Infection Mitigation in Outpatient Settings

INFECTION CONTROL AND MITIGATION STRATEGIES IN OUTPATIENT SETTINGS

A guide for addiction treatment clinicians and programs working to treat patients with substance use disorders safely and effectively during the COVID-19 pandemic1.

For additional recommendations for the Ongoing Management of the Continuum of Addiction Care during COVID-19, please click here.

INFECTION CONTROL AND MITIGATION STRATEGIES IN OUTPATIENT SETTINGS

Purpose of the document

This document provides guidance to outpatient addiction treatment clinicians and programs (ASAM Levels 0.5, 1, 2.1, 2.5, OTP and OTS) when developing infection control procedures to address the COVID-19 pandemic. In addition to the risks associated with COVID-19, the current crisis has increased risks associated with substance use and substance use disorder – due to the anxiety, social isolation, and stress associated with the pandemic and its response. It is critical that addiction treatment services remain accessible throughout this crisis. Treatment programs should focus on infection control and mitigation within the facility and strategies for providing remote treatment services where possible.

Download Guidance

Updated: 9/18/20

 Principles:

  1. Protect patients and staff from coronavirus infection.
  2. Maintain access to addiction treatment services.
  3. Maintain a therapeutic environment for patients with SUDs.

Considerations:

  1. Acuity of SUD treatment needs.
  2. Medical risk if infected with Covid-19 virus.
  3. Likelihood of spreading Covid-19 virus to other persons.

Note: This guidance does not supersede any regulations, emergency proclamations, or directions from local, state and federal officials.

Topics:

Phone Screening Before Arrival: When possible, scheduled patients should be pre-screened by phone for symptoms consistent with COVID-19 (fever, cough, shortness of breath, new loss of taste or smell), recent contact with anyone who has tested positive for COVID-19 or is awaiting their COVID-19 test result, or close contact with others who have symptoms of COVID-19 but have not been tested. Appointment may be deferred or converted to telehealth if clinically appropriate. If an in-person visit is deemed clinically necessary for a patient with identified risk for COVID-19, the patient should be isolated from other patients and steps should be taken to minimize risk for exposure of staff. See Managing Patients Who Screen or Test Positive for COVID-19 Acute Infection.

Screening and Triage Upon Arrival:

All patients should be screened, on arrival to their appointment for symptoms consistent with COVID-19 (fever, cough, shortness of breath, new loss of taste or smell), recent contact with anyone who has tested posi-tive for COVID-19 or is awaiting their COVID-19 test result, or close contact with others who have symptoms of COVID-19 but have not been tested. This screening procedure should occur prior to the patient entering an area with other individuals. This might be at the front door of a facility or in a specially designated, separate screening area immediately inside the front doors. Screening may be done through an app survey (such as one developed by the Veterans Administration ttps://www.va.gov/covid19screen/), or a physical person wearing appropriate personal protective equipment (PPE). Signs denoting the signs and symptoms of COVID-19 should be posted at entry to the facility and in public areas (e.g. waiting rooms, hallways, exam rooms). Screening should include checking temperatures for fever if this is feasible (e.g., contactless thermome- ters or infrared temperature screeners). Patients should also be screened for exposure to known individuals who have either tested positive for COVID-19, are awaiting the results of their COVID-19 test, or have symptoms of COVID-19 but have not been tested within the last 14 days.

All individuals who enter a facility should wear masks; either cloth-based or surgical masks are acceptable. If an individual does not have a mask, the staff should provide a mask upon entry. Mask usage should strongly be considered mandatory for all patients as long as they are in the facility.

If the patient appears seriously ill, consider calling emergency medical services, letting them know you suspect COVID-19. Place the patient in an isolated area of the clinic.

Patient who screen positive based on screening procedures should be isolated from other patients/staff, if seen, or have their visit deferred (or transitioned to telehealth), if clinically appropriate. All individuals in this situation who need to be in the facility should wear masks; either cloth-based or surgical masks are acceptable. Facemasks with exhalation valves or vents are not recommended as they do not provide source control of respiratory droplets.

If a patient screens positive for symptoms of COVID-19, promptly refer them to be evaluated by a medical provider, ideally over the phone and as soon as possible. This medical provider should be able to appropriately evaluate the patient’s symptoms and recommend next steps..

Depending on COVID-19 testing availability in your area, consider referral to a testing center. If no testing is avail- able, and the patient has mild symptoms and has no risk factors for severe COVID-19 illness, recommend self-isolation and provide education about red-flag symptoms that would indicate the patient should go to the emergency department (ED). If the patient appears ill or has