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COVID-SAFE: Strategies for safeguarding your outpatient clinical practice against COVID-19
No question, the COVID-19 pandemic has been a challenging time for medical practices across the United States. Uncertainty remains regarding bringing patients and services back into our offices. One factor that distinguishes many ObGyn practices from other specialties is that our practices have remained open—in some form—since the beginning of the pandemic. In various parts of the country, gynecologic surgeries and routine office visits have been significantly reduced; however, deliveries and gynecologic emergencies have continued.
In this article, I suggest a framework of strategies and resources to provide insight for outpatient operations. Individual practices will vary across the nation depending on local conditions. Full practice capacity may take on a different look than it had prior to the pandemic, and there is opportunity to change the way we operate.
Strategy 1: Consult regulatory requirements frequently
As the local status of COVID-19 evolves quickly, it is essential to examine the frequently updated recommendations from regulatory agencies at the federal, state, and local levels. Clinical practices that function within health systems need to demonstrate alignment with hospital or university policies and procedures. The Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), Centers for Medicare and Medicaid Services (CMS), and individual state departments of health provide dynamic resources that are easily accessible online.1-3
The American College of Obstetricians and Gynecologists (ACOG) continues to be an excellent medical society resource.4 Subspecialty organizations that provide up-to-date guidance include the Society for Maternal-Fetal Medicine (SMFM), Society of Gynecologic Surgeons (SGS), AAGL (American Association of Gynecologic Laparoscopists), American Society for Reproductive Medicine (ASRM), and Society of Gynecologic Oncology (SGO).5-9 These resources are updated as more information about COVID-19 emerges, and they may be modified to different local-regional conditions.
The professional liability insurance carrier is an important source of insight for a number of circumstances, including modifications to your office practice, such as returning to full-scope or part-time practice; operating outside normal clinical service arrangements (for example, assisting with emergency care); offering telehealth services; and adding extra hours or employees to accommodate the patient backlog. Business insurance coverage is a separate issue to consider. Reviewing the practice policy may protect your business from COVID-related liabilities.
Consulting with legal counselors can be helpful. They can assist with navigating various practice and personnel COVID-related changes, as well as developing a viable plan for patients who were previously insured pre–COVID-19 who are currently uninsured.
Continue to: Strategy 2: Reimagine schedule capacity...
Strategy 2: Reimagine schedule capacity
The waxing and waning of the COVID-19 crisis presents an opportunity to evaluate our office practices and make necessary and positive changes. The question becomes, do we operate our practices as usual or do we rethink our strategy for seeing patients and integrate lessons learned from the pandemic? Patients are deciding when they are comfortable to schedule elective surgeries and routine office encounters. This gives us the chance to break from the tradition of 100% in-person visits and change the way we care for women.
The coronavirus has accelerated the rise of telehealth/telemedicine and is, perhaps, a silver lining of the pandemic. Telehealth is a valuable tool for accessing health services when in-person visits are not possible. Evaluating and triaging patients for in-person versus telehealth visits is now a viable option for clinical practice and reduces exposure to COVID-19 infection.
Telemedicine is convenient, and clinicians can use it to counsel and screen for various health issues as well as to extend their reach to rural communities. Appropriate consent should be documented in the patient chart. As some areas continue to be without adequate access to WiFi, telephone contact also is currently acceptable. Telehealth does not replace the in-person visit but can be viewed as a complementary and supplementary service.
Consider a balance between telehealth and in-person visits by evaluating which visits can continue remotely and which can alternate with in-person visits. This offers tremendous flexibility and will expand delivery of essential health care to patients.10 Integrating telemedicine into clinical practice provides an additional benefit: It minimizes the exposure and transmission of COVID-19 to health care workers and patients and preserves supplies, including personal protective equipment (PPE).
Prioritize the backlog of patients who require follow-up testing, procedures, and surgeries. Communicate with patients that it is safe to be seen and important to not avoid routine and preventative visits that might reveal concerns or conditions that require treatment.
Strategy 3: Institute infection prevention and control measures
The importance of instituting and ensuring safety measures for office personnel and patients cannot be underestimated. Recently, a study from King’s College in London found that frontline health care workers with PPE still have 3 to 4 times the risk of contracting coronavirus compared with the general public.11 Health care systems should ensure adequate PPE availability and develop additional strategies to protect health care workers from COVID-19. We have to be fanatical about cleanliness and PPE. We have to be diligent about how we space ourselves and our patients. Consider adjusting workflows to ensure that visits can be conducted as quickly and safely as possible.
Communicating updated safety plans and processes are invaluable for both patients and health care workers. Patients want to be reassured that safety precautions are in place to keep the environment safe and clean. Additionally, privacy and confidentiality concerns should be addressed.
Consider a modified office schedule that can reduce the number of people in the office, person-to-person contact, and COVID-19 transmission. Social distancing is improved and PPE and other supplies are preserved.
Continue to: Employees can work on alternating days...
- Employees can work on alternating days or during different parts of the day.
- Administrative staff who do not need to be physically present in the office might work remotely.
- Expanding office hours (early morning, evening, and weekends) spreads patient visits throughout the day and minimizes high-volume in-person visits.
Institute a daily COVID-19 symptom attestation and temperature check for employees on arrival at work.
Health care personnel with symptoms of COVID-19 should be prioritized for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) RNA testing with an approved nucleic acid or antigen detection assay. A negative result indicates that the person most likely did not have an active SARS-CoV-2 infection at the time the sample was collected. A second test for SARS-CoV-2 RNA may be performed at the discretion of the evaluating health care provider, particularly when a higher level of clinical suspicion for infection exists.
The return to work decision should be determined by an agreed on symptom-based approach to clearance. If needed on a case-by-case basis, a review can be performed with the individual’s health care provider.12
Require universal masking and appropriate protective equipment.
- All staff members, patients, and visitors must wear masks correctly in the facilities (except children under age 2).
- All clinical staff members must wear masks correctly and eye protection during every patient encounter.
Reconfigure the waiting room and patient flow.
- Configure waiting room furniture to reinforce 6 feet of physical distancing.
- Remove all books, magazines, and toys from all waiting areas.
- Laminate signage for display.
- Install plexiglass at the check-in desk to minimize virus transmission.
- If possible, ask patients to wait in their car until their appointment time or to go directly to their exam room on arrival if it is available.
- Implement virtual check-in and check-out so that patients reduce unnecessary contact with surfaces and staff.
- Limit a high volume of patients to maintain social distancing etiquette, avoid delays, and allow adequate cleaning time between patients.
- Permit visitors to accompany adult patients to their ambulatory appointments only if special assistance is required.
- Limit the number of staff members in the exam and treatment rooms and maintain at least 6 feet between people except during medical care activities.
- Consider patient flow in a one-way traffic pattern.
Focus on keeping the clinical practice clean. (Follow the instructions and disinfect with a registered disinfectant product that meets the US Environmental Protection Agency criteria for use against COVID-19.13)
- Clean waiting rooms and restrooms frequently.
- Coordinate patient appointments to allow for infection control measures.
- Frequently clean high-touch surfaces, including tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
- Clinicians and all medical staff members should wash their hands before and after interacting with patients.
- Clean and disinfect the exam and treatment rooms before and after each patient.
- Use products that are effective against a range of organisms and viruses, including the coronavirus that causes COVID-19.
