Updated November 23, 2020: As the pandemic hits its third nationwide surge, families are gathering for the holidays, and practices are preparing for a potential increase in cases. Medical offices in states that were not strongly affected by the first and second waves of the virus may now be facing an influx of COVID-19 patients. Therefore, medical offices must remain very attentive to the widespread outbreak of COVID-19, continuing to proactively take steps to safely manage patients while protecting clinical staff.
Below, you will find recommendations for this season of the pandemic, such as protective recordkeeping, documentation and follow-up for noncompliance and coordination of care, managing patients who resist infection-control measures, and tracking ongoing guidance from health authorities.
Vital Pandemic Recordkeeping
Maintain records of staff-patient contact, i.e., who was assigned to work with the patient, either in a log or in the electronic health record. Document so that you are able to track and notify contacts in case of a COVID-19 diagnosis or probable exposure on either the patient or provider side.
Further, to protect your practice, file records of staff screening and of those entering your facility in your administrative records, as well as all protocols and updated policies your office is following during this crisis. Keep records of PPE supplies/shortages, cleaning protocols followed, communications with patients, case incidence, and available medical resources within your community. Documentation that you have taken steps to follow recommended infection control protocol may be your best defense should COVID-19-related litigation occur in the future. For details, see Keep a COVID-19 Diary: Document Now in Case of Future Lawsuits.
Managing Difficult Patients
Due to our country’s current political environment, which has impacted perspectives on COVID-19, many practices are experiencing patients who believe the virus is a hoax based on “fake news” and refuse to follow safety protocols. When making an appointment for in-office visits, set expectations prior to the patient coming into the office about established infection control protocol. If the patient is uncooperative upon arrival, ask the patient to step aside to a private area and acknowledge their position. Listen to the patient’s concerns and remain calm. If the patient is angry, do not lose your temper, and remind the patient you are obligated to follow guidelines from the Centers for Disease Control and Prevention (CDC) as well as other government mandates, and that all infection control policies remain in place to ensure everyone’s safety. If the patient remains emotionally volatile and uncooperative, suggest the patient seek care with another healthcare provider.
Planning for a Vaccine—During Flu Season
- Vaccine Distribution:Under the Trump Administration, Operation Warp Speed was “created as a joint effort between the Department of Health and Human Services and the Department of Defense, engaging with private firms and other federal agencies, to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics.” In mid-August, the CDC contracted with McKesson Corporation to support vaccine distribution. Practices should begin making plans now to determine if and how they will handle administering a vaccine, which could be available in some areas as early as November 2020. For more information on Operation Warp Speed, see the Strategy for Distributing a COVID-19 Vaccine, the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, and the Vaccine Distribution Process.
- Considerations During Flu Season: Due to delays in testing and misdiagnosis, patients have 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. In this regard, flu season poses special challenges. Both the flu and COVID-19 are respiratory illnesses and can present in similar ways, so providers should devote attention to learning COVID-specific symptoms such as new loss of smell or taste. For further guidance, see Flu or COVID-19? Convergence of Two Viruses Creates Risk of Diagnostic Errors.
Staying Abreast of Changes
The following recommendations will assist in the ongoing screening and management of suspected COVID-19 patients in your practice:
- Legislation and Guidance: Reference the CDC, your state medical board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation, as this continues to be a fluid situation. Monitor for an increase in 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 assessment protocol for early disease detection for patients presenting to your practice. Patients should be screened using these guidelines: Overview of Testing for SARS-CoV-2 (COVID-19). We recommend that you check this CDC website often for any updates in screening criteria. Essential visitors to your facility should also be assessed for symptoms of coronavirus and contact exposure and redirected to remain outside if suspect.
- Accepting Patients: 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.
- Designated Triage Location: 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.
- Telehealth Triage: With community spread and the resurgence of COVID-19 in some states, 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 versus those who need to be seen either at the office or at a properly designated community facility. See Healthcare Facilities: Managing Operations During the COVID-19 Pandemic. The CDC provides Phone Advice Line Tools, which includes sample phone script, a clinical decision-making algorithm, and advice messages. The Doctors Company offers resources on telemedicine in our COVID-19 Telehealth Resource Center as does the CDC: Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. For a list of telehealth COVID-19 rules by state, visit Federation of State Medical Boards: COVID-19.
- Patient Testing: Physicians should determine which patients require testing based on presenting symptoms, history, contact exposure, community transmission of disease, and for early identification in special settings (e.g., nursing home admission). 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 Testing for COVID-19 and Overview of Testing for SARS-CoV-2 (COVID-19). The CDC advises, “Healthcare providers should immediately notify their local or state health department in the event of the identification of a PUI (Person Under Investigation) for COVID-19.” The CDC 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: Check with regional governmental and health authorities on the provision of nonessential and elective healthcare visits and group-related activities. States and counties vary depending on number of cases, availability of personal protective equipment (PPE), and availability of hospital beds. For diagnostic and therapeutic interventions, including surgery, the CDC provides the Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic. Also, the American College of Surgeons (ACS) published Clinical Issues and Guidance on triage and management of surgical cases, including specialty guidelines. Many states continue or have reinstated restrictions on the provision of nonurgent, elective surgeries and procedures (See ACOS: COVID-19: Executive Orders by State on Dental, Medical, and Surgical Procedures). In some states, violations may result in physician jail time, fines, or complaints to the medical board. Check with state and local regulatory agencies for any related mandates.
