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Ambulatory Resource Page

COVID-19 Ambulatory Resource Page

Page last updated 7/24/2020 at 11:54 AM

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Guiding Principles

The information on this page is general guidance and may be operationalized differently to fit the needs of each ambulatory service and facility. Guiding principles that should be followed in the ambulatory setting:

  • Universal Masking of patients, visitors, and associates is required
  • Physical distancing in all clinic/waiting areas (in addition to masking) must be prioritized
  • Hand hygiene and cleaning/disinfection procedures must be followed
  • Symptom screening of patients, visitors, and associates should occur upon arrival and prior to scheduled visits
  • Personal protective equipment (PPE): N95 respirators are not required for patient care in the ambulatory setting except while performing an aerosol-generating procedure (AGPs)
    • Initiating the performance of AGPs in the ambulatory setting should be planned in partnership with Infection Prevention/Infectious Disease.

Schedule Coordination

Physical Distancing

Adjust schedules to accommodate adequate time for patient visits, to ensure appropriate physical distancing in waiting and clinical areas, and to allow time for cleaning. Onsite leadership will identify strategies to implement and achieve appropriate physical distancing according to the physical layout and clinical care provided at each ambulatory location. Some strategies to consider include:

  • Expand scheduled time blocks.
  • Avoid double-booking patients for in-person visits in a single appointment slot.
  • Determine scheduling details, including handling of late patients, at the discretion of each provider in partnership with the site lead(s). Allowances should be made as able, given the special circumstances that may present challenges to patients.

Before a Patient Visit

Scheduling

During scheduling, patients will be asked about a recent diagnosis of COVID-19 for themselves or household contacts and about COVID-19 symptoms. Scripts have been prepared to provide guidance and will be updated each time a CDC update occurs.

Reminders to Give Patients

During scheduling, staff should remind patients of the following current MedStar Health practices:

Scheduling Visits in Patients with Likelihood of Active COVID-19

Likelihood of active COVID-19 includes current COVID-19 symptoms, living with someone with a recent COVID-19 diagnosis, or testing positive in the last 10 days).

Telehealth visits should be prioritized whenever clinically feasible and appropriate (video visits or MedStar e-Visits)

Recommendations for in-person visit scheduling:

  • Patients with COVID-19 diagnosis/symptoms:
    • COVID-19+:
      • Asymptomatic for at least 3 days and at least 10 days after symptom onset may be scheduled as per routine.
        • For patients returning for care to locations with immunosuppressed populations (i.e. infusion centers, transplant clinics), consider prioritizing telehealth visits for 30 days after COVID diagnosis. If this is not clinically feasible, patient scheduling should be considered by the provider on a case-by-case basis with Infectious Disease/Infection Prevention.
    • COVID-19 symptoms:
      • Specialty clinic providers, non-primary care clinic providers, and providers at ambulatory care centers should prioritize a video visit or consider rescheduling appointment if possible until patient is asymptomatic for at least 3 days and at least 10 days past a positive COVID-19 test. Recommend the patient contact MedStar e-Visit or be seen at MedStar Urgent Care or their primary care doctor for evaluation if not previously evaluated or if patient reports worsened symptoms
      • Primary care clinics may consider delaying appointments as above or schedule COVID+ or PUI for telehealth or in-person visits, as per clinic leadership and providers
  • Asymptomatic patient with COVID+ household contact:
    • As per clinic leadership and provider, consider using telehealth or delaying appointment for 2 weeks from the date of the household contact’s positive test if possible.
Pre-Appointment Contact

As per clinic leadership, clinic administrative staff may also contact patients again prior to a scheduled appointment to remind patients of current policies or re-screen for recent diagnosis or symptoms. If patient has a new diagnosis of COVID-19 or has new COVID-19 symptoms, refer to recommendations above.

Testing

Visit the Pre-Operative Testing Page for all information and resources related to pre-op testing.

Effective Tuesday, June 30, at 5PM, the testing tents in Brandywine, Federal Hill and Bethesda will close permanently. Instead pre-operative testing will be available at select hospital-based locations. Reference Pre-Op Covid-19 Testing Hospital, Primary Care, Urgent Care Locations for a full list of testing locations and Pre-Op Testing Locations for Rapid Turnaround (less than 72 hours).

