Infection Prevention: More and Less

Physician practices adopt creative solutions, and sales reps adapt

What Repertoire readers are witnessing in their customers’ offices during this pandemic may not be entirely new. The guidelines for infection prevention were agreed-upon by infection prevention professionals years ago. (See the Centers for Disease Control and Prevention’s Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.) But changes are afoot, and they already are affecting everyone associated with outpatient care, including physicians and office staff, patients and their families, and visitors, including sales reps.

From this point forward, infection prevention will be a matter of “more and less.”

PPE
Emphasis on hand hygiene.
Wiping down hard surfaces.
Patient screening.
Attention paid to ventilation systems.
Telehealth.

Less:

Face-to-face visits of all kinds.
Lunch-and-learns with vendors.
Waiting room traffic.
Breakroom camaraderie among staff.

Creative solutions

“Masks, handwashing and social distancing are important in communities, and they are important in doctors’ offices as well,” says Amy Mullins, M.D., medical director for quality and science for the American Academy of Family Physicians.

Some practices are scheduling visits through telemedicine/telehealth technology, she says. But if choosing to see the physician face-to-face, patients will be asked to alter the normal way they move through the office. Some offices have implemented temperature checks as well as questions to determine a patient’s risk of exposure (e.g. recent travel or known exposures).

“Patients may be asked to wait in their car instead of the waiting room, or they may be asked to come alone or with only one other person,” says Mullins. “But as the weather turns colder, asking patients to wait outside or in their cars instead of a warm waiting room will be challenging. Physicians may need to think creatively about solutions, such as calling patients in advance of their visit to let them know how long their wait will be.”

The infection-prevention practices each healthcare organization takes depends a lot on where it is located, says Diane Cullen, MSN, RN, MBA, CIC, associate director, Standards Interpretation Group, The Joint Commission. State and county public health departments are taking varying approaches to directing facilities and issuing mandates, so sales reps should be aware of what is happening locally.

That aside, “there have been a lot of changes in ambulatory settings – many are similar to those that have taken place in hospitals,” she says. Some healthcare organizations are staggering the number of individuals in waiting rooms at one time, and even relocating chairs to facility hallways to lower the risk of inadvertent exposure. Others are labeling chairs with “Xs” to physically distance patients from one another.

Hand hygiene and disinfection of surfaces have always been important infection prevention strategies, but now they are receiving more attention than ever, says Cullen. Patients may be asked to clean their hands with alcohol sanitizer or have their temperature taken upon arrival.

Accessing personal protective equipment and cleaning supplies remains a challenge. “Products that healthcare organizations might have used previously may not be available from their distributor, because of high demand,” says Cullen. The challenge for facilities is this: Staff has historically used, say, one brand of disinfectant, and now they must use another brand. Now, staff must be retrained, as contact time or considerations about exposure to skin may be different. “Providing that extra training can be significantly challenging for small organizations.”

New protocols

At each of its two locations in Sarasota and Venice, Florida Cardiac Consultants has positioned screening nurses at folding tables to check the temperature and blood oxygen levels of patients. “We ask each patient about 15 questions, such as, ‘Have you traveled lately?’ or ‘Have you been exposed to someone with COVID-19?’” says practice administrator Mark Spetsios. The protocol is new since COVID-19, and it is a way of protecting staff while giving patients a sense of safety, knowing the practice is taking the pandemic seriously. But it comes with a financial cost. “We have had to hire two additional people for the sole purpose of manning the screening tables,” he says.

A year ago, 12 or 15 people might be seated in the waiting rooms of the practice’s offices, but now the practice limits it to two. Patients wait in their cars until called to come in, and with some exceptions, they are not allowed to bring companions with them. “No one is permitted in the office unless they’re a patient,” says Spetsios. “Pharmaceutical reps can drop off samples or literature at the screening tables. And if a vendor wants to talk to me, I’ll meet them outside, where we have a parking garage.”

Silver linings

Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of ambulatory infection prevention and control for Highland Hospital in Rochester, New York, says one thing is certain: “Because of COVID-19, the focus on infection prevention has escalated, and that’s a good thing.” Pettis is president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC), and is responsible for infection prevention in all ambulatory settings at Highland Hospital and approximately 30 ambulatory locations.

“We have never taken our hands off the wheel” in terms of monitoring infection prevention practices at the health system’s outpatient settings, she says. “This is not a one-and-done thing. We have been steadily auditing the practices.” Because of COVID, Pettis has instituted weekly conference calls with the outpatient facilities to share knowledge and best practices.

“Since March, we have learned how to do things better than ever,” says Pettis. Scheduling may be the most important one. “You have to be vigilant in how you schedule, so patients aren’t sitting in waiting rooms.” Having patients wait in their cars until called for their appointment works in warm weather, but is more difficult in cold-weather climates. “And telehealth will be much more important, probably in perpetuity.”

As of November, sales reps were still discouraged from visiting Highland practices except in cases of emergency. But business is being conducted. One vendor – a maker of hand sanitizer – inserviced all the practices virtually on a new product. “Across the board, we recognize the importance of working with our vendors,” says Pettis. “Thankfully, we have technology to help us do that.”