- Place signs indicating that rooms have been cleaned; this will assure and comfort patients. Take credit for your infection control processes.
Keep abreast of isolation and precaution guidelines. Based on data available at the time of this article’s publication, the CDC recommends ending isolation and transmission-based precautions for most people with COVID-19 using a symptom-based strategy.14 This limits unnecessary prolonged isolation and use of laboratory testing resources.
Generally, repeat SARS-CoV-2 polymerase chain reaction (PCR) testing is not recommended for “COVID-19 recovered” patients. Specifically, those patients with a prior positive SARS-CoV-2 PCR test result and who have met criteria for isolation discontinuation do not need a follow-up PCR test. A test-based strategy to discontinue isolation and transmission-based precautions is required only for severely immunocompromised patients.15
Prepare for a future COVID-19 surge and review your emergency plan and responses and revise as needed. Review handling of the current pandemic and best practices plus areas of improvement.
Symptom-based criteria for discontinuing transmission-based precautions include the following:
Patients with mild to moderate illness, not severely immunocompromised:
- at least 10 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are not severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.
Patients with severe to critical illness, severely immunocompromised:
- at least 20 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.
Continue to: Strategy 4: Implement frequent employee communication and care...
Strategy 4: Implement frequent employee communication and care
The safety and well-being of our health care workers and patients in our clinical practices is paramount. Continuing to communicate this message and developing and sharing a plan may ameliorate the obvious toll on mental and emotional well-being. Frequent and effective communication with your clinical team is vital to reinforce policies and protocols, eliminate silos, and reduce errors.
Practice communication and care with these approaches:
- Offer regular employee COVID-19 testing.
- Re-educate staff about infection control protocols to ensure buy-in.
- Communicate with staff about the plan to address staffing shortages.
- Implement regular employee team huddles that can address accomplishments, challenges, areas for improvement, and top priorities.
- Perform regular celebrations for staff appreciation.
- Address mental health and chronic stress and offer empathy and coping resources and services to staff and clinicians. This will have a valuable, long-term benefit.
Patient communication. As the COVID-19 pandemic continues and stay-at-home policies are in place, patients should be encouraged to seek medical care if they are ill or have acute or chronic conditions. Communicate regularly with patients and let them know that their safety and well-being is the top priority. Prior to in-person visits, inform them of the safety processes that are in place to protect them.
Fostering an honest clinician-patient relationship enhances communication. Despite these efforts, some patients may not be forthcoming about their COVID-19 symptoms, illness, exposure, or travel. Health care staff can be encouraged to set a tone of tolerance and compassion and treat everyone with universal precautions.
Rising to the challenges
During the coronavirus pandemic, ObGyns continue to safely care for pregnant women and also triage and treat women who require timely office care as well as emergency and cancer-related surgeries.
The COVID-19 environment rapidly changes depending on the practice location. The strategies described represent a compilation of resources from key organizations that hopefully will prove useful and can be shaped to fit your practice. Local and regional recommendations vary, and no one can predict the course of the virus.
Consider reviewing your contingency plans regularly. As we have learned over the last several months, there is a science to maintaining a COVID-SAFE environment.
Practice operations likely will change to adapt to new conditions. The pandemic has challenged us to evolve, and we have responded with new capabilities and resilience while we continue to deliver superior and compassionate care for women.
For additional strategies on how to safeguard your practice against COVID-19, see the box below. ●
Continue to: Additional strategies on how to safeguard your practice against COVID-19...
Strategy 5: Develop a resource plan for practice operations
Assess financial solvency. Because of the mitigation measures taken during the pandemic, physician practices of all sizes are facing financial hardships and instability. As the pandemic progresses, physicians in private practice and those employed by health systems may benefit from existing resources and pandemic relief to help navigate COVID-related challenges.
Frequent revision of your financial plan may safeguard cash flow in the event of fewer patient visits and elective surgeries. Many medical organizations, including ACOG, are advocating for financial relief, fair reimbursement for telehealth and in-person visits, and access to adequate PPE. ACOG provides updated information on practice management.1
The American Medical Association (AMA) has created resources for physician practices to assist in staying focused on business and financial operations. The AMA has provided a summary of the Health, Economic Assistance, Liability Protection and Schools Act (HEALS Act).2 This is the next proposed coronavirus relief fund package, which includes provisions that benefit physicians and physician practices.
Create a plan. Review available resources and establish processes to optimize your practice capacity during the ongoing COVID-19 pandemic. Develop a game plan for patient care with a phased approach to identify and address challenges. This planning will allow your practice to pivot in response to changing local COVID-19 conditions to help you anticipate and prepare for a future surge. Maintain and revise plans as the pandemic shifts. Thinking ahead avoids the need to navigate issues in real time. Communicating clearly and often with all members of the office staff and patients lets everyone know that their safety is the main priority.
Assess staffing for flexible coverage. Frequent needs assessment helps to determine the number of staff needed to maintain a safe work environment for the patient volume.
Staff shortages may occur because of COVID-19 exposure, personal or family member illness, or childcare constraints due to daycare or school availability. Staff readiness includes evaluating individual availability and willingness.
Staff members with health issues, including comorbidities and chronic medical conditions, may not be comfortable working. Nonclinical staff members with health concerns could work remotely, although some may not be able to work from home due to technology-related issues such as WiFi deficiencies.
The CDC has interim guidelines to assist employers with providing a safe workplace and employees with making the best health decisions for themselves and their families.3,4 The US Office of Personnel Management provides guidance for COVID-19–related leave and benefits for federal employees.5
To mitigate staff shortages, approaches include adjusting schedules, cross-training to perform the tasks of other positions, and hiring additional personnel. A needs assessment can help determine if existing personnel could be cross-trained for other purposes or if additional staff should be hired. Understanding the minimum number of staff required for safe and effective patient care will assist in planning for shortages as the pandemic progresses. Understanding the availability of external resources could be a critical part of an office contingency plan.6
Proactively manage your supply chain. The pandemic has caused global supply shortages. Solid supply chain management is crucial for practice operations. Take inventory of your PPE and various supplies and place orders in advance. Analyze cash flow and connect with vendors as well as local and state health agencies to understand available resources. Given ongoing PPE shortages, practices should consider preserving PPE and employ appropriate strategies for optimizing supplies of face masks.7
Certain medications and vaccines administered in the office setting may be outdated and need to be replaced. Office equipment that has not been used for several months will need to be tested. For equipment used in office electrosurgery procedures, certain safety measures can be taken to reduce the transmission of aerosolized viral particles to the health care team. While currently the risk is theoretical and more research is needed, this potential risk should be mitigated.8 Assessing availability of hospital and ambulance or transport services also is recommended as these may change depending on the local COVID-19 status.
Strategy 6: Establish and refine the patient screening process
Patients want reassurance that the health care environment is safe and that their well-being is a priority. In advance of a patient’s visit, relieve any anxiety by explaining the COVID-SAFE measures that your practice has taken.
For employee use, consider telephone and in-person scripting to ensure consistent messaging for patients.
Prescreening. At the time of appointment scheduling and on the day prior to the scheduled appointment, all patients should be screened for symptoms of COVID-19,9 fever, exposure within 14 days to someone newly diagnosed with COVID-19, and travel within 14 days from a foreign country or from a US state with a quarantine requirement.
