Hello Ohio Doctors,
We hope this letter finds you well! Hopefully, you and your family stayed healthy during the lockdown and are now ready to get back to work. Before you do, there are some things you need to think about. This message will serve to give you some food for thought, so that when you get to work, you do it safely for your patients, staff and yourself. Please check with your state’s department of health and medical board regulations to make sure your office is in compliance with your local regulations. This checklist is intended for physicians practicing in Ohio.
There are several steps to take as you open your office to a full schedule, and range of procedures, during the coronavirus pandemic of 2020. I will list them in order:
1. Check with your state
First, check with your state for when you can resume normal medical office visits and medical/surgical procedures. In Ohio, medical offices were never shut down. Office visits could continue, if done in a safe manner, with social distancing and use of personal protective equipment (PPE). Non-medical offices can reopen as of May 1, 2020. Elective procedures were previously banned and emergent cases could only proceed at the physician's discretion. Elective procedures can now resume as of May 1, 2020, as long as the patient can be discharged the same day.
2. Prepare your office and staff for new safety measures
Prepare your office for the new paradigm of social distancing and required use of PPE. Every staff member should be screened on a daily basis for signs of illness and their temperature should be checked and logged. In Ohio, a ban on mass gatherings of more than 10 people remains in place. Restructure the office to minimize clustering of staff at break areas and patients in the waiting room or check out areas. All business offices can open as of May 1, but all employees in the offices need to wear masks. There are no clear guidelines that mandate visitors or patients in a doctor’s office or hospitals have to wear masks, but it would be prudent to encourage your patients to do so. Only patients should be allowed in your office; drivers and/or family members should not be allowed in the office. Of course, if the patient needs assistance from a family member or the patient is a minor, then one person may accompany them. Patients should be screened for signs of illness, asked about their travel history to any area where COVID-19 is highly prevalent (not just to China or other foreign hotspots), questioned about any loss of smell, and have their temperature checked. Ideally, screening is done outside the building and any staff member doing the screening would be wearing PPE. Patients may use their own personal mask in your office but if they don’t have one, you should provide one.
The office should be prepared for social distancing. The chairs in the waiting room should be spaced 6 feet apart and all excess chairs should be removed from the waiting room. All surfaces in the office that would be expected to come in contact with people should be wiped down at the start of the day, the middle of the day, and the end of the day. Any chair or table used by a patient should be wiped down after each use. The restrooms should be monitored, cleaned and wiped down after each use. Hand sanitizer is required in high traffic areas.
Any work that can be done from home should be encouraged. This might include back office work such as accounting, bookkeeping, insurance authorizations and billing. Staff work hours could be staggered such that work that doesn’t require the patient's presence can be done after clinic hours by staff coming in later in the day. Work stations in the office may need to be reconfigured to allow proper spacing between work staff. Telemedicine has gained much more acceptance and is now being used by most offices. This should be continued as offices open to a more regular schedule, as it will help to reduce patient traffic in offices.
Make sure you have an adequate supply of PPE for all medical and clerical staff in the office and for patients. Expect greater utilization of PPE than before due to increased use by staff and patients. You will need to maintain an adequate stock to remain open and be in compliance with Ohio Department of Health (ODH) recommendations. Each office will have to decide on the type of masks their staff will wear and whether face shields are needed.
3. Organize scheduling and maximize telemedicine
Telemedicine was encouraged by the US Government as a way to continue caring for the US population during this pandemic without exposing the patients or healthcare workers to the coronavirus. Just because the country is slowly opening up does not mean the virus is no longer a risk. Telemedicine involves communication with a patient who is not physically in the same room with the provider. The providers and patients who have used it have found it to be a nice way of delivering healthcare in the comfort of their own homes. Patients at home or work can take 15 minutes to do a follow up on the phone with the provider, rather than drive across town for a visit. We should continue to offer telemedicine for these reasons.
Right now, because of a waiver, the reimbursements for telemedicine visits that utilize audio or audiovisual communication can be coded as a standard evaluation and management visit code and receive the same reimbursement. It is uncertain if this will continue after the waiver period ends, whenever this public health emergency is over. Until then, we should incorporate telemedicine to the fullest in our offices to take advantage of its benefits in terms of social distancing, safety and convenience to the patients and healthcare providers. Since no patients are coming into the office for a telemedicine visit, these visits can be scheduled back to back, or closer together, without concern for social distancing in the office. During a day in which only telemedicine visits are scheduled, a schedule can be filled to the maximum; thus by using telemedicine, a clinic might actually see more patients in standard workday.