Pettis says she tries to emphasize one more thing with the hospitals’ practices: The patient’s perception is their reality. “If the rugs are tattered or stained, or if things don’t look like they’ve been well-taken-care-of, patients get the impression the office isn’t safe.” Some practices have gone the extra mile by displaying signage indicating if a stall is clean and ready for use.

The human factor

Financial, logistical and training issues aside, the biggest challenge to proper infection prevention might be human behavior.

“People get tired of social distancing and wearing face masks,” says Spetsios. “And we get that. But it’s going to be the reality for a while.” Vendor lunches are on hold, and staff members no longer congregate in the breakroom. “You lose some of that collegial environment,” he says.

“People like to gather,” says Pettis. “It’s who we are. But now is not the time to let our guard down. We remind staff that not only do we want to be safe for our patients, but for each other too. If one of them becomes sick or is quarantined, who will take care of their patients?”

Sidebar 1:

PPE spending by physician practices

64% of practice owners said that summertime spending on PPE was up from
pre-pandemic. Average increase in PPE spending was 57%.

13% said PPE spending increased by 1-25%

12% said PPE spending increased by 25-49%

14% said PPE spending increased by 50-74%

25% said PPE spending increased by at least 75%

15% said PPE spending remained the same

2% said PPE spending decreased

19% said Don’t know

Source: www.ama-assn.org/system/files/2020-10/covid-19-physician-practice-financial-impact-survey-results.pdf,
American Medical Association. (Survey of 3,500 physicians administered from mid-July through end of August 2020.)

Sidebar 2:

Checklist to Prepare Physician Offices for COVID-19

Editor’s note: Below are some provisions of the American Academy of Family Physicians’ Checklist to Prepare Physician Offices for COVID-19. Amy Mullins, M.D., medical director for quality and science for the AAFP, cautions that the use of the checklist and its implementation may vary among offices depending on their particular workflow and the level of virus spread in their community. Local public health offices are excellent resources for information on number of cases in the community as well as particulars on infection control practices in that community.

Office preparedness

Design a COVID-19 office management plan that includes patient flow, triage, treatment and design.
Consider designing and installing engineering controls to reduce or eliminate exposures by shielding staff and other patients from infected individuals.
Provide hand sanitizer, approved respirators, face shields/goggles, surgical masks, gloves, and gowns for all caregivers and staff to use when within six feet of patients with suspected COVID-19 infection. Provide training for staff on respirators to ensure fit and appropriate use.
Ensure adherence to standard precautions, including airborne precautions and use of eye protection. Assume that every patient is potentially infected or colonized with a pathogen that could be transmitted in a healthcare setting.
Implement mechanisms and policies that promptly alert key facility staff – including infection control, healthcare epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff – about known suspected COVID-19 patients. Keep updated lists of staff and patients to identify those at risk in the event of an exposure.
Staff should follow the CDC guidelines collecting, handling and testing clinical specimens from suspected COVID-19 patients.
Prepare for office staff illness, absences, and/or quarantine.
Cross-train staff for all essential office and medical functions.
Review proper office and medical cleaning routines. Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol- generating procedures are performed. Products with emerging viral pathogens claims are recommended for use against SARS-CoV-2.

Triage and patient flow systems

Distribute respiratory prevention packets consisting of a disposable surgical mask, facial tissues, and cleansing wipes to all symptomatic patients.
Develop a triage protocol for your practice based on patient and community outbreak.
Recommend that patients with respiratory symptoms and fever call the office before arrival.
Implement alternative patient flow systems.
Attempt to isolate all patients with suspected symptoms of any respiratory infection using doors, remote office areas, or negative-pressure rooms, if available.
Evaluate patients with acute respiratory illness (ARI) promptly.
After delivering care, exit the room as quickly and directly as possible (i.e., complete documentation in clean area).
Clean room and all medical equipment completely with appropriate cleaning solutions.
When possible, reorganize waiting areas to keep patients with respiratory symptoms a minimum of 6 feet away from others and/or have a separate waiting area for patients with respiratory illness.
Consider arranging a separate entrance for symptomatic patients.
Schedule patients with ARI for the end of a day or at another designated time.
Provide no-touch waste containers with disposable liners in all reception, waiting, patient care, and restroom areas.
Provide alcohol-based hand rub and masks in all reception, waiting, patient care, and restroom areas for patients with respiratory symptoms. Always keep soap dispensers stocked with handwashing signs.
Discontinue the use of toys, magazines, and other shared items in waiting areas, as well as office items shared among patients, such as pens, clipboards, phones, etc.
Dedicate equipment, such as stethoscopes and thermometers, to be used in ARI areas. This equipment should be cleaned with appropriate cleaning solutions for each patient. Consider the use of disposable equipment when possible (e.g., blood pressure cuffs).

Other topics covered in the Checklist are education of staff; additional options to prevent community transmission; referral or transfer of patients; waste disposal; and required equipment/supplies.