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Resumption of Services in Medical Practices during COVID-19

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Professional Guidelines Regarding Resumption of Services in Medical Practices during COVID-19

Preamble

Due to the COVID-19 pandemic many physicians discontinued or reduced many in-person non-essential and elective medical services and made practice accommodations to ensure patients received safe and timely care.

The flexibility and commitment of physicians during the COVID-19 pandemic has been critical in managing this public health emergency. The College thanks all physicians for their efforts in providing care using digital technology and limiting face-to-face contact to only urgent issues requiring physical examination of the patient.

As the public health measures imposed to limit the spread of COVID-19 are loosened, the College expects physicians to use professional judgment when providing care to patients in person. Physicians must continue to use due diligence in determining if offering face-to-face appointments is in the best interest of the patient, public and clinical staff. Resuming in-person practice should be a thoughtful and planned process to ensure all necessary measures are in place.

This document is intended to guide physicians in determining which services are reasonable to resume while ensuring that the appropriate safeguards and precautions are in place to provide protection for patients and health professional safety.  Physicians must assume any patient seen in person could be an asymptomatic SARS-2-CoV carrier.

Our knowledge of COVID-19 and of the best manners to respond to COVID-19 is evolving.  The College anticipates that the guidance in this document will evolve.  The College will regularly update this document.  Physicians are expected to remain current with this guideline.

Guidelines

1. Considerations Regarding Resumption of Services

As the knowledge of COVID-19 evolves, physicians will have to determine how best to deliver medical care and conduct business. College standards apply whether the care provided is virtual or in person.

The College recognizes the role virtual care/telemedicine plays in providing access to care in the pandemic as well as in remote or underserviced areas. The move to virtual care during the pandemic has identified a need for education and guidance to physicians on how to practice virtual medicine. 

Physicians are expected to follow the direction as provided for in the College’s Professional Standards Regarding the Provision of Telemedicine Services.  Physicians are also encouraged to review the Getting Started with Virtual Care toolkit developed by Doctors Nova Scotia as well as the Virtual Care Playbook developed by the Canadian Medical Association.

Using virtual care to assess what services should be offered in person is helpful. Virtual care should be used when a physical examination is not required. Medical services best suited for virtual care delivery include:

  • triaging patients;
  • managing acute illnesses that do not require a face-to-face visit; and
  • managing select patients with chronic disease.

The Canadian Medical Association advises that physicians can safely use virtual care to:

  • assess and treat mental health issues;
  • assess and treat many skin problems (photos submitted in advance provide resolution that is much better than the resolution of even a high-quality video camera);
  • assess and treat urinary, sinus and minor skin infections (pharyngitis too if you can arrange throat swabs);
  • provide sexual health care including screening and treatment for sexually transmitted infections and hormonal contraception;
  • provide travel medicine;
  • assess and treat conditions monitored with home devices and/or lab tests

(e.g., hypertension, lipid management, thyroid conditions and some diabetes care; in-person consultations will still be needed for some exam elements);

  • review lab, imaging and specialist reports; and
  • conduct any other assessments that do not require palpation or auscultation.

                                                                                              (source: CMA Virtual Care Playbook, page 6)

There may be other circumstances where a physical examination, procedure or diagnostic test is needed to ensure adequate diagnosis and treatment. The College advises physicians to stay current with the direction provided by Nova Scotia’s Public Health regarding screening criteria for COVID-19.

Factors to consider when deciding to bring a patient into an office, community or testing facility:

  • what is the acuity of the health problem?
  • is the care one which can only be provided in person?
  • is the onsite visit essential to the patient’s health and well-being?
  • is the medical benefit worth the risk of face-to-face contact to the patient, physician and office/hospital staff?
  • could delay in the care or tests result in a worst patient outcome?
  • talk to the patient about COVID-19 risks versus the need for medical care. Does the patient feel the benefit of therapy exceeds the risk of leaving their home?
  • will the care or tests prevent the need for a patient to access acute care in the foreseeable future?