Patients who screen positive for symptoms, exposure, or travel should be referred to a clinician. If possible, asymptomatic patients who report exposure or travel should have their in-person visit deferred until after the required 14-day quarantine.
Consider restricting visitors from accompanying adult patients to their appointment unless they are required for special assistance.
Arrival screening. At the time of presentation for the appointment, all patients and any accompanying visitors should be rescreened. The optimal location for arrival screening should be determined by the local operations team and the infection prevention and control program.
At presentation, all patients and visitors should appropriately don a surgical mask or other face covering. Patients and visitors should have their temperature checked on arrival. Patients who screen positive for symptoms, exposure to COVID-19, and/or travel should be referred to a clinician or the visit deferred and a telehealth visit considered.
Visitors who screen positive for symptoms, fever, or exposure to COVID-19 are not permitted to accompany the patient. Asymptomatic parents or guardians of pediatric patients may serve as support persons.
References
- American College of Obstetricians and Gynecologists. Financial support for physicians and practices during the COVID-19 pandemic. https://www.acog.org/practice -management/coding/coding-library/financial-support-for-physicians-and-practices-during-the-covid-19-pandemic. Accessed July 23, 2020.
- American Medical Association. HEALS Act: What physicians and medical students need to know. https://www.ama-assn.org/delivering-care/public-health/heals-act -what-physicians-and-medical-students-need-know. Accessed July 29, 2020.
- Centers for Disease Control and Prevention. Interim guidance for businesses and employers responding to coronavirus disease 2019 (COVID-19). https://www.cdc.gov /coronavirus/2019-ncov/community/guidance-business-response.html. Accessed July 12, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov /coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Office of Personnel Management. Questions and answers on human resources flexibilities and authorities for coronavirus disease 2019 (COVID-19). https://www .opm.gov/policy-data-oversight/covid-19/questions-and-answers-on-human-resources-flexibilities-and-authorities-for-coronavirus-disease-2019-covid-19.pdf. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages. https://www.cdc.gov/coronavirus/2019-ncov/hcp /mitigating-staff-shortages.html. Accessed July 17, 2020.
- Centers for Disease Control and Prevention. Strategies for optimizing the supply of facemasks. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face -masks.html. Accessed July 3, 2020.
- Rahman S, Klebanoff J, Moawad G. Smoke evacuation in the age of COVID-19. Contemporary OB/GYN. July 2, 2020. https://www.contemporaryobgyn.net/view/smoke -evacuation-in-the-age-of-covid-19. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Symptoms of coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed July 25, 2020.
- Centers for Disease Control and Prevention. Information for healthcare professionals about coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html. Accessed July 22, 2020.
- US Department of Labor Occupational Safety and Health Administration. COVID-19 control and prevention: healthcare workers and employers. https://www.osha.gov/SLTC/covid-19/healthcare-workers.html. Accessed August 5, 2020.
- Centers for Medicare and Medicaid Services. COVID-19 resources for health care professionals and researchers. https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers. Accessed August 7, 2020.
- American College of Obstetricians and Gynecologists. COVID-19. https://www.acog.org/topics/covid-19. Accessed August 7, 2020.
- Society for Maternal-Fetal Medicine. Coronavirus (COVID-19). https://www.smfm.org/covid19. Accessed August 7, 2020.
- Society of Gynecologic Surgeons. Joint statement on re-introduction of hospital and office-based procedures in the COVID-19 climate for the practicing gynecologist. https://www.sgsonline.org/joint-statement-on-re-introduction-of-hospital-and-office-based-procedures-in-the-covid-19-climate. Accessed August 7, 2020.
- AAGL. COVID-19 articles, resources and webinars. https://www.aagl.org/covid-19/. Accessed August 7, 2020.
- American Society for Reproductive Medicine. COVID-19 updates and resources. https://www.asrm.org/news-and-publications/covid-19/. Accessed August 7, 2020.
- Society of Gynecologic Oncology. COVID-19 resources for health care practitioners. https://www.sgo.org/practice-management/covid-19/. Accessed August 7, 2020.
- Centers for Disease Control and Prevention. Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. Accessed July 3, 2020.
- Nguyen LH, Drew DA, Graham MS, et al; on behalf of the COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet. July 31, 2020. http://www.thelancet-press.com/embargo/hcwcovid.pdf. Accessed August 25, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Environmental Protection Agency. List N: Disinfectants for use against SARS-CoV-2 (COVID-19). https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19. Accessed August 24, 2020.
- Centers for Disease Control and Prevention. Duration of isolation and precautions for adults with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. Accessed July 23, 2020.
- Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html#fn1. Accessed July 23, 2020.
Dr. Rosser is Assistant Professor and Director, Integrated Women’s Health, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center/ New York Presbyterian, New York, New York.
The author reports no financial relationships relevant to this article.
Dr. Rosser is Assistant Professor and Director, Integrated Women’s Health, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center/ New York Presbyterian, New York, New York.
The author reports no financial relationships relevant to this article.
Dr. Rosser is Assistant Professor and Director, Integrated Women’s Health, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center/ New York Presbyterian, New York, New York.
The author reports no financial relationships relevant to this article.
No question, the COVID-19 pandemic has been a challenging time for medical practices across the United States. Uncertainty remains regarding bringing patients and services back into our offices. One factor that distinguishes many ObGyn practices from other specialties is that our practices have remained open—in some form—since the beginning of the pandemic. In various parts of the country, gynecologic surgeries and routine office visits have been significantly reduced; however, deliveries and gynecologic emergencies have continued.
In this article, I suggest a framework of strategies and resources to provide insight for outpatient operations. Individual practices will vary across the nation depending on local conditions. Full practice capacity may take on a different look than it had prior to the pandemic, and there is opportunity to change the way we operate.
Strategy 1: Consult regulatory requirements frequently
As the local status of COVID-19 evolves quickly, it is essential to examine the frequently updated recommendations from regulatory agencies at the federal, state, and local levels. Clinical practices that function within health systems need to demonstrate alignment with hospital or university policies and procedures. The Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), Centers for Medicare and Medicaid Services (CMS), and individual state departments of health provide dynamic resources that are easily accessible online.1-3
The American College of Obstetricians and Gynecologists (ACOG) continues to be an excellent medical society resource.4 Subspecialty organizations that provide up-to-date guidance include the Society for Maternal-Fetal Medicine (SMFM), Society of Gynecologic Surgeons (SGS), AAGL (American Association of Gynecologic Laparoscopists), American Society for Reproductive Medicine (ASRM), and Society of Gynecologic Oncology (SGO).5-9 These resources are updated as more information about COVID-19 emerges, and they may be modified to different local-regional conditions.
The professional liability insurance carrier is an important source of insight for a number of circumstances, including modifications to your office practice, such as returning to full-scope or part-time practice; operating outside normal clinical service arrangements (for example, assisting with emergency care); offering telehealth services; and adding extra hours or employees to accommodate the patient backlog. Business insurance coverage is a separate issue to consider. Reviewing the practice policy may protect your business from COVID-related liabilities.
Consulting with legal counselors can be helpful. They can assist with navigating various practice and personnel COVID-related changes, as well as developing a viable plan for patients who were previously insured pre–COVID-19 who are currently uninsured.
Continue to: Strategy 2: Reimagine schedule capacity...
