Close Encounters: Modifying In-Person Visit Procedures to Minimize Transmission

By Andrew L. Concoff, MD, FACR, CAQSM

In these trying times, it has been tremendously inspirational to see the bravery and commitment of the Rheumatologists who have continued to rise to the challenges COVID-19 presents. 

This document will turn our attention to a series of innovative methods that seek to decrease the risk of transmission of COVID-19 during in-person visits.  These approaches are intended as a “toolkit” for this purpose.  As always, each clinic should evaluate this content to determine its applicability to your local circumstances.  Furthermore, certain basic elements of this approach, notably masks, are in short supply.  In the near-term, if the local supply of materials is inadequate, it may be necessary to make use of reasonable alternatives, such as replacing masks with bandanas or with t-shirt-crafted, respiratory masks (production described at  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373043/pdf/05-1468.pdf)

  1. Pre-Visit Screening of Scheduled Patients
    (Suggested Timeframe: Days – Weeks Prior to a Scheduled In-Person Visit)
    Please refer to our prior description of an in-depth consideration of Pre-Visit Patient Screening.  New information is presented here to augment the prior discussion:
    • Limit Unnecessary in Person Visits

      The best way to limit the risk of COVID-19 is to practice the medical version of “social distancing”, that is, never having an in-person visit with an infected patient and, instead, converting to Telemedicine visits.  The importance of this approach has been magnified by the recognition that asymptomatic patients infected with COVID-19 are likely responsible for transmitting 30-60% of the cases seen in Singapore and certain areas of China and that 10% of all COVID-19 infections in Italy have affected health care workers.  The upshot of this scenario is that screening patients for symptoms or checking body temperature prior to a visit will fail to identify a significant portion of those infected, thus placing you and your staff at risk of infection.  By the same token, there is no way to tell if you or your staff have already been infected and risk transmitting the virus to each other or to your patients via this form of “stealth spread”.

      In-person visits should be limited to those in need of procedures or urgent evaluation that cannot be performed virtually. 

    • Communicate the New Screening Process to Those Who Will Have an In-Person Visit
      It is important to inform those patients in whom an in-patient visit is deemed necessary, that they will experience a new screening process leading up to their visit in order to keep them and the clinic staff safe.  This will avoid surprise and concern as they experience the new measures. 
    • Communicate Additional Pre-In-Person Visit Instructions
      Patients should be told to do the following:
    • Call the Clinic to Cancel In-Person Visit if They Develop:
      1. Symptoms of COVID-19 Infection
      2. Fever (as indicated by a thermometer)
        • Patient should be specifically instructed to check his/her/their temperature prior to leaving their house for their visit.
  2. Preparing Patients for In-Person Visits:
    Pre-Visit Text
    (Suggested Timeframe:  Day Prior to and/or Day of Clinic Visit) 
    • Pre-Visit Text:
      Patient should be reminded via text:
      1. “Take your temperature with a thermometer on the day of the visit prior to leaving home. Call to cancel if you have a fever.”

        Although “stealth spread” means that this screening tool will miss a significant percentage of infected patients, those with a fever clearly should not attend the scheduled visit (i.e., such screening is necessary but not sufficient.)

