctors Company “Communicating With COVID-19 Vaccine-Hesitant Patients: Top Tips.
  • Vaccine Administration: If your practice is designated as a vaccine administration site, establish policies and procedures for storage and inventory, scheduling and patient screening, patient education, documentation and patient follow-up, and managing medication errors and emergencies. If you are assigned a state-sponsored vaccination team to administer vaccines on your behalf within your facility, review the state’s protocols to ensure safe practices, and inform patients that the vaccine administration is being conducted by the state. The CDC provides guidance on vaccine storage and handling best practices, a training module for healthcare professionals, and reference material for training and education, as does the World Health Organization (WHO) through its online training. The FDA offers fact sheets (Pfizer-BioNTechModerna Janssen) for healthcare providers administering the different vaccines under emergency use authorization and gives information on vaccine administration, safety, storage, informed consent, and reporting adverse events specific to the manufacturer’s vaccine. Other resources include the CDC’s patient screening tool, “Prevaccination Checklist for COVID-19 Vaccines,” and The Doctors Company’s “FAQs About COVID-19 Vaccinations.”
  • Reimbursement: See the Health Resources and Services Administration’s “What Providers Need to Know About COVID-19 Vaccine Fees and Reimbursements.”

Staying Diligent

The following recommendations will assist in ongoing screening and management of suspected COVID-19 patients in your practice:

