During the COVID-19 outbreak, and in the months and possibly years that follow, all primary healthcare providers should follow these basic protocols for all office visits to ensure their own safety, and the safety of their patients:
- Following basic infection control procedures during patient contacts:
- Basic patient screening for COVID-19 symptoms and further testing if symptoms are present
- Hand-washing protocols for patients and staff
- Following proper PPE protocols
- Reducing office visits through a combination of:
- Eliminating non-essential appointments
- Shifting to telehealth services
- Educate patients and staff on COVID-19 symptoms and safety protocols
“First, Do No Harm” – Reducing Contact is The Basis of Staff and Patient Protection
COVID-19 is the big healthcare crisis of the moment, but it did not suddenly erase all the other many healthcare challenges facing Americans. For those, primary care clinics and physicians remain a vital resource—but only if treatment doesn’t increase their risks of infection.
Physicians, nurse practitioners, and any other healthcare professionals serving in a primary care role can take a number of basic steps to keep themselves, their staff, and their patients safe while still delivering important consultation and treatment for routine patients, as well as those who might have COVID-19, both during and after the pandemic.
The basic principle behind social distancing is that reduced interpersonal contact and mingling in shared spaces reduces opportunities for SARS-CoV-2 to be transmitted between individuals. Current understanding of the mechanisms of transmission shows that it is spread by airborne droplets, just like other coronaviruses and the common flu, with a limited capacity to survive on surfaces and lead to infection if someone touches a surface with infected droplets on it and then touches the face. Some degree of transmission is known to occur even when patients are asymptomatic, meaning all visitors carry some potential risk.
These protocols should help you reduce patient contact points:
Establish an Infection Control Lead or Committee
Keeping track of the following protocols, and keeping them updated as new information comes out, is a demanding task. Appoint a facility lead or committee if your clinic doesn’t already have one to establish and monitor your safety protocols throughout the crisis. This creates a single point of contact for staff and providers to keep everyone on the same page.
Cancel Elective Procedures and Non-Critical Visits
Many conditions treated in primary care are not urgent and can safely be pushed back to later dates:
- Regular wellness checks and physicals
- Periodic monitoring of chronic conditions
- Follow-up visits from other procedures
- Screening appointments
Increase Screening and Triage Efforts
Both to identify non-critical patients and to prioritize and prepare for those who may need an on-site visit, your remote screening and triage steps should be revised to include checks for COVID-19 symptoms and create treatment plans that minimize the number of in-person visits a patient has to make. This can include referrals or advice for patients who are showing symptoms, directing them to remain in isolation or to seek immediate treatment. It should also drill down to determine how critical other cases are in order to weigh the risks of bringing them into the office. Further, triage can assess not only health conditions, but also how receptive patients will be to telehealth services.
Increase the Availability of Telehealth Appointments
Where possible, telehealth services should be used in place of office visits. This will involve at least as many demands on providers and support staff as regular in-office visits.
Follow Heightened Infection Control Procedures
The CDC has released interim infection control guidance for healthcare facilities treating known or suspected COVID-19 patients. In most cases, primary care clinics should avoid seeing infected patients, but following these infection control procedures in your clinic is still smart since asymptomatic spread is still a concern.
Basic steps should include:
- Require basic symptom screening on arrival for patients; refer symptomatic patients elsewhere.
- Require hand washing on arrival for patients, and between patients for staff.
- Staff should wear approved PPE including gloves, face masks, eye protection, or shields and gowns, depending on procedures. Masks should be medical-grade, at a minimum, with N95 or better respirators as available.
- Patients should be required to wear masks, at a minimum (cloth masks are appropriate).
- Frequent use of alcohol-based hand sanitizer between 60% and 90% concentration.
- Establish distancing in patient waiting and reception areas, with either physical barriers or markings indicating appropriate distance. Separate chairs and remove couches or other seating arrangements that are close together.
- Control patient movement along established routes through the clinic, to avoid possible infection spread in predominantly staff areas.
- Regularly disinfect treatment rooms and other patient areas with EPA-approved disinfectants.
Communicate with Patients
Patients might be frightened and confused during the pandemic, and may not understand either the disease or your steps to keep them safe. Patient communication is paramount, both prior to appointments, and on arrival. The CDC has pre-printed advisories and signs available to download for free that you can post at clinic entries, reception desks, and as handouts for patients to help explain your infection control procedures and how to respond to symptoms.