Pre-procedural testing should be completed 72 – 96 hours prior to the procedure. Calculate 72 – 96 hours from the time of the courier pickup to the surgery time. When counting days, count Day 1 as the day of the test, and Day 5 as the day of the surgical procedure.

Refer to the MMG Labcorp COVID Testing Algorithm for detailed guidance on when and where to order pre-procedural testing.

If a test must be completed less than 72 hrs prior to surgery, you must refer patients to these rapid turnaround locations ONLY. For urgent testing, calculate 48 – 72 hours from the time of the courier pickup to the surgery time.

Refer to the Pre-Operative Testing Timeline or click the image below for full details on when to order testing depending on the day of surgery:

Pre-Operative Testing Timeline. Click the image for more information.

All patients are educated about self-quarantining at the time of testing, and are responsible for self-quarantining between the time of the test and when they arrive for surgery. However, findings indicate that MedStar Health has had no conversions to COVID-19 positive status for patients who could not or did not quarantine. Therefore, effective July 10, 2020 the updated pre-operative COVID-19 testing protocol no longer includes the second test requirement or the need to cancel elective surgeries for patients who could not or did not quarantine. Reference this Updated! Pre-Operative COVID-19 Testing Protocol memo for more information.

MMG and Urgent Care: Nasal Self Swab Specimen Guidance

Onsite Clinic Operating Principles

Physical Distancing

Each facility should arrange waiting areas and clinic spaces to accommodate physical distancing. Please note that strategies to achieve physical distancing may vary between clinics and facilities. Guidance is being developed by the MedStar Health Real Estate services and will be posted on this page once available.

Some examples to consider include: decreasing the number of waiting room chairs, adding floor tape boundaries, or having patients wait outside or in their cars once they have completed the check-in process to be notified when they are ready to be seen. 

Signage should be placed to remind patients/visitors of physical distancing requirements. MedStar Health Marketing has developed extensive signage, decals, and floor graphics to support physical distancing. Please contact Marketing for order forms and information.

Universal Masking

All staff are to wear a surgical or procedural masks at all times. Masking and physical distancing are additive.

All patients and visitors are required to wear a mask which should be brought from home. Clinic staff should ensure that this step is done prior to registration and before the patient moves within the clinic space.

If a patient does not have a mask from home, provide them with a mask from the MedStar supply:

  • Asymptomatic patients and visitors should be given an Under Armour cloth mask. Refer to the Under Armour Mask Assembly Instructions and the Visitor Mask Assembly Video for assistance.
  • Visitors who wear masks with valves must have them replaced. Please print this sign in visitor areas to spread the word.
  • Patients with recent (within 10 days) diagnosis of COVID-19 or who have COVID-19 symptoms should be given a procedural mask.

For more information on the masking and visitor policy, see the Temporary Patient Visitor Restrictions During COVID-19.

Onsite Registration Screening

All patients and visitors should answer screening questions at time of entry to the clinic using a standard MedStar front desk screening tool. Patient temperature screening may be administered at time of entry to clinic at pilot facilities (see below).

Primary Care Front Desk Screening

Ambulatory Patient Screening Questionnaire

Primary Care Front Desk Screening Script

  • If a patient indicates they are experiencing symptoms or has been previously positive for COVID-19 within the last 10 days, ensure they are wearing a procedure mask.
    • Patient should be handed the patient screening questionnaire to complete. If the screening form shows COVID-19 symptoms, the registrar should immediately notify an MA/RN to coordinate escorting the patient to an empty exam room.
    • Personal protective equipment and cleaning protocols below should be followed.
    • Any other clinic-specific protocols should be followed.

Non-Primary Care Front Desk Screening

Specialty Care Front Desk Screening Script

RadAmerica Front Desk Screening Script

MNRN Front Desk Screening Script

  • If a patient has a fever (>100.0), which indicates that they could be experiencing COVID-19 symptoms, or has been previously positive for COVID-19 in the last 10 days, ensure they are wearing a procedure mask.
    • The provider should determine if a patient should be seen and taken to an exam room, referred to MedStar Urgent Care or primary care, or rescheduled.
    • PPE and cleaning protocols below should be followed.
    • Any other clinic-specific protocols should be followed.

If a visitor reports COVID-19 symptoms or recent diagnosis, he/she should not be permitted entry to the clinic as a visitor. If the clinic evaluates patients for COVID-19 (e.g. urgent care, primary care), the visitor may be offered to be seen as a patient if possible.