Strategy 2: Reimagine schedule capacity
The waxing and waning of the COVID-19 crisis presents an opportunity to evaluate our office practices and make necessary and positive changes. The question becomes, do we operate our practices as usual or do we rethink our strategy for seeing patients and integrate lessons learned from the pandemic? Patients are deciding when they are comfortable to schedule elective surgeries and routine office encounters. This gives us the chance to break from the tradition of 100% in-person visits and change the way we care for women.
The coronavirus has accelerated the rise of telehealth/telemedicine and is, perhaps, a silver lining of the pandemic. Telehealth is a valuable tool for accessing health services when in-person visits are not possible. Evaluating and triaging patients for in-person versus telehealth visits is now a viable option for clinical practice and reduces exposure to COVID-19 infection.
Telemedicine is convenient, and clinicians can use it to counsel and screen for various health issues as well as to extend their reach to rural communities. Appropriate consent should be documented in the patient chart. As some areas continue to be without adequate access to WiFi, telephone contact also is currently acceptable. Telehealth does not replace the in-person visit but can be viewed as a complementary and supplementary service.
Consider a balance between telehealth and in-person visits by evaluating which visits can continue remotely and which can alternate with in-person visits. This offers tremendous flexibility and will expand delivery of essential health care to patients.10 Integrating telemedicine into clinical practice provides an additional benefit: It minimizes the exposure and transmission of COVID-19 to health care workers and patients and preserves supplies, including personal protective equipment (PPE).
Prioritize the backlog of patients who require follow-up testing, procedures, and surgeries. Communicate with patients that it is safe to be seen and important to not avoid routine and preventative visits that might reveal concerns or conditions that require treatment.
Strategy 3: Institute infection prevention and control measures
The importance of instituting and ensuring safety measures for office personnel and patients cannot be underestimated. Recently, a study from King’s College in London found that frontline health care workers with PPE still have 3 to 4 times the risk of contracting coronavirus compared with the general public.11 Health care systems should ensure adequate PPE availability and develop additional strategies to protect health care workers from COVID-19. We have to be fanatical about cleanliness and PPE. We have to be diligent about how we space ourselves and our patients. Consider adjusting workflows to ensure that visits can be conducted as quickly and safely as possible.
Communicating updated safety plans and processes are invaluable for both patients and health care workers. Patients want to be reassured that safety precautions are in place to keep the environment safe and clean. Additionally, privacy and confidentiality concerns should be addressed.
Consider a modified office schedule that can reduce the number of people in the office, person-to-person contact, and COVID-19 transmission. Social distancing is improved and PPE and other supplies are preserved.
Continue to: Employees can work on alternating days...
- Employees can work on alternating days or during different parts of the day.
- Administrative staff who do not need to be physically present in the office might work remotely.
- Expanding office hours (early morning, evening, and weekends) spreads patient visits throughout the day and minimizes high-volume in-person visits.
Institute a daily COVID-19 symptom attestation and temperature check for employees on arrival at work.
Health care personnel with symptoms of COVID-19 should be prioritized for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) RNA testing with an approved nucleic acid or antigen detection assay. A negative result indicates that the person most likely did not have an active SARS-CoV-2 infection at the time the sample was collected. A second test for SARS-CoV-2 RNA may be performed at the discretion of the evaluating health care provider, particularly when a higher level of clinical suspicion for infection exists.
The return to work decision should be determined by an agreed on symptom-based approach to clearance. If needed on a case-by-case basis, a review can be performed with the individual’s health care provider.12
Require universal masking and appropriate protective equipment.
- All staff members, patients, and visitors must wear masks correctly in the facilities (except children under age 2).
- All clinical staff members must wear masks correctly and eye protection during every patient encounter.
Reconfigure the waiting room and patient flow.
- Configure waiting room furniture to reinforce 6 feet of physical distancing.
- Remove all books, magazines, and toys from all waiting areas.
- Laminate signage for display.
- Install plexiglass at the check-in desk to minimize virus transmission.
- If possible, ask patients to wait in their car until their appointment time or to go directly to their exam room on arrival if it is available.
- Implement virtual check-in and check-out so that patients reduce unnecessary contact with surfaces and staff.
- Limit a high volume of patients to maintain social distancing etiquette, avoid delays, and allow adequate cleaning time between patients.
- Permit visitors to accompany adult patients to their ambulatory appointments only if special assistance is required.
- Limit the number of staff members in the exam and treatment rooms and maintain at least 6 feet between people except during medical care activities.
- Consider patient flow in a one-way traffic pattern.
Focus on keeping the clinical practice clean. (Follow the instructions and disinfect with a registered disinfectant product that meets the US Environmental Protection Agency criteria for use against COVID-19.13)
- Clean waiting rooms and restrooms frequently.
- Coordinate patient appointments to allow for infection control measures.
- Frequently clean high-touch surfaces, including tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
- Clinicians and all medical staff members should wash their hands before and after interacting with patients.
- Clean and disinfect the exam and treatment rooms before and after each patient.
- Use products that are effective against a range of organisms and viruses, including the coronavirus that causes COVID-19.
- Place signs indicating that rooms have been cleaned; this will assure and comfort patients. Take credit for your infection control processes.
Keep abreast of isolation and precaution guidelines. Based on data available at the time of this article’s publication, the CDC recommends ending isolation and transmission-based precautions for most people with COVID-19 using a symptom-based strategy.14 This limits unnecessary prolonged isolation and use of laboratory testing resources.
Generally, repeat SARS-CoV-2 polymerase chain reaction (PCR) testing is not recommended for “COVID-19 recovered” patients. Specifically, those patients with a prior positive SARS-CoV-2 PCR test result and who have met criteria for isolation discontinuation do not need a follow-up PCR test. A test-based strategy to discontinue isolation and transmission-based precautions is required only for severely immunocompromised patients.15
Prepare for a future COVID-19 surge and review your emergency plan and responses and revise as needed. Review handling of the current pandemic and best practices plus areas of improvement.
Symptom-based criteria for discontinuing transmission-based precautions include the following:
Patients with mild to moderate illness, not severely immunocompromised:
- at least 10 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are not severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.
Patients with severe to critical illness, severely immunocompromised:
- at least 20 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.
Continue to: Strategy 4: Implement frequent employee communication and care...
Strategy 4: Implement frequent employee communication and care
The safety and well-being of our health care workers and patients in our clinical practices is paramount. Continuing to communicate this message and developing and sharing a plan may ameliorate the obvious toll on mental and emotional well-being. Frequent and effective communication with your clinical team is vital to reinforce policies and protocols, eliminate silos, and reduce errors.
Practice communication and care with these approaches:
- Offer regular employee COVID-19 testing.
- Re-educate staff about infection control protocols to ensure buy-in.
- Communicate with staff about the plan to address staffing shortages.
- Implement regular employee team huddles that can address accomplishments, challenges, areas for improvement, and top priorities.
- Perform regular celebrations for staff appreciation.
- Address mental health and chronic stress and offer empathy and coping resources and services to staff and clinicians. This will have a valuable, long-term benefit.
Patient communication. As the COVID-19 pandemic continues and stay-at-home policies are in place, patients should be encouraged to seek medical care if they are ill or have acute or chronic conditions. Communicate regularly with patients and let them know that their safety and well-being is the top priority. Prior to in-person visits, inform them of the safety processes that are in place to protect them.