  • Legislation and Guidance: Reference the CDC, your state licensing board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation, as the situation continues to be fluid. Monitor for outbreaks of COVID-19 cases within your community. Stay on top of current trends to protect your patients and your practice.
  • Screening Criteria: Follow the CDC’s patient screening protocol for early disease detection for patients presenting to your practice. Check the CDC website regularly for any updates to screening criteria. Assess essential visitors to your facility for symptoms and contact exposure and direct them to remain outside if COVID-19 infection is suspected.
  • Comparing COVID-19 and the Flu: Both the flu and COVID-19 are respiratory illnesses and can present in similar ways. For further guidance, see our article “Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors.”
  • Accepting Patients: It is strongly recommended that practices not turn away patients who are not fully vaccinated or simply because a patient calls with acute respiratory symptoms. Triage all patients over the phone or via telemedicine and manage them according to CDC recommendations. Refusing assessment/care may lead to concerns of patient abandonment.
  • Designated Triage Location: To limit exposure in your facility, check with your local public health authorities for locations designated to triage suspected patients should COVID-19 infections rise significantly in your community. Community emergency preparedness plans have been activated so that parties are coordinating efforts to deliver effective public health intervention.
  • Telehealth Triage: The CDC recommends alternatives to face-to-face triage and visits, particularly for high-risk patients, 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 versus those who need to be seen at the office or at a designated community facility. See the CDC’s “Managing Healthcare Operations During COVID-19.” The CDC also provides a “Phone Advice Line Tool” with recommendations for children ages two to 17 or adults (≥18 years) with possible COVID-19. The Doctors Company offers resources on telehealth, as does the CDC in “Using Telehealth to Expand Access to Essential Health Services During the COVID-19 Pandemic.” For a list of telehealth COVID-19 rules by state, see the from the Federation of State Medical Boards (FSMB).
  • Patient Testing: Medical and dental practitioners should determine which patients require testing based on presenting symptoms, history, contact exposure, community transmission of disease, and for early identification in special settings (such as nursing home admission or elective surgery). See the CDC’s “COVID-19 Testing: What You Need to Know and “Overview of Testing for SARS-CoV-2, the Virus That Causes COVID-19.” The CDC provides instructions for reporting COVID-19 cases. The CDC also offers the “Clinician Call Center,” which is available to healthcare personnel to assist with diagnosis, clinical management, and infection control protocol. Dial (800) CDC-INFO [(800) 232-4636] and ask for the Clinician Call Center.
  • Elective Services: If cases of COVID-19 trend upward within your community, check with regional health authorities on the provision of nonessential and elective healthcare visits and group-related activities. States and counties vary depending on the number of cases, availability of PPE, and availability of hospital beds. For diagnostic and therapeutic interventions, including surgery, the CDC provides “Managing Healthcare Operations During COVID-19.” The American College of Surgeons (ACS) has also published “Clinical Issues and Guidance on triage and management of surgical cases, including specialty guidelines. Some states may reinstate restrictions on the provision of nonurgent, elective surgeries and procedures. (See the FSMB’s “COVID-19 Related Legislation.” In some states, violations may result in fines or complaints to the medical or dental board. Check with state and local regulatory agencies for any related mandates.
  • Office Messaging: Post front-door signage requiring patients and visitors who are exhibiting COVID-19 symptoms or who have had contact exposure to immediately notify facility personnel via telephone for instructions on accessing care. (See the CDC’s “Symptoms of COVID-19.”) Include information on the practice website regarding office policies for appointments, telephone assessment/telemedicine, and visitors. Also, post COVID-19 resources for patients, ,” with a reminder to maintain physical distance, wear a face mask, and follow local orders to lessen community spread. If the office is closed, update voicemail messages to address telephone assessment, telemedicine, and how to reach in the event of an emergency.
  • Physical Distancing: The CDC still recommends physical distancing within healthcare facilities. Require patients and staff to sit at least six feet or more apart. Patients can be asked to wait in their car if that option is necessary. Reconfigure seating as needed. Remove magazines and toys from the waiting room. Disinfect the waiting room routinely throughout the day. Develop a cleaning schedule and checklist for your facility, and document in administrative files that it is followed.
  • Suspected Infection: Evaluate patients on a case-by-case basis. If presenting symptoms and/or contacts are suspicious for COVID-19 and it is determined that the patient must be seen, have the patient call prior to arrival so your facility can 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  by segregating them from other patients in the facility in a designated regular exam room with dedicated patient care equipment. If possible, use a back entrance. Patients with suspected infections should be seen only by vaccinated office staff.
  • Patient Precautions: Ask all individuals entering your facility about  of coronavirus, and document findings on an administrative log. Instruct patients and visitors to put on a face mask or respirator covering the nose and mouth (source control), use tissues, practice good hand hygiene, and physically distance from others in the designated waiting area. Educational resources, including posters and print resources for use in the medical and dental office are available from the CDC (“Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings) and the WHO. Reference the CDC’s “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) for patient management guidance.
  • Visitor Precautions: Allow only those visitors who are essential for the patient’s well-being and care to enter your healthcare facility, and require screening and source control masks as indicated.