If patients will be brought to the office, then scheduled appointments will have to be spaced further apart so that social distancing can be accommodated in the office. That is, the appointments will need to be further apart to reduce the chance of patients crowding each other in the waiting room or office hallways. This will reduce the total number of visits an office can handle in a day. Ideally, patients will arrive at, or just before, the time of their appointment, receive their screening and temperature check and then get promptly taken to their rooms for their visit or procedure. When they are checked out this should be done in a way that also minimizes patient crowding. Also, no-touch, or non-contact, ways of payment should be explored such as Venmo, Zelle, PayPal or even just having the patient read out the numbers on their credit card to your receptionist. The patient should also be allowed to leave the office quickly and then the follow up visit can be scheduled later over the telephone or by email. During pre-appointment reminder calls, patients should be pre-screened, notified of new in-office measures and encouraged to wear personal masks to their office visit.
You may also want to consider the risks of performing pain procedures based on the patient’s age, medical history, physical condition and residence status (i.e. nursing home, assisted living). The attached American Society of Interventional Pain Physicians (ASIPP) toolkit contains recommendations on risk stratification.
4. Testing
If a patient is asymptomatic and has not had a reason to be tested for coronavirus before, what do you do? If the patient is coming in for a routine visit, then routine screening, including a temperature check, should suffice. Current Ohio Department of Health recommendations say coronavirus testing should be available in the office, but not that every patient should be tested. Testing all patients now may not be realistic due to limited testing availability. The American Society of Anesthesiologists (ASA) and The Anesthesia Patient Safety Foundation (ASPF) issued a joint statement on April 29, 2020. Testing might be reasonable for patients undergoing any procedure that might generate aerosolized droplets from the patient, such as intubation and general anesthesia for their procedure, or if they are undergoing any kind of procedure of the nose, mouth, face and/or neck. For pain procedures in awake patients where the airway, face and neck are not involved, testing may not be necessary if they are asymptomatic and pass all standard coronavirus screenings, including temperature checks. The ASA & ASPF essentially use the CDC guidelines, with variation allowed for areas where COVID-19 is or is not prevalent.
If a person has a history of a positive coronavirus test, elective procedures should be delayed until the patient is considered no longer infectious and has recovered. The CDC uses both test-based and non-test based strategies.
Test-based strategy
No fever without use of fever-reducing medicines.
Improvement of respiratory symptoms.
Negative results from two SARS-CoV-2 tests >= 24 hours apart.
Non-test-based strategy
Afebrile for 72 hours without use of fever-reducing medicines.
At least 7 days since the symptoms first appeared.
The ASA & ASPF do not feel that antibody testing has a role in perioperative screening and risk stratification.
5. Consent
Finally, as you open your offices, you should consider the use of a consent to explain the risks to your patients in this uncertain time. The consent should discuss the risks of leaving the safety of their own home to seek medical care and receiving medical treatments that might alter their response to the coronavirus should they get it (i.e., their infection may be more severe). An example consent can be found in the link below to the ASIPP toolkit for restarting your practice after the recent COVID-19 shutdown.
May you all stay safe and be healthy,
Ricardo Buenaventura M.D., M.B.A.
President, Ohio Society of Interventional Pain Physicians
Amol Soin M.D., M.B.A.
C.E.O., Ohio Society of Interventional Pain Physicians
Disclaimer: This letter and checklist aggregates guidelines and recommendations from the state of Ohio and other entities, and any questions or concerns about legality or standard of care should be addressed towards them. The links to each are included at the end. Recommendations from different organizations may be in conflict with each other and the reader will have to decide which one takes precedence.
Reopening the Office Checklist and Links
Check with your state and local officials about reopening during the coronavirus pandemic.
Prepare your office before reopening
Incorporate social distancing in your office scheduling and incorporate telemedicine.
Testing
Consent and Risk Stratification.
ASIPP toolkit, risk stratification guidelines and consent: ASSIP Toolkit
Also see the attached PDFs to the Ohio Department of Health’s Responsible Restart Ohio General Protocol and Healthcare Guide.