Fostering an honest clinician-patient relationship enhances communication. Despite these efforts, some patients may not be forthcoming about their COVID-19 symptoms, illness, exposure, or travel. Health care staff can be encouraged to set a tone of tolerance and compassion and treat everyone with universal precautions.
Rising to the challenges
During the coronavirus pandemic, ObGyns continue to safely care for pregnant women and also triage and treat women who require timely office care as well as emergency and cancer-related surgeries.
The COVID-19 environment rapidly changes depending on the practice location. The strategies described represent a compilation of resources from key organizations that hopefully will prove useful and can be shaped to fit your practice. Local and regional recommendations vary, and no one can predict the course of the virus.
Consider reviewing your contingency plans regularly. As we have learned over the last several months, there is a science to maintaining a COVID-SAFE environment.
Practice operations likely will change to adapt to new conditions. The pandemic has challenged us to evolve, and we have responded with new capabilities and resilience while we continue to deliver superior and compassionate care for women.
For additional strategies on how to safeguard your practice against COVID-19, see the box below. ●
Continue to: Additional strategies on how to safeguard your practice against COVID-19...
Strategy 5: Develop a resource plan for practice operations
Assess financial solvency. Because of the mitigation measures taken during the pandemic, physician practices of all sizes are facing financial hardships and instability. As the pandemic progresses, physicians in private practice and those employed by health systems may benefit from existing resources and pandemic relief to help navigate COVID-related challenges.
Frequent revision of your financial plan may safeguard cash flow in the event of fewer patient visits and elective surgeries. Many medical organizations, including ACOG, are advocating for financial relief, fair reimbursement for telehealth and in-person visits, and access to adequate PPE. ACOG provides updated information on practice management.1
The American Medical Association (AMA) has created resources for physician practices to assist in staying focused on business and financial operations. The AMA has provided a summary of the Health, Economic Assistance, Liability Protection and Schools Act (HEALS Act).2 This is the next proposed coronavirus relief fund package, which includes provisions that benefit physicians and physician practices.
Create a plan. Review available resources and establish processes to optimize your practice capacity during the ongoing COVID-19 pandemic. Develop a game plan for patient care with a phased approach to identify and address challenges. This planning will allow your practice to pivot in response to changing local COVID-19 conditions to help you anticipate and prepare for a future surge. Maintain and revise plans as the pandemic shifts. Thinking ahead avoids the need to navigate issues in real time. Communicating clearly and often with all members of the office staff and patients lets everyone know that their safety is the main priority.
Assess staffing for flexible coverage. Frequent needs assessment helps to determine the number of staff needed to maintain a safe work environment for the patient volume.
Staff shortages may occur because of COVID-19 exposure, personal or family member illness, or childcare constraints due to daycare or school availability. Staff readiness includes evaluating individual availability and willingness.
Staff members with health issues, including comorbidities and chronic medical conditions, may not be comfortable working. Nonclinical staff members with health concerns could work remotely, although some may not be able to work from home due to technology-related issues such as WiFi deficiencies.
The CDC has interim guidelines to assist employers with providing a safe workplace and employees with making the best health decisions for themselves and their families.3,4 The US Office of Personnel Management provides guidance for COVID-19–related leave and benefits for federal employees.5
To mitigate staff shortages, approaches include adjusting schedules, cross-training to perform the tasks of other positions, and hiring additional personnel. A needs assessment can help determine if existing personnel could be cross-trained for other purposes or if additional staff should be hired. Understanding the minimum number of staff required for safe and effective patient care will assist in planning for shortages as the pandemic progresses. Understanding the availability of external resources could be a critical part of an office contingency plan.6
Proactively manage your supply chain. The pandemic has caused global supply shortages. Solid supply chain management is crucial for practice operations. Take inventory of your PPE and various supplies and place orders in advance. Analyze cash flow and connect with vendors as well as local and state health agencies to understand available resources. Given ongoing PPE shortages, practices should consider preserving PPE and employ appropriate strategies for optimizing supplies of face masks.7
Certain medications and vaccines administered in the office setting may be outdated and need to be replaced. Office equipment that has not been used for several months will need to be tested. For equipment used in office electrosurgery procedures, certain safety measures can be taken to reduce the transmission of aerosolized viral particles to the health care team. While currently the risk is theoretical and more research is needed, this potential risk should be mitigated.8 Assessing availability of hospital and ambulance or transport services also is recommended as these may change depending on the local COVID-19 status.
Strategy 6: Establish and refine the patient screening process
Patients want reassurance that the health care environment is safe and that their well-being is a priority. In advance of a patient’s visit, relieve any anxiety by explaining the COVID-SAFE measures that your practice has taken.
For employee use, consider telephone and in-person scripting to ensure consistent messaging for patients.
Prescreening. At the time of appointment scheduling and on the day prior to the scheduled appointment, all patients should be screened for symptoms of COVID-19,9 fever, exposure within 14 days to someone newly diagnosed with COVID-19, and travel within 14 days from a foreign country or from a US state with a quarantine requirement.
Patients who screen positive for symptoms, exposure, or travel should be referred to a clinician. If possible, asymptomatic patients who report exposure or travel should have their in-person visit deferred until after the required 14-day quarantine.
Consider restricting visitors from accompanying adult patients to their appointment unless they are required for special assistance.
Arrival screening. At the time of presentation for the appointment, all patients and any accompanying visitors should be rescreened. The optimal location for arrival screening should be determined by the local operations team and the infection prevention and control program.
At presentation, all patients and visitors should appropriately don a surgical mask or other face covering. Patients and visitors should have their temperature checked on arrival. Patients who screen positive for symptoms, exposure to COVID-19, and/or travel should be referred to a clinician or the visit deferred and a telehealth visit considered.
Visitors who screen positive for symptoms, fever, or exposure to COVID-19 are not permitted to accompany the patient. Asymptomatic parents or guardians of pediatric patients may serve as support persons.
References
- American College of Obstetricians and Gynecologists. Financial support for physicians and practices during the COVID-19 pandemic. https://www.acog.org/practice -management/coding/coding-library/financial-support-for-physicians-and-practices-during-the-covid-19-pandemic. Accessed July 23, 2020.
- American Medical Association. HEALS Act: What physicians and medical students need to know. https://www.ama-assn.org/delivering-care/public-health/heals-act -what-physicians-and-medical-students-need-know. Accessed July 29, 2020.
- Centers for Disease Control and Prevention. Interim guidance for businesses and employers responding to coronavirus disease 2019 (COVID-19). https://www.cdc.gov /coronavirus/2019-ncov/community/guidance-business-response.html. Accessed July 12, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov /coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Office of Personnel Management. Questions and answers on human resources flexibilities and authorities for coronavirus disease 2019 (COVID-19). https://www .opm.gov/policy-data-oversight/covid-19/questions-and-answers-on-human-resources-flexibilities-and-authorities-for-coronavirus-disease-2019-covid-19.pdf. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages. https://www.cdc.gov/coronavirus/2019-ncov/hcp /mitigating-staff-shortages.html. Accessed July 17, 2020.
- Centers for Disease Control and Prevention. Strategies for optimizing the supply of facemasks. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face -masks.html. Accessed July 3, 2020.