      2. Text the clinic when you arrive at the Parking Lot to our clinic. Stay in your car with your windows up.  Let us know the make, model and color of your car and your license plate number.  One of our staff members will meet you at your car.” Whenever possible, it is advisable to screen patients’ temperature before they enter the clinic to prevent contamination of the waiting room or triage area.  In some clinic scenarios, this may not be feasible, and an “ante-room” triage area can be established in the lobby, hallway, or elsewhere prior to the entrance of the clinic to limit potential exposures.    
  3. On-Site Pre-Visit Screening
    • When the Patient Arrives
      • As mentioned above, patients have already been instructed to text that they have arrived. When this text is received:
        1. The check in process should begin.
        2. A text response from the should indicate that a Staff member will meet them in the parking lot shortly.
    • On-Site Temperature Screening:
      • Parking Lot Screening
        • A staff member wearing appropriate personal protective equipment should locate the patient’s car and approach:
          1. Patients should roll down their window half-way down.
          2. Staff member should briefly identify themselves.
          3. Staff member should inquire about symptoms of COVID-19 infection.
            • If patient endorses symptoms of COVID-19, the staff member should indicate that the patient cannot be seen. Appropriate resources should be offered.
            • If the patient denies such symptoms, the staff member should take the patient’s temperature.
              1. Patients with a fever should be politely dismissed and not seen in clinic.
              2. Those without a fever should be:
                • Asked to remain in their car and wait for a text indicating that they may enter the clinic.
                • Provided a mask (or equivalent) to wear and instructed to wear it throughout their visit.
      • Ante-room screening
        1. The process flow for ante-room screening is similar to that above, except that:
          • Patients wait in their cars until texted to enter the clinic when the temperature screening staff is available.
          • Patients immediately undergo temperature screening upon entering the “ante-room”.
          • Responses to temperature screening:
            1. Patients with a fever should be politely dismissed and not seen in clinic.
            2. Those without a fever should be asked to complete check-in as indicated below.
  4. Modifications to the Waiting Room, Check-In and Patient Flow
    • Protective Equipment in the Clinic
      Because “stealth spread” means that it is impossible to determine which patients, staff members or providers are infected, all clinic staff and patients should wear masks (or their equivalent) throughout their time in the clinic. 
      1. Patients should be specifically instructed to keep the mask (or equivalent) in a position that covers their mouth and nose AT ALL TIMES.
        • It has not been uncommon in my past experience to enter an exam room in which a patient was asked to wear a mask (or equivalent) only to find the patient hurriedly redonning the mask or casually wearing it over his/her/their nose OR mouth only.
      2. The intent of wearing masks (or equivalent) in not to protect the wearer, but to protect others in the case that the wearer is infected.
    • Social Distancing in the Waiting Room
      1. Patients should be invited via text to enter the waiting room only when a space in open for them to sit six or more feet from any other patient or staff member. It is expected that no more than 2 or 3 patients shall remain iun the waiting room at any one time.
      2. Chairs should be removed to make such limitations clear to front office staff and patients.
      3. As previously indicated, magazines and self-service beverage areas should be removed.
    • Check-In
      1. Patients should check-in while maintaining a six-foot distance whenever possible without approaching the desk, from an area marked on the floor for this purpose.
      2. The exchange of hard copies of paperwork and signatures should be limited as much as possible to limit risk of spread. E-mail or text may be appropriate communication options to this end. This approach may be facilitated by e-mailing paperwork to be completed prior to the visit.
      3. Front office staff should wear gloves at all times and should wash their hands and change gloves after each patient is checked in.
    • Check-out
      1. Whenever possible, in order to limit the frequency with which patients come into contact with one another or with staff, patients should exit through a different route than they enter.
      2. It is recognized that the structural arrangements of many clinic setting make this approach impractical or impossible.
  5. The In-Person Visit
    It is anticipated that the large majority of in-person visits that are deemed necessary after appropriate screening will involve a procedure.
    • Patient and Provider Should Wear Masks Throughout All Procedures
      1. Given the specific risk of COVID-19 infection of healthcare workers during the epidemic and the prolonged exposure to patients required by each such procedure, both patients and providers should wear masks (or their equivalents) throughout the period of patient interactions.
      2. N95 Respirators and sterile gowns are recommended for providers during such procedures when available but may not be required for most Rheumatologic procedures.
      3. Infusion Suites should be modified to maintain “social distancing” rules of 6-feet between patients.
        • Patients should wear masks throughout infusion visits.
    • Appropriate Disinfection and Sterilization in keeping with CDC Recommendations should be maintained. For details visit https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html 

The advent of the COVID-19 pandemic has fundamentally changed the practice of Rheumatology. One way that we can face such uncertainty and confront these challenges is band together virtually, by sharing our thoughts and approaches.  Please send your concerns, solutions, thoughts, and novel approaches to info@unitedrheumatology.com. 

Stay safe, stay healthy, stay United. 

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