Facilities Must ‘Identify, Isolate, and Inform’ During Resumption of Operations
By the Accreditation Association for Ambulatory Health Care
The emergence of the COVID-19 pandemic has created new burdens and unprecedented challenges for the U.S. healthcare system. Healthcare facilities around the country are constantly adapting to rapid changes and adopting novel strategies as they navigate executive orders and the coronavirus itself, while ensuring staff, patient, and visitor safety.
Whether offering limited services, operating at full capacity, or preparing to reopen after temporary closure, ambulatory healthcare facilities must continue to stay up to date on the coronavirus situation to implement best practices, both during the state of emergency and following the gradual reopening of state healthcare systems.
Following guidelines from the Centers for Disease Control and Prevention (CDC), the Accreditation Association for Ambulatory Health Care (AAAHC) has released recommendations to help organizations safely navigate the evolving stages of the COVID-19 pandemic, with an emphasis on steps to identify, isolate, and inform.
The three key components that must be identified to help protect a healthcare facility during a public health emergency are 1) an emergency preparedness plan, 2) potential risks, and 3) patient scheduling and pre-screening procedures.
- Emergency preparedness plan: Conduct a thorough review of the written emergency preparedness plan, and ensure it addresses internal and external threats.
- Infection control risk assessment: Comprehensive infection prevention and control includes evaluations of equipment and staff training.
- Patient scheduling and pre-screening: In anticipation of the possible need to manage an influx of COVID-19 patients, your organization should have a plan for how to assess patients prior to entry into your system.
To ensure the plan is optimized for COVID-19 prevention, update the section addressing the prevalence of infectious diseases and isolation policies.
A comprehensive plan should include strategies to manage patient flow and capacity. Consider staffing issues that may occur due to exposure; provisions for safe evacuation, especially for those who are at greater risk; and measures for participation in a potential community health crisis. This includes possible coordination with the city, county, state, or Centers for Medicare & Medicaid Services (CMS). Once the emergency preparedness plan is sufficiently updated and approved by all necessary executive parties, disseminate the document to your entire staff. All staff should be educated on these updates in a timely manner.
Outside assistance to conduct infection control risk assessments can prove beneficial because internal management teams may be too deeply involved with daily operations.
Optimize the supply of personal protective equipment (PPE) by fully understanding your ongoing PPE inventory and utilization rates. The CDC has a spreadsheet-based PPE burn rate calculator that will help healthcare facilities plan and optimize the use of PPE. It is recommended that facilities review their PPE plan to incorporate strategies for PPE prioritization. The CDC addresses prioritization in three ways:
- Conventional capacity, which involves strategies that should already be in place
- Contingency capacity measures, which conserve supply during periods of PPE shortages
- Crisis capacity, which is implemented when supplies cannot meet the facility’s utilization rate
Designate time to educate staff on CDC updates, revised facility procedures, PPE, COVID-19 symptoms, management and notification, and transmission-based precautions. Ensure all employees become familiar with infection prevention and control guidance for managing COVID-19 patients for the duration of the pandemic.
Depending on your state and local guidelines, you may proceed with some elective and non-urgent appointments and eventually resume more standard operations. However, continue to offer patients alternatives to office visits, such as telehealth, patient portals, and advice lines, to further reduce risk. Additionally, eliminate any penalties in place for cancellations to encourage sick patients to stay home or seek an office visit alternative as discussed above.
To help prevent transmission, pre-screening patients about previous COVID-19 testing results and symptoms during a pre-visit call is essential. Ask specific questions about testing dates, recent travel, or known exposures, and note if they have had fevers or any other COVID-19 symptoms. Create algorithms to identify which patients can be managed by telephone and advised to stay home, and which patients will need to be sent for emergency care or come to your facility.
Consider reaching out to patients who may be at higher risk of COVID-19-related complications, such as seniors and those with medical comorbidities or respiratory diseases, to ensure adherence to current medications and therapeutic regimens. Confirm they have sufficient medication refills, and provide instructions to notify their provider by phone if they become ill.
Some healthcare facilities have incorporated rapid antigen testing into pre-screening processes. Rapid tests are now commonly used in the diagnosis of COVID-19 for symptomatic persons within the first five to seven days of symptom onset, and a list of tests is available on the Food and Drug Administration website. The CDC also provides specific guidance on the collection and handling of clinical specimens.
Isolation is needed to prevent a spike in cases and avoid overwhelming hospitals and health centers. This involves a focus on transmission-based precautions, patient monitoring and placement, and environmental cleaning.