  • Provider/Staff Precautions: Follow the CDC’s “Standard Precautions for All Patient Care” and “Transmission-Based Precautions,” including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that follow OSHA’s recommendations. If there is a shortage of N95 respirators in your facility, access current CDC and review “Optimizing Personal Protective Equipment (PPE) Supplies.” Because patients will scrutinize your adherence to infection control protocol, ensure that staff follow it precisely. Failure to do so may result in licensing board complaints, negative social media coverage, or patients leaving the practice permanently. Provide updated staff training on infection control protocols as needed. See the CDC’s “ for more information.
  • Limit Exposure: Limit staff exposure to suspected COVID-19 patients by keeping the exam room door closed. Ideally, the designated exam room should be at the back of the office, away from other staff and patients. Only employees should interact with these patients.
  • Surface Disinfection: Disinfect surfaces once the patient exits the room. Ensure that participating staff members continue to wear PPE. For general guidance, see the CDC’s “Cleaning and Disinfection of Environmental Surfaces.” The CDC recommends that healthcare facilities use the cleaning agents noted in the Environmental Protection Agency’s “” for use against SARS-CoV-2.
  • Dental Office Considerations: The CDC’s applies to all healthcare settings, including dentistry. Continue to prescreen patients for coronavirus symptoms and postpone nonurgent dental care if the patient is symptomatic for COVID-19. Urgent febrile patients may be seen if the fever is suspected to be due to a dental condition, but the dentist should make this determination. Continue to follow the most current PPE guidelines, including masking. Periodically review state health department COVID-19 guidance and county infection rates. Devices such as ultrasonic scalers, high-speed dental handpieces, and air/water syringes produce aerosols during use, creating additional exposure risk for clinicians. The CDC recommends additional precautions, such as four-handed dentistry, high-evacuation suction, and the use of dental dams during these procedures to reduce the risk of droplets. Participating staff should wear NIOSH-approved N95 masks or higher-level respirators in areas with high rates of coronavirus transmission. Review the CDC’s “setting-specific considerations for dentistry in their entirety (scroll down to “Dental Facilities”).
  • Patient Education: Refer to CDC resources for providing suspected COVID-19 patients and their close contacts with up-to-date, factual information about the virus. Provide information about how to follow infection-control practices at home, such as in-home isolation and quarantine, hand hygiene, cough etiquette, waste disposal, and the use of masks. Remind patients and their families to access information about the virus through reputable sources such as the CDC, not through social media.
  • Provider/Staff Exposure: Encourage vaccination among your staff. Screen healthcare personnel daily for symptoms/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed, monitored, and documented in administrative files. See the CDC’s “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.” If any providers and/or staff test positive within your facility, conduct and document a risk assessment identifying contacts, type of interaction, and PPE in use, then contact local health authorities for additional instruction. The CDC provides guidance under the section “Infection Control” for management. Disclosure to patients may be necessary depending on the type of exposure that occurred, if any, but always take necessary steps to protect the privacy of the infected employee. Telephone calls directly to patients are the most efficient method of notification, followed with a letter. Suggested notification includes, “We are calling to inform you that someone in our office tested positive for COVID-19 on the day of your visit...” followed by recommendations for assessment and any needed follow-up. If deemed necessary, your local health department may assist with patient notifications. Contact your patient safety risk manager at The Doctors Company, as needed, for additional guidance. For return-to-work guidance, review the CDC’s “Return to Work Criteria.”
  • Staff Training: Assess the need for additional staff training to review screening and triage protocols, patient management, use of PPE, patient communications, and any revision in policies and procedures that have been made to adapt to the evolution of the virus. Document all training provided to staff and maintain records in administrative files.
  • Team Briefs: Conduct daily staff briefs/huddles and end-of-day debriefs. These provide all staff with opportunities to discuss issues anticipated during the day and identify concerns, pre- and post-clinic, including COVID-19 updates. (See The Doctors Company’s on-demand course, TeamSTEPPS® Teamwork Training in the Office Practice, and the Agency for Healthcare Research and Quality’s TeamSTEPPS Fundamentals.) Acknowledge the need to provide emotional support to staff who may be dealing with fear or other stressors by making employee assistance programs or other support mechanisms available. Communicate resources to employees.

Managing Legal Risks

According to the COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopikins University, The influx of variants in the U.S. will continue to present unique challenges. Government authorities in some states may mandate additional restrictions of public activities, while other states will likely maintain unrestricted business operations. Medical and dental offices will continue to face multiple challenges, including in-pandemic rules for operation, vaccinations, managing sick employees, and providing “catch-up” care for patients who had clinical services postponed while offices were closed or put off contacting healthcare providers because of fears.

The bottom line: Even with the availability of the vaccine, medical and dental practices must not become complacent or be less vigilant. Because the virus continues to be a moving target, all healthcare providers and facilities must remain well-informed and current on public health guidance for screening protocols and patient management, as well as regulatory requirements affecting their practices. Continued careful screening with a bias for suspicion that a patient might have COVID-19 will serve healthcare providers well in this situation.

As the pandemic moves forward, we emphasize that keeping office policies and procedures current while following recommended guidelines and documenting adherence (in both administrative files and medical and dental records) are key to future litigation defense.

The dynamics surrounding the virus will continue to evolve, particularly with the spread of variants this spring and as the population is vaccinated. What does not change is that healthcare providers and care teams must remain vigilant and adapt their practices accordingly. Remain 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.



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.

04/22

Subscribe for Updates

SIGN UP