2019 Novel Coronavirus and Patient Safety in the Medical Office

Debbie Hill, MBA, RN, Senior Patient Safety Risk Manager, The Doctors Company

The 2019 novel coronavirus (COVID-19) continues to spread across multiple continents, infecting tens of thousands of individuals worldwide, with thousands of deaths. On Tuesday, February 25th, the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, urged the U.S. public to begin making preparations for the possibility of a U.S. pandemic with “the expectation that this could be bad.” Given that outbreaks are expected to occur at a community level, medical offices will undoubtedly experience an influx of patients seeking assistance. The question is: Are medical offices doing enough to prepare?

Most medical offices have, for the most part, learned from experience and are paying closer attention to widespread outbreaks of disease. One lesson learned from Ebola, measles, and other recent outbreaks—when many healthcare organizations were unprepared—is that all medical offices should have an infection control and emergency preparedness plan in place.

The CDC has been responsive in its role to gather data and advise clinicians on COVID-19; however, it is up to physicians and all healthcare facilities to take necessary steps to provide effective screening for the public, followed by recommended protocols.

Preparedness Matters

A well-constructed infection control preparedness plan for COVID-19 is essential for facilities where patients receive care, such as physician offices, dental offices, long-term care facilities, and ambulatory care centers. Leading into the Ebola crisis, nearly 80 percent of hospitals in the U.S. acknowledged that they were unprepared to deal with patients who might present with Ebola symptoms. That led to avoidable early mistakes when clinicians encountered cases they had not anticipated seeing. Unlike Ebola, patients with a COVID-19 infection may look a lot like patients with fairly routine cold and flu symptoms, or they may be infectious without any presenting symptoms at all. But by following best practices, facilities where patients receive care can make great strides in identifying and treating the coronavirus early. Careful screening with a bias for suspicion that a patient might have the coronavirus will serve healthcare providers well in this situation.

The following are some recommendations in the event a patient with suspected COVID-19 seeks care:

Follow the CDC’s patient assessment protocolfor early disease detection. If a patient calls to schedule an appointment for an acute respiratory illness (e.g., fever, cough, and difficulty breathing), he or she should be screened using the Flowchart to Identify and Assess 2019 Novel Coronavirus.
If presenting symptoms, travel history, or patient contacts are suspicious, immediately isolate patients coming into the office (segregate them from other patients in the facility) in a designated exam room with dedicated patient care equipment. A back entrance may be utilized, if available. Since most medical offices don’t have negative pressure airflow, a spare bathroom with negative exhaust fans may be an option in the medical office setting instead of a regular exam room. The CDC provides guidelinesfor environmental infection control in healthcare facilities. Be aware that it is unknown how long the virus remains airborne once a room is vacated, and there are currently no CDC instructions on length of time before the room may be used again.
Once suspected patients are inside the facility, instruct them to put on a face mask, utilize tissues, practice good hand hygiene, and dispose properly of any contaminated protective equipment/tissues in a designated waste receptacle. Educational resources, including posters for use in the medical office, are available from the World Health Organization (WHO).
Follow Standard, Contact, and Airborne precautions including gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit-tested. This applies to all healthcare staff interacting with patients.
Limit staff exposure to suspected patients, with the exam room door kept closed.
When there is a reasonable presumption that a patient may have been exposed to COVID-19, contact the local or state health department to determine if the patient needs to be tested.
Maintain records of staff-patient contact, i.e., who was assigned to work with the patient, either in a log or in the medical record.
Once the patient exits the room, conduct surface disinfection while staff continues to wear personal protective equipment (PPE).
Provide up-to-date, factual information on the virus to the patient and close contacts, including how to follow infection-control practices at home, such as in-home isolation, hand hygiene, cough etiquette, waste disposal, and the use of face masks.
Remind patients and their families to access information about the virus through reputable sources such as the CDC, not social media.
Check with your local public health authorities for locations designated to triage suspected patients so exposure is limited in general medical offices. Emergency preparedness plans most likely will be activated so that parties are coordinating efforts to deliver effective public health intervention.

Suspected cases must be reported to applicable local and state health departments. The CDC provides instruction on their website for reporting requirements by medical offices to state and local health departments, who, in turn, report “persons under investigation” (PUI) to the CDC for further evaluation and testing. Also, any unprotected occupational exposure by staff members should be assessed and monitored.

Consider Legal Risks

When the Ebola virus was new to the U.S., there was one well-reported case where a patient who came to the hospital with Ebola was sent home without treatment. Such situations not only put the patients and others at risk, but also put healthcare providers and hospitals at risk for litigation.

We recommend that when in doubt, healthcare providers should adopt a clinical suspicion of COVID-19 to protect the patient and others. The dynamics surrounding the virus will continue to change in the days and weeks ahead. What must not change is that physicians and care teams should remain vigilant and careful. They should be exceptionally proactive in asking the right questions, documenting interactions, following rigorous protocol, and keeping abreast of emerging insights and data as they become available from the CDC.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.