Are there any tips for infection control methods and planning for doctors in their clinics

Posted on April 13, 2020 by Raymond Cho

Summary

Virtual care and primary care clinic planning (i.e. previsit messaging, MOA triage, office layout, PPE, staff management, etc.) can be used for infection control in clinics.

I.   VIRTUAL CARE AND DECISION FOR IN-PERSON VISITS

  • The Ministry of Health encourages all primary care providers to implement a virtual care system. Non-essential appointments should be postponed or converted to virtual (1).
  • Set-up and best practices for virtual care can be found in the following links: Quick Start Session, CMA Virtual Care Playbook, and PHSA COVID-19 Virtual Health Toolkit (2,3,4).
  • There are situations where an in-person visit is necessary. BC Family Doctors has provided a non-exhaustive list of conditions that are more likely to require an in-person consultation (5):
    • Priority A: patients with urgent needs and would otherwise have to go to hospital for care (e.g. pregnancy complications, acute infections, abdominal pain NYD, etc.).
    • Priority B: Patients who require services that can be deferred a few weeks (e.g. well baby checks, uncomplicated pregnancy, stable chronic disease – diabetes, HTN, etc.).

Priority C: non-urgent patients whose services can be deferred or managed alternatively (well-child check-ups, nutrition counselling, pap smears, etc.).

II.   PREPARING PRIMARY CARE CLINIC FOR COVID-19 PANDEMIC

  • VCH has prepared a pandemic preparedness checklist for physician offices (6).
  • Triage and Scheduling approaches (7)
    • Pre-visit messaging: office telephone message instructing patients on changes to practice and how to seek instructions on assessment of influenza-like illnesses.
    • Patients should be directed not to visit the office without making an appointment.
      • MOAs should triage patients with respiratory symptoms and redirect those with positive symptoms to phone or virtual appointments.
      • Patients should be called or messaged prior to their scheduled visit to screen for development of new respiratory symptoms.
    • Patients with COVID-19-like symptoms at higher risk or those whose illnesses progress rapidly should be seen at an urgent care centre or emergency department.
    • Non-essential visits should be deferred (see BC Family Doctors list above).
  • The Clinic (7,8)
    • General
      • Adapt office layout to improve patient flow, encourage 2-meter distancing.
      • Barriers between people such as privacy curtains.
      • Engineering: maintain temperature 21-24 degrees Celsius and 45-60% relative humidity. Open windows and sunlight in waiting areas for natural ventilation.
    • Reception Area
      • Signage: infection control procedures posted at the entrance, triage desk and in the waiting room should be considered (9).
      • Keep doors open to avoid patients/staff touching doorknobs.
      • Plexiglass partitions can be installed at reception counters to prevent transmission from patient to staff.
      • Hand sanitizers should be available at every entrance, reception, waiting room and inside/outside the exam rooms.
    • Waiting Room
      • Toys, soft plushies and magazines should be removed.
      • Waiting room chairs should be configured to maintain 2 m between patients. Offices can consider swapping cloth chairs for metal folding chairs (10).
      • Alternatively, patients may wait outside or in cars to be called in when ready.
    • Exam Room
      • One examination room should be designated for patients with respiratory symptoms, ideally closest to the entrance to allow rapid isolation.
      • The bare minimum equipment should be used (exam table, BP cuff, lights).
      • Air circulation should be increased (speak to the building manager).
    • Best Practices for Environmental Cleaning (11)
  • PPE for Patients and Staff
    • The OMA has provided recommendations for use of PPE (12).
    • Cough etiquette and hand cleansing should be encouraged for both patients and staff in the clinic (see above signages).
    • Patients with respiratory symptoms should be instructed to wear a surgical mask.
    • Office staff should also wear surgical masks with eye protection.
      • Although unlikely in a primary care setting, N95 respirators should be worn if conducting an aerosol-generating procedure in a patient with symptoms. 
  • Office Management (7)
    • Staff education and communication is critical in pandemic situations.
    • Staff scheduling: there may be increased staffing needs but also increased absenteeism. A list of potential replacement staff should be developed in anticipation.
    • Sick leave: staff with suspected or confirmed COVID-19 should be asked to stay home. However, in emergency situations, “fit-for-work with restrictions” approach can be taken provided the following requirements are met and an open discussion is held prior to sickness:
      • Only mild symptoms
      • Feel well enough to work
      • Only be assigned to patients with symptoms of COVID-19
      • Practice strict respiratory and hand hygiene protocols
      • Wear a mask whenever they are in a common area

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. COVID-19 Guidance: Primary Care Providers in a Community Setting [Internet]. Ontario Ministry of Health. 2020 [cited 2020Apr13]. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_primary_care_guidance.pdf
  2. Sambor K, Renzitti M, Scott P, Travis C, Mettler B, Chow N. Virtual Care Quick Start Session for Medical Office Assistants in British Columbia [Internet]. Doctors Technology Office. Doctors of BC; 2020 [cited 2020Apr13]. Available from: https://www.doctorsofbc.ca/sites/default/files/dto_moa_virtual_care_quick_start_session.pdf
  3. Dermer M. Virtual Care Playbook [Internet]. Canadian Medical Association. 2020 [cited 2020Apr13]. Available from: https://www.cma.ca/sites/default/files/pdf/Virtual-Care-Playbook_mar2020_E.pdf
  4. COVID-19 Virtual Health Toolkit [Internet]. Provincial Health Services Authority. [cited 2020Apr13]. Available from: http://www.phsa.ca/health-professionals/professional-resources/office-of-virtual-health/covid-19-virtual-health-toolkit
  5. What are Essential Services in Primary Care? [Internet]. BC Family Doctors. 2020 [cited 2020Apr13]. Available from: https://bcfamilydocs.ca/wp-content/uploads/2020/03/What-are-Essential-Services-in-Primary-Care-032520.pdf
  6. Pandemic Response Planning Checklist for Physicians’ Offices [Internet]. Sneezes Diseases. Vancouver Coastal Health; 2020 [cited 2020Apr13]. Available from: https://sneezesdiseases.com/assets/uploads/15839692909nsSEJSjsWrF6p6oaL5SCYpdyD4P.pdf
  7. Foggin T, Daniels S. British Columbia’s Pandemic Influenza Response Plan: Guidelines for Pandemic Influenza-related Office Management and Infection Control for Private Physicians [Internet]. Young E, Campbell D, Henry B, Mackie B, Bernard K, editors. Government of British Columbia. 2012 [cited 2020Apr13]. Available from: https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/bc-pandemic-influenza-private-physican-office-infection-control-guidelines-2012.pdf
  8. COVID-19 Vancouver Island Task Group. Prepping for COVID-19 in Primary Care [Internet]. Google Docs. Google; [cited 2020Apr13]. Available from: https://docs.google.com/document/d/1Q79NBvjEhsZVGiYH24Kh76fvgeKKekslJ9bVfYvWwuE/edit
  9. Signage & posters [Internet]. BC Centre for Disease Control. [cited 2020Apr13]. Available from: http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/signage-posters
  10. Doremalen NV, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020Mar17.
  11. Muller M, Amirov C, Armstrong I, et. al. Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 3rd Edition [Internet]. Public Health Ontario. PIDAC; 2018 [cited 2020Apr13]. Available from: https://www.publichealthontario.ca/-/media/documents/bp-environmental-cleaning.pdf
  12. Recommendations for Use of Personal Protective Equipment [Internet]. Ontario Family Physicians. Ontario Medical Association; [cited 2020Apr13]. Available from: https://www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/oma-summary-of-pho-ppe-recommendations_final.pdf

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.