- Rahman S, Klebanoff J, Moawad G. Smoke evacuation in the age of COVID-19. Contemporary OB/GYN. July 2, 2020. https://www.contemporaryobgyn.net/view/smoke -evacuation-in-the-age-of-covid-19. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Symptoms of coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed July 25, 2020.
No question, the COVID-19 pandemic has been a challenging time for medical practices across the United States. Uncertainty remains regarding bringing patients and services back into our offices. One factor that distinguishes many ObGyn practices from other specialties is that our practices have remained open—in some form—since the beginning of the pandemic. In various parts of the country, gynecologic surgeries and routine office visits have been significantly reduced; however, deliveries and gynecologic emergencies have continued.
In this article, I suggest a framework of strategies and resources to provide insight for outpatient operations. Individual practices will vary across the nation depending on local conditions. Full practice capacity may take on a different look than it had prior to the pandemic, and there is opportunity to change the way we operate.
Strategy 1: Consult regulatory requirements frequently
As the local status of COVID-19 evolves quickly, it is essential to examine the frequently updated recommendations from regulatory agencies at the federal, state, and local levels. Clinical practices that function within health systems need to demonstrate alignment with hospital or university policies and procedures. The Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), Centers for Medicare and Medicaid Services (CMS), and individual state departments of health provide dynamic resources that are easily accessible online.1-3
The American College of Obstetricians and Gynecologists (ACOG) continues to be an excellent medical society resource.4 Subspecialty organizations that provide up-to-date guidance include the Society for Maternal-Fetal Medicine (SMFM), Society of Gynecologic Surgeons (SGS), AAGL (American Association of Gynecologic Laparoscopists), American Society for Reproductive Medicine (ASRM), and Society of Gynecologic Oncology (SGO).5-9 These resources are updated as more information about COVID-19 emerges, and they may be modified to different local-regional conditions.
The professional liability insurance carrier is an important source of insight for a number of circumstances, including modifications to your office practice, such as returning to full-scope or part-time practice; operating outside normal clinical service arrangements (for example, assisting with emergency care); offering telehealth services; and adding extra hours or employees to accommodate the patient backlog. Business insurance coverage is a separate issue to consider. Reviewing the practice policy may protect your business from COVID-related liabilities.
Consulting with legal counselors can be helpful. They can assist with navigating various practice and personnel COVID-related changes, as well as developing a viable plan for patients who were previously insured pre–COVID-19 who are currently uninsured.
Continue to: Strategy 2: Reimagine schedule capacity...
Strategy 2: Reimagine schedule capacity
The waxing and waning of the COVID-19 crisis presents an opportunity to evaluate our office practices and make necessary and positive changes. The question becomes, do we operate our practices as usual or do we rethink our strategy for seeing patients and integrate lessons learned from the pandemic? Patients are deciding when they are comfortable to schedule elective surgeries and routine office encounters. This gives us the chance to break from the tradition of 100% in-person visits and change the way we care for women.
The coronavirus has accelerated the rise of telehealth/telemedicine and is, perhaps, a silver lining of the pandemic. Telehealth is a valuable tool for accessing health services when in-person visits are not possible. Evaluating and triaging patients for in-person versus telehealth visits is now a viable option for clinical practice and reduces exposure to COVID-19 infection.
Telemedicine is convenient, and clinicians can use it to counsel and screen for various health issues as well as to extend their reach to rural communities. Appropriate consent should be documented in the patient chart. As some areas continue to be without adequate access to WiFi, telephone contact also is currently acceptable. Telehealth does not replace the in-person visit but can be viewed as a complementary and supplementary service.
Consider a balance between telehealth and in-person visits by evaluating which visits can continue remotely and which can alternate with in-person visits. This offers tremendous flexibility and will expand delivery of essential health care to patients.10 Integrating telemedicine into clinical practice provides an additional benefit: It minimizes the exposure and transmission of COVID-19 to health care workers and patients and preserves supplies, including personal protective equipment (PPE).
Prioritize the backlog of patients who require follow-up testing, procedures, and surgeries. Communicate with patients that it is safe to be seen and important to not avoid routine and preventative visits that might reveal concerns or conditions that require treatment.
Strategy 3: Institute infection prevention and control measures
The importance of instituting and ensuring safety measures for office personnel and patients cannot be underestimated. Recently, a study from King’s College in London found that frontline health care workers with PPE still have 3 to 4 times the risk of contracting coronavirus compared with the general public.11 Health care systems should ensure adequate PPE availability and develop additional strategies to protect health care workers from COVID-19. We have to be fanatical about cleanliness and PPE. We have to be diligent about how we space ourselves and our patients. Consider adjusting workflows to ensure that visits can be conducted as quickly and safely as possible.
Communicating updated safety plans and processes are invaluable for both patients and health care workers. Patients want to be reassured that safety precautions are in place to keep the environment safe and clean. Additionally, privacy and confidentiality concerns should be addressed.
Consider a modified office schedule that can reduce the number of people in the office, person-to-person contact, and COVID-19 transmission. Social distancing is improved and PPE and other supplies are preserved.
Continue to: Employees can work on alternating days...
- Employees can work on alternating days or during different parts of the day.
- Administrative staff who do not need to be physically present in the office might work remotely.
- Expanding office hours (early morning, evening, and weekends) spreads patient visits throughout the day and minimizes high-volume in-person visits.
Institute a daily COVID-19 symptom attestation and temperature check for employees on arrival at work.
Health care personnel with symptoms of COVID-19 should be prioritized for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) RNA testing with an approved nucleic acid or antigen detection assay. A negative result indicates that the person most likely did not have an active SARS-CoV-2 infection at the time the sample was collected. A second test for SARS-CoV-2 RNA may be performed at the discretion of the evaluating health care provider, particularly when a higher level of clinical suspicion for infection exists.
The return to work decision should be determined by an agreed on symptom-based approach to clearance. If needed on a case-by-case basis, a review can be performed with the individual’s health care provider.12
Require universal masking and appropriate protective equipment.
- All staff members, patients, and visitors must wear masks correctly in the facilities (except children under age 2).
- All clinical staff members must wear masks correctly and eye protection during every patient encounter.
Reconfigure the waiting room and patient flow.
- Configure waiting room furniture to reinforce 6 feet of physical distancing.
- Remove all books, magazines, and toys from all waiting areas.
- Laminate signage for display.
- Install plexiglass at the check-in desk to minimize virus transmission.
- If possible, ask patients to wait in their car until their appointment time or to go directly to their exam room on arrival if it is available.
- Implement virtual check-in and check-out so that patients reduce unnecessary contact with surfaces and staff.
- Limit a high volume of patients to maintain social distancing etiquette, avoid delays, and allow adequate cleaning time between patients.
- Permit visitors to accompany adult patients to their ambulatory appointments only if special assistance is required.
- Limit the number of staff members in the exam and treatment rooms and maintain at least 6 feet between people except during medical care activities.
- Consider patient flow in a one-way traffic pattern.
Focus on keeping the clinical practice clean. (Follow the instructions and disinfect with a registered disinfectant product that meets the US Environmental Protection Agency criteria for use against COVID-19.13)
- Clean waiting rooms and restrooms frequently.
- Coordinate patient appointments to allow for infection control measures.
- Frequently clean high-touch surfaces, including tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
- Clinicians and all medical staff members should wash their hands before and after interacting with patients.