- Office Messaging: Practices should 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. 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’ Coronavirus (COVID-19) page and COVID-19 Frequently Asked Questions] with a reminder to maintain physical distance, to wear a face mask, and to follow local orders 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.
- Physical Distancing:To maintain physical 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. 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, 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 regular exam room with dedicated patient care equipment. A back entrance should be utilized.
- Patient Precautions: For individuals entering your facility, instruct them to put on a face mask, utilize tissues, practice good hand hygiene, and properly dispose 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 CDC (Contact Precautions, Droplet Precautions, and Airborne Precautions). Reference the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) for patient management guidance.
- Provider/Staff Precautions: Follow Standard Precautions and Transmission-Based Precautions, including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit-tested. If there is a shortage of N95 respirators in your facility, access current CDC respirator recommendations and review Optimizing Personal Protective Equipment (PPE) Supplies. Remember that patients will scrutinize your adherence to infection control protocol; ensure that staff follow it precisely. Failure to do so may result in medical board complaints, negative social media reviews, and the patient leaving the practice permanently. Provide updated staff training on infection control protocol as needed.
- Limit Exposure: 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.
- Surface Disinfection: Once the patient exits the room, conduct surface disinfection while staff continues to wear PPE. For general guidance, see Clinical Questions about COVID-19: Questions and Answers. The CDC has updated guidelines for considerations on how long exam rooms should remain vacant between patients. Be mindful 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. Follow the CDC for updated guidance on how COVID-19 spreads: “It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes. This is not thought to be the main way the virus spreads . . .”
- Patient Education: Provide up-to-date, factual information on the virus to suspected COVID-19 positive patients and their 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.
- Provider/Staff Exposure: Screen healthcare personnel daily for symptoms/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 Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. Should 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 here under the section “Infection Control,” as does the American Dental Association: What to Do if Someone on Your Staff Tests Positive for COVID-19. 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 the patient are the most efficient method of notification, followed by mail. Suggested notification may include “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. The health department may assist with patient notification if determined to be necessary. Contact your patient safety risk manager at The Doctors Company, as needed, for additional guidance. For return-to-work guidance, review the Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance).
- 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 crisis. Document all training provided to staff and maintain records in administrative files.
- Team Briefs: Conduct daily staff briefs/huddles and end-of-day debriefs. This provides all staff opportunities to discuss anticipated issues during the day and identify concerns, pre- and post-clinic, including COVID-19 updates. Acknowledge the need to provide emotional support to staff who may be dealing with fear or other stressors through employee assistance programs or other support mechanisms. Communicate resources to employees.
Managing Legal Risks, Staying Vigilant
COVID-19, declared a global pandemic by the World Health Organization (WHO), continues to infiltrate multiple continents, infecting more than 40 million worldwide, with global deaths reaching beyond 1 million. Within US borders, more than 8 million Americans have been infected, with the death rate approaching 225,000. Government authorities in some states continue to mandate shelter-in-place, as new outbreaks continue to cluster in many regions across the United States. Other states are reopening, while some areas are again shutting down. Medical offices are faced with challenges including in-pandemic rules for operation and the provision of “catch-up” care for patients who had clinical services postponed while offices were closed, or who put off contacting their physician because of infection fears.
Daily, the CDC continues to process data and advise clinicians on COVID-19 through its website and televised press conferences, while government authorities at all levels mandate legislative updates for the provision of safe healthcare operations. Because this continues to be a moving target, physicians and all healthcare facilities must remain well-informed and current on public health guidance for screening protocols and patient management, as well as regulatory requirements impacting their practices.
By now, most healthcare facilities and physician practices have encountered COVID-19 patients. Early on, medical facilities and the entire healthcare industry were poorly prepared for this outbreak, leading to early mistakes when clinicians encountered cases they had not anticipated seeing. Due to issues with diagnostic testing, and because the clinical presentation of patients suspicious for COVID-19 infection resembled patients with fairly routine cold, flu, or seasonal allergies (or presenting with no symptoms at all), delays in diagnosis and treatment have been common. But with improved testing capabilities, and by following current clinical guidelines, facilities where patients receive care can be more effective in identifying and treating COVID-19 in a timely manner. Careful screening with a bias for suspicion that a patient might have COVID-19 will serve healthcare providers well in this situation.
As we move forward, we emphasize that keeping office policies and procedures current while following recommended guidelines, with documentation of adherence in both administrative files and medical records, is key to litigation defense in the future.
The dynamics surrounding the virus will continue to change in the weeks and months ahead. What must not change is that physicians and care teams should remain vigilant and adapt their practices accordingly. 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.