                                                                                            (source: CPSA – COVID-19: Reopening practice)

2. Mitigating Risks

Physicians have an obligation to provide a safe environment for themselves, their patients and staff within their private offices. Physicians must ensure workplace measures are established to mitigate any risks from COVID-19.

a. Scheduling office appointments

  • Patients must be screened for risk factors and symptoms of COVID-19 prior to attendance at the onsite visit;
  • Office receptionists or answering machines can screen patients for COVID-19 symptoms;
  • Patients should be advised to self-screen the day of the appointment;
  • If a patient is requesting an appointment for a non-COVID-19 medical problem but screens positive for COVID-19 symptoms, the physician should know what local resources are available for in-person patient assessment and refer appropriately;
  • If exhibiting symptoms of COVID-19, patients should be told not to go to the physician’s office unless the office is set up to manage possible COVID-19 patients;
  • Some COVID-19 infected patients are asymptomatic. Health professionals must assume any patient seen in person could be a SARS-2-CoV carrier. Offices and clinics should adhere to physical distancing, separation from clinical staff as much as possible, all staff should wear masks, and minimize time spent in the waiting area;
  •  Request patients remain in their car and text/phone them when it is time to be seen;
  • Alternate between virtual and in-person visits to spread out the time between in-person visits;
  • Unless necessary to have additional support, ask the patient to attend the face-to-face meeting alone; and
  • For patients at higher risk for complications from COVID-19, consider scheduling strategies, e.g., first appointment of the day.

b. Office design

  • Optimize office space and patient schedule;
  • Have visible signage at the entrance reminding patients about COVID-19 symptoms and appropriate hygiene;
  • Ensure waiting room has ample hand sanitizer available for patients;
  • Ensure waiting area is set up to maintain appropriate distancing;
  • Arrange traffic flow to maximize physical distancing. Use visual clues (e.g., tape on floor) to assist patients in maintaining adequate distancing;
  • Remove toys, magazines, brochures and other shared items from the office space; and
  • Consider providing a barrier for the reception area such as glass or Plexiglas so staff won’t require a PPE.

c. Office procedures

  • Minimize office staff if possible. Determine what tasks can be done from home or outside regular hours;
  • Limit the number of patients in the waiting area;
  • Limit the number of examination rooms in use; and
  • Require staff to screen themselves for COVID-19 symptoms before beginning work.

d. PPE

  • Ensure the office has adequate PPE supplies and masks before opening to onsite visits;
  • Physicians in direct contact with patients must wear surgical masks (not N95);
  • Follow droplet and contact precautions when seeing symptomatic respiratory patients or suspected COVID-19. Isolate the patient in a single examination room; 
  • Patients who screen positive should be given a surgical mask and be advised to perform hand hygiene; and
  • Consider all patients as possible asymptomatic carriers and act accordingly.

e. Infection Control Measures

  • Follow routine cleaning and infection control measures and precautions and implement additional measures to control virus spread;
  • Build in extra time for cleaning and sanitizing examination rooms and equipment used during the patient visit;
  • Practice rigorous disinfecting of patient contact areas and common areas after each patient visit;
  • All staff must practice frequent hand washing or use health Canada approved hand sanitizer; and
  • Appropriately handle, clean, and dispose of masks, material, equipment and biomedical waste.

3. Suspected COVID-19 Positive Patient

Primary care providers should be familiar with their local COVID-19 testing centers and criteria for testing.

There may be patients who are seen in the clinic/office who shortly after the visit test positive for COVID-19. If appropriate clinic/office set-up and procedures are followed, the risk to the physician and staff should be minimal. If there is any doubt, contact Public Health for advice and possible COVID-19 testing and consider the need to temporarily close the clinic/office.

4. Physician Health

Physicians are serving patients in unprecedented times of uncertainty, resource limitations and personal risk. Physicians must consider not only their patients and staff well-being but their own health. It is important for physicians to monitor their own health and seek support if necessary. Considering the pandemic could play out for some time, physicians should implement strategies to deal with fatigue, stress and uncertainty.

Recommended Reading

College of Physicians & Surgeons of Nova Scotia 

Doctors Nova Scotia 

Nova Scotia Health Authority

Nova Scotia Department of Health & Wellness

Canadian Medical Association

Acknowledgements

The College of Physicians & Surgeons of Nova Scotia gratefully acknowledges the College of Physicians and Surgeons of Alberta’s Advice to the Profession – COVID-19: Reopening practice and the College of Physicians and Surgeons of British Columbia’s Resumption of Services in Non-Hospital Facilities in the preparation of this document.

Document History

Approved by the Council of the College of Physicians and Surgeons of Nova Scotia on: May 29, 2020

Approximate date of next review: 2023