- Clean and disinfect the exam and treatment rooms before and after each patient.
- Use products that are effective against a range of organisms and viruses, including the coronavirus that causes COVID-19.
- Place signs indicating that rooms have been cleaned; this will assure and comfort patients. Take credit for your infection control processes.
Keep abreast of isolation and precaution guidelines. Based on data available at the time of this article’s publication, the CDC recommends ending isolation and transmission-based precautions for most people with COVID-19 using a symptom-based strategy.14 This limits unnecessary prolonged isolation and use of laboratory testing resources.
Generally, repeat SARS-CoV-2 polymerase chain reaction (PCR) testing is not recommended for “COVID-19 recovered” patients. Specifically, those patients with a prior positive SARS-CoV-2 PCR test result and who have met criteria for isolation discontinuation do not need a follow-up PCR test. A test-based strategy to discontinue isolation and transmission-based precautions is required only for severely immunocompromised patients.15
Prepare for a future COVID-19 surge and review your emergency plan and responses and revise as needed. Review handling of the current pandemic and best practices plus areas of improvement.
Symptom-based criteria for discontinuing transmission-based precautions include the following:
Patients with mild to moderate illness, not severely immunocompromised:
- at least 10 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are not severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.
Patients with severe to critical illness, severely immunocompromised:
- at least 20 days have passed since symptoms first appeared and
- at least 24 hours have passed since last fever without fever-reducing medications and
- symptoms (cough, shortness of breath) have improved.
Note: For patients who are severely immunocompromised and are asymptomatic throughout their infection, transmission-based precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.
Continue to: Strategy 4: Implement frequent employee communication and care...
Strategy 4: Implement frequent employee communication and care
The safety and well-being of our health care workers and patients in our clinical practices is paramount. Continuing to communicate this message and developing and sharing a plan may ameliorate the obvious toll on mental and emotional well-being. Frequent and effective communication with your clinical team is vital to reinforce policies and protocols, eliminate silos, and reduce errors.
Practice communication and care with these approaches:
- Offer regular employee COVID-19 testing.
- Re-educate staff about infection control protocols to ensure buy-in.
- Communicate with staff about the plan to address staffing shortages.
- Implement regular employee team huddles that can address accomplishments, challenges, areas for improvement, and top priorities.
- Perform regular celebrations for staff appreciation.
- Address mental health and chronic stress and offer empathy and coping resources and services to staff and clinicians. This will have a valuable, long-term benefit.
Patient communication. As the COVID-19 pandemic continues and stay-at-home policies are in place, patients should be encouraged to seek medical care if they are ill or have acute or chronic conditions. Communicate regularly with patients and let them know that their safety and well-being is the top priority. Prior to in-person visits, inform them of the safety processes that are in place to protect them.
Fostering an honest clinician-patient relationship enhances communication. Despite these efforts, some patients may not be forthcoming about their COVID-19 symptoms, illness, exposure, or travel. Health care staff can be encouraged to set a tone of tolerance and compassion and treat everyone with universal precautions.
Rising to the challenges
During the coronavirus pandemic, ObGyns continue to safely care for pregnant women and also triage and treat women who require timely office care as well as emergency and cancer-related surgeries.
The COVID-19 environment rapidly changes depending on the practice location. The strategies described represent a compilation of resources from key organizations that hopefully will prove useful and can be shaped to fit your practice. Local and regional recommendations vary, and no one can predict the course of the virus.
Consider reviewing your contingency plans regularly. As we have learned over the last several months, there is a science to maintaining a COVID-SAFE environment.
Practice operations likely will change to adapt to new conditions. The pandemic has challenged us to evolve, and we have responded with new capabilities and resilience while we continue to deliver superior and compassionate care for women.
For additional strategies on how to safeguard your practice against COVID-19, see the box below. ●
Continue to: Additional strategies on how to safeguard your practice against COVID-19...
Strategy 5: Develop a resource plan for practice operations
Assess financial solvency. Because of the mitigation measures taken during the pandemic, physician practices of all sizes are facing financial hardships and instability. As the pandemic progresses, physicians in private practice and those employed by health systems may benefit from existing resources and pandemic relief to help navigate COVID-related challenges.
Frequent revision of your financial plan may safeguard cash flow in the event of fewer patient visits and elective surgeries. Many medical organizations, including ACOG, are advocating for financial relief, fair reimbursement for telehealth and in-person visits, and access to adequate PPE. ACOG provides updated information on practice management.1
The American Medical Association (AMA) has created resources for physician practices to assist in staying focused on business and financial operations. The AMA has provided a summary of the Health, Economic Assistance, Liability Protection and Schools Act (HEALS Act).2 This is the next proposed coronavirus relief fund package, which includes provisions that benefit physicians and physician practices.
Create a plan. Review available resources and establish processes to optimize your practice capacity during the ongoing COVID-19 pandemic. Develop a game plan for patient care with a phased approach to identify and address challenges. This planning will allow your practice to pivot in response to changing local COVID-19 conditions to help you anticipate and prepare for a future surge. Maintain and revise plans as the pandemic shifts. Thinking ahead avoids the need to navigate issues in real time. Communicating clearly and often with all members of the office staff and patients lets everyone know that their safety is the main priority.
Assess staffing for flexible coverage. Frequent needs assessment helps to determine the number of staff needed to maintain a safe work environment for the patient volume.
Staff shortages may occur because of COVID-19 exposure, personal or family member illness, or childcare constraints due to daycare or school availability. Staff readiness includes evaluating individual availability and willingness.
Staff members with health issues, including comorbidities and chronic medical conditions, may not be comfortable working. Nonclinical staff members with health concerns could work remotely, although some may not be able to work from home due to technology-related issues such as WiFi deficiencies.
The CDC has interim guidelines to assist employers with providing a safe workplace and employees with making the best health decisions for themselves and their families.3,4 The US Office of Personnel Management provides guidance for COVID-19–related leave and benefits for federal employees.5
To mitigate staff shortages, approaches include adjusting schedules, cross-training to perform the tasks of other positions, and hiring additional personnel. A needs assessment can help determine if existing personnel could be cross-trained for other purposes or if additional staff should be hired. Understanding the minimum number of staff required for safe and effective patient care will assist in planning for shortages as the pandemic progresses. Understanding the availability of external resources could be a critical part of an office contingency plan.6
Proactively manage your supply chain. The pandemic has caused global supply shortages. Solid supply chain management is crucial for practice operations. Take inventory of your PPE and various supplies and place orders in advance. Analyze cash flow and connect with vendors as well as local and state health agencies to understand available resources. Given ongoing PPE shortages, practices should consider preserving PPE and employ appropriate strategies for optimizing supplies of face masks.7
Certain medications and vaccines administered in the office setting may be outdated and need to be replaced. Office equipment that has not been used for several months will need to be tested. For equipment used in office electrosurgery procedures, certain safety measures can be taken to reduce the transmission of aerosolized viral particles to the health care team. While currently the risk is theoretical and more research is needed, this potential risk should be mitigated.8 Assessing availability of hospital and ambulance or transport services also is recommended as these may change depending on the local COVID-19 status.
Strategy 6: Establish and refine the patient screening process
Patients want reassurance that the health care environment is safe and that their well-being is a priority. In advance of a patient’s visit, relieve any anxiety by explaining the COVID-SAFE measures that your practice has taken.