Monitor and Train Staff for COVID-19 Procedures
Staff will also need additional training in these procedures. They should follow the same protocols when reporting to work as patients do when entering the office: a symptom screen, hand-washing, and putting on PPE.
Specific training should include:
- Appropriate hand-washing technique
- PPE donning and doffing technique
- Patient screening and triage procedures
- Proper contact points to notify infection control leads or public health officials of suspected COVID-19 cases
Stay Informed of New COVID-19 Developments
COVID-19 is a new disease and medical understanding of the symptoms, effects, treatments, and transmission patterns is constantly evolving. Stay up-to-date by monitoring the CDC and WHO webpages for healthcare professionals.
Dealing With Difficulties in Maintaining COVID-19 Safety Protocols
Although the basics of the safety protocols for primary care services are straightforward during and in the months and years after the pandemic, there are quite a few obstacles that most clinics will face while trying to follow them.
Dealing With Technology Issues
Many of the safety protocols require a shift to remote services and screening. Most clinics are not set up to handle a full transition to telehealth. Just getting started in making services available remotely is going to come with major training and technology obstacles for many clinics.
In the same way, it’s a good idea to establish an infection control lead or committee early on in the crisis, you should also establish a technology or telehealth resource in order to:
- Establish best practices
- Train staff and providers on telehealth procedures
- Spearhead procurement
- Offer technical and operational support
Handling Procurement Problems
Following PPE protocols is difficult if you can’t get your hands on the required equipment. That’s been a significant problem worldwide, made worse by confusion and organizational issues in the United States.
It’s best to try to stock up on equipment and supplies sooner than later. It’s likely that some of your early attempts will fall through, but you have some time before social distancing restrictions are relaxed and your schedule starts to fill up again, and with patients who may have been putting medical problems off for months.
Since COVID-19 is expected to come in several waves, it may be worth reaching out to other healthcare facilities, particularly those involved in emergency and critical care treatment. At the same time your primary care visits are likely to jump, their emergency visits should be plunging. They may be able to share any overstock with you; similarly, as cases climb and distancing is re-imposed, you can offer back any surplus equipment you might have acquired.
Managing Staffing Shortages
Most businesses are facing staffing issues currently. For primary care clinics, it’s an even bigger problem:
- With many school systems closed, parents are having to stay home with kids even if there aren’t restrictions in their state preventing them from going to work.
- Healthcare workers are more likely to be exposed to the disease, resulting in:
- Becoming sick and being off-work until they recover
- Undergoing mandatory two-week self-isolation at home
- Some providers may be volunteering at hard-hit critical care facilities during the crisis.
This is an area where advanced practice nurses can contribute more than most. A number of states have relaxed practice restrictions for APRNs to allow them to independently handle cases remotely and without a supervising physician in states that would otherwise require oversight or a collaborative agreement. Don’t be afraid to step up and offer to take on additional services within your scope of training and expertise.
The AANP (American Association of Nurse Practitioners) is maintaining a master list of states where APRN practice restrictions have been lifted.
Tension with Practice Financial Well-Being
The cost of implementing effective safety protocols could be a major problem for some primary care practices. Patient visits are down dramatically, from both official restrictions and the simple fact that patients are afraid to seek medical treatment. As a result, many practices are bringing in less money.
And staff are spending a lot of time performing services like screening and cleaning that you won’t be remitting to the insurers for reimbursement as you would for normal patient services.
Other factors are cutting into revenues too:
- Procedures that might otherwise be performed may be too risky from an exposure perspective
- Providers themselves are under stay-at-home orders and can’t provide services
- Many telehealth visits can’t be billed under conventional medical billing rules, or bring in significantly less revenue
These factors all add up to generate even less money for staff time necessary to follow proper safety protocols, and less ability to purchase the equipment and supplies that are necessary. While there is likely a backlog of services waiting to be performed after the first wave crests, money coming in next year will not help with today’s crisis.
Congress provided some support in late March with the CARES Act, which included $100 billion to help providers with lost revenue and additional expenses. A supplementary bill, the Paycheck Protection Program and Health Care Enhancement Act offers an additional $75 billion for health care provider relief. And some of the other CARES provisions aimed at small business support may be open to eligible primary care practices.
It’s fairly clear that all those sums will be far too small to bridge the actual gap in funding for the duration of the crisis, however. Additional lobbying, either directly with elected officials, or through organizations like the AANP, might be the most important safety-related practice you can take on right now.