Standard precautions, both at the pandemic’s height and in the foreseeable future, assume that every person is potentially infected or colonized with a transmittable pathogen. Therefore, facilities need to have safeguards in place to protect patients and staff from cross-infection. At minimum, your organization should have written policies and procedures that ensure the isolation or immediate transfer of patients with COVID-19 symptoms, timely communication to public health authorities of reportable conditions, and adequate surveillance of people and facilities. Reinforce the necessary safety measures as much as possible among both staff and patients. Hand hygiene audits should be conducted—the foundation of transmission-based precautions. Educate everyone to thoroughly wash their hands for a minimum of 20 seconds. Alcohol-based hand rub (ABHR) should have at least 60% alcohol and be readily accessible for makeshift pre-screening zones in the absence of a hand basin with soap and water.
Staff should strictly follow the procedures for safely and correctly donning and removing PPE. In surgical settings, stress that staff must don their mask before entry into the patient room and put on eye protection, gloves, and gowns upon entry. In other settings, staff should be wearing PPE before coming within 6 feet of any patient.
Patient monitoring and placement
Patient management is key to maintaining high-quality service and protecting the health of both patients and staff.
Healthcare facilities should limit the number of patients allowed inside at one time. Start by implementing triage before patients even enter your facility. Avoid having visitors in the facility, or limit to only one visitor at a time to accompany patients under 18, patients with disabilities (ADA), and/or post-procedure patients. Inform patients that you require drivers to wait outside. In some settings, medically stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
Pre-screened symptomatic patients who need to be seen in a clinical setting should be asked to call before they leave home, so staff are ready to receive them using appropriate infection control practices and PPE.
Upon arrival, take each patient’s (and visitor’s) temperature and clean the thermometer. Establish separate, well-ventilated spaces for patients with symptoms of suspected COVID-19, with easy access to respiratory hygiene supplies, and away from other patients seeking care.
Increased attention to sanitation and assessment of cleaning practices is important to help isolate COVID-19. Evaluate all your environmental cleaning practices, from discharge cleaning and wipe-downs of high-touch objects to terminal cleaning and sterilization of dedicated medical equipment. In-depth cleaning throughout the entire facility should be done between every shift, while high-touch surface areas should always be cleaned between patients as well as regularly in high-traffic areas, such as waiting rooms and nurse stations.
The CDC recommends EPA-registered hospital disinfectants that are effective against other respiratory pathogens, such as seasonal influenza and other human coronaviruses. Educate staff on the appropriate surface contact time for each cleaning agent and ensure that manufacturers’ recommendations for use are followed, such as dilution and care in handling.
Amidst the dynamics of this rapidly changing situation, monitor reliable sources of information, such as the World Health Organization and CDC, as well as state and county health departments that can provide local updates.
As a cross-infection prevention measure, establish an internal system to track persons under investigation (PUI) and confirmed cases in your facility and local area. Identify staff to collaborate with local and state health authorities and notify them of reportable conditions. Additionally, ensure that communication protocols include completion and submission of the PUI case report to the CDC.
Effectively stay up to date and streamline communications by designating a small team of employees to monitor related local and national news. Next, implement mechanisms and policies to promptly alert key facility staff and then disseminate relevant updates to all employees.
To ensure everyone understands the COVID-19 plans and protocols, consider allowing staff to submit questions, or hold regular Q&A sessions. An easy way to keep everyone informed is to send daily or real-time e-newsletters with any changes or updates in protocols. Or consider holding a morning meeting with key staff members who can then distribute the information to the rest of the employees.
Last but not least, remind staff about patient confidentiality.
All organizations across all settings should remain vigilant about practices that impact employee and patient safety and the quality of care delivered. By providing clear, actionable methods, accreditation allows ambulatory healthcare centers to meet the challenges of COVID-19 by setting a foundation on which to build an appropriate emergency preparedness plan, identify areas for quality improvement, and assess adherence to guidelines during all phases of the pandemic and throughout the reopening process.
To support efforts to mitigate risk of spreading infection, AAAHC has been guiding its accredited organizations through the necessary processes and carefully following recommendations from the CDC to help healthcare providers maintain essential services and provide safe and quality care as operations resume more widely. For the foreseeable future, AAAHC accreditation processes will include a heightened focus on infectious disease protocols, including preparation for managing patients with COVID-19. Indeed, the accreditation process can be used as a starting point to effectively incorporate quality improvement initiatives needed to adapt to this dynamically evolving pandemic.
Like most initiatives with great vision, accreditation first requires a significant commitment from those adopting the model, and then ongoing evaluation, refinements, and time to succeed. It is a transformative process that can prove invaluable during turbulent times. Ultimately, the AAAHC accreditation process can help pinpoint areas of improvement for a facility’s emergency plans and protocols specific to COVID-19 identification, isolation, and information.