For employee use, consider telephone and in-person scripting to ensure consistent messaging for patients.
Prescreening. At the time of appointment scheduling and on the day prior to the scheduled appointment, all patients should be screened for symptoms of COVID-19,9 fever, exposure within 14 days to someone newly diagnosed with COVID-19, and travel within 14 days from a foreign country or from a US state with a quarantine requirement.
Patients who screen positive for symptoms, exposure, or travel should be referred to a clinician. If possible, asymptomatic patients who report exposure or travel should have their in-person visit deferred until after the required 14-day quarantine.
Consider restricting visitors from accompanying adult patients to their appointment unless they are required for special assistance.
Arrival screening. At the time of presentation for the appointment, all patients and any accompanying visitors should be rescreened. The optimal location for arrival screening should be determined by the local operations team and the infection prevention and control program.
At presentation, all patients and visitors should appropriately don a surgical mask or other face covering. Patients and visitors should have their temperature checked on arrival. Patients who screen positive for symptoms, exposure to COVID-19, and/or travel should be referred to a clinician or the visit deferred and a telehealth visit considered.
Visitors who screen positive for symptoms, fever, or exposure to COVID-19 are not permitted to accompany the patient. Asymptomatic parents or guardians of pediatric patients may serve as support persons.
References
- American College of Obstetricians and Gynecologists. Financial support for physicians and practices during the COVID-19 pandemic. https://www.acog.org/practice -management/coding/coding-library/financial-support-for-physicians-and-practices-during-the-covid-19-pandemic. Accessed July 23, 2020.
- American Medical Association. HEALS Act: What physicians and medical students need to know. https://www.ama-assn.org/delivering-care/public-health/heals-act -what-physicians-and-medical-students-need-know. Accessed July 29, 2020.
- Centers for Disease Control and Prevention. Interim guidance for businesses and employers responding to coronavirus disease 2019 (COVID-19). https://www.cdc.gov /coronavirus/2019-ncov/community/guidance-business-response.html. Accessed July 12, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov /coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Office of Personnel Management. Questions and answers on human resources flexibilities and authorities for coronavirus disease 2019 (COVID-19). https://www .opm.gov/policy-data-oversight/covid-19/questions-and-answers-on-human-resources-flexibilities-and-authorities-for-coronavirus-disease-2019-covid-19.pdf. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages. https://www.cdc.gov/coronavirus/2019-ncov/hcp /mitigating-staff-shortages.html. Accessed July 17, 2020.
- Centers for Disease Control and Prevention. Strategies for optimizing the supply of facemasks. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face -masks.html. Accessed July 3, 2020.
- Rahman S, Klebanoff J, Moawad G. Smoke evacuation in the age of COVID-19. Contemporary OB/GYN. July 2, 2020. https://www.contemporaryobgyn.net/view/smoke -evacuation-in-the-age-of-covid-19. Accessed July 3, 2020.
- Centers for Disease Control and Prevention. Symptoms of coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed July 25, 2020.
- Centers for Disease Control and Prevention. Information for healthcare professionals about coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html. Accessed July 22, 2020.
- US Department of Labor Occupational Safety and Health Administration. COVID-19 control and prevention: healthcare workers and employers. https://www.osha.gov/SLTC/covid-19/healthcare-workers.html. Accessed August 5, 2020.
- Centers for Medicare and Medicaid Services. COVID-19 resources for health care professionals and researchers. https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers. Accessed August 7, 2020.
- American College of Obstetricians and Gynecologists. COVID-19. https://www.acog.org/topics/covid-19. Accessed August 7, 2020.
- Society for Maternal-Fetal Medicine. Coronavirus (COVID-19). https://www.smfm.org/covid19. Accessed August 7, 2020.
- Society of Gynecologic Surgeons. Joint statement on re-introduction of hospital and office-based procedures in the COVID-19 climate for the practicing gynecologist. https://www.sgsonline.org/joint-statement-on-re-introduction-of-hospital-and-office-based-procedures-in-the-covid-19-climate. Accessed August 7, 2020.
- AAGL. COVID-19 articles, resources and webinars. https://www.aagl.org/covid-19/. Accessed August 7, 2020.
- American Society for Reproductive Medicine. COVID-19 updates and resources. https://www.asrm.org/news-and-publications/covid-19/. Accessed August 7, 2020.
- Society of Gynecologic Oncology. COVID-19 resources for health care practitioners. https://www.sgo.org/practice-management/covid-19/. Accessed August 7, 2020.
- Centers for Disease Control and Prevention. Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. Accessed July 3, 2020.
- Nguyen LH, Drew DA, Graham MS, et al; on behalf of the COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet. July 31, 2020. http://www.thelancet-press.com/embargo/hcwcovid.pdf. Accessed August 25, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Environmental Protection Agency. List N: Disinfectants for use against SARS-CoV-2 (COVID-19). https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19. Accessed August 24, 2020.
- Centers for Disease Control and Prevention. Duration of isolation and precautions for adults with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. Accessed July 23, 2020.
- Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html#fn1. Accessed July 23, 2020.
- Centers for Disease Control and Prevention. Information for healthcare professionals about coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html. Accessed July 22, 2020.
- US Department of Labor Occupational Safety and Health Administration. COVID-19 control and prevention: healthcare workers and employers. https://www.osha.gov/SLTC/covid-19/healthcare-workers.html. Accessed August 5, 2020.
- Centers for Medicare and Medicaid Services. COVID-19 resources for health care professionals and researchers. https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers. Accessed August 7, 2020.
- American College of Obstetricians and Gynecologists. COVID-19. https://www.acog.org/topics/covid-19. Accessed August 7, 2020.
- Society for Maternal-Fetal Medicine. Coronavirus (COVID-19). https://www.smfm.org/covid19. Accessed August 7, 2020.
- Society of Gynecologic Surgeons. Joint statement on re-introduction of hospital and office-based procedures in the COVID-19 climate for the practicing gynecologist. https://www.sgsonline.org/joint-statement-on-re-introduction-of-hospital-and-office-based-procedures-in-the-covid-19-climate. Accessed August 7, 2020.
- AAGL. COVID-19 articles, resources and webinars. https://www.aagl.org/covid-19/. Accessed August 7, 2020.
- American Society for Reproductive Medicine. COVID-19 updates and resources. https://www.asrm.org/news-and-publications/covid-19/. Accessed August 7, 2020.
- Society of Gynecologic Oncology. COVID-19 resources for health care practitioners. https://www.sgo.org/practice-management/covid-19/. Accessed August 7, 2020.
- Centers for Disease Control and Prevention. Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. Accessed July 3, 2020.
- Nguyen LH, Drew DA, Graham MS, et al; on behalf of the COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet. July 31, 2020. http://www.thelancet-press.com/embargo/hcwcovid.pdf. Accessed August 25, 2020.
- Centers for Disease Control and Prevention. Criteria for return to work for healthcare personnel with SARS-CoV-2 infection (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html. Accessed July 20, 2020.
- US Environmental Protection Agency. List N: Disinfectants for use against SARS-CoV-2 (COVID-19). https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19. Accessed August 24, 2020.
- Centers for Disease Control and Prevention. Duration of isolation and precautions for adults with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html. Accessed July 23, 2020.
- Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html#fn1. Accessed July 23, 2020.