  • If the primary patient required the visitor to accompany them to the visit, the clinic staff should consider rescheduling the primary patient’s appointment.
Room Closure Guidance

To ensure the safety of subsequent patients by allowing airborne particles to clear the environment, extended room closure is required after AGPs are performed on COVID+ patients and PUIs. This principle is applicable to all settings including the operating room, inpatient rooms, and ambulatory exam/procedure rooms. For full protocol information, please reference Room Closure Guidance for COVID-19 Positive and PUI Post-Aerosol Generating Procedures.

Cleaning and Disinfection

Surfaces should be frequently cleaned/disinfected, in both the clinical and waiting/check-in areas. Staff should follow standard disinfection protocol and use EPA approved disinfectants for COVID-19.

  • Non-porous, high-touch areas, and horizontal surfaces in common spaces (e.g. waiting areas) should be cleaned/disinfected on a frequent and consistent basis (at least twice per day).
  • Clinical areas and equipment should be cleaned/disinfected after each patient encounter or use.
  • For room disinfection (including in-room equipment):
    • After use by a known COVID+ patient in the first 10 days after diagnosis:
      • If patient’s mask was removed during the visit: wear gown, gloves, surgical/procedural mask, and eye protection.
      • If patient’s mask was NOT removed during visit: wear surgical/procedural mask and gloves.
    • After use by all other patients: wear surgical/procedural mask and gloves.
  • Hand sanitizer should be made available to patients and associates throughout the clinic.
    • Associates should perform hand hygiene before and after each patient encounter, after removing PPE, before and after eating, after handling specimens, and after using the bathroom.
    • Patients should be reminded to perform frequent hand hygiene.

PPE

The following grid outlines the appropriate level of PPE by scenario to ensure protection of all associates.

PPE for Ambulatory Locations

Beginning Monday, June 22, there will be a phased rollout of eye protection for all associates. All associates and physicians during any patient interactions in the clinical environment, regardless of COVID-19 or Person Under Investigation (PUI) status, will be initiated.

Please refer to the Eye Protection Poster for a guide to approved eye protection.

The document below outlines the appropriate PPE for procedures on COVID-19 negative and non-PUI patients . Click on the image for further detail.

PPE for Office Based Procedures on Patients without COVID-19 Symptoms

For Pre-op Testing on Asymptomatic Patients

Associate/provider should wear gloves, eye protection, and surgical or procedural mask

For non-COVID/non-PUI Patient Visits

Associate/provider should wear a surgical or procedural mask, eye protection, and use standard precautions

For Known COVID+ Patient Visits

In-person visits:

  • Days 1-10 after COVID-19 diagnosis:
    • If patient’s mask remains in place, associate/provider wears surgical mask, eye protection, and gloves.
      • Temporal temperatures are preferred. If an oral temperature is taken, patient should slightly lift their mask (does not remove).
    • If patient’s mask will be removed, associate/provider wears surgical mask, eye protection, gown and gloves.
  • Day 11 after COVID-19 diagnosis and beyond:
    • Associate/provider wears surgical mask, eye protection, and use universal precautions.
  • Selected, highly-immunocompromised patient populations (e.g., transplant patients) returning for office visits or procedures in the clinic should be managed on a case-by-case basis with local Infection Prevention and/or Infectious Disease input, as PPE requirements may vary.

Aerosol Generating Procedures:

  • If an AGP must be performed within 30 days of COVID-19 diagnosis, then full COVID-19 precautions (eye protection, N95, gown and gloves) should be used and appropriate room cleaning/disinfection and air handling requirements should be followed.

N95 Seal Checks

If an N95 is necessary per the guidelines above, a seal check should always be performed prior to use. Refer to the videos below for instructions on how to properly perform a seal check:

How to Perform a Seal Check: Key Steps

How to Perform a Seal Check: Full OSHA Instructions

Additional Resources for Ambulatory Practices

Who to Test: Green/Yellow Testing Algorithm

Return to Work Guidance for Patients who are Non Healthcare Workers

Ambulatory Pneumonia Guidelines for COVID Positive or PUI Patients

COVID-19 Outpatient Rehabilitation Referral

Plasma Study

We are seeking plasma donors who tested positive for COVID-19 and are now fully recovered. Patient flyers are provided in English and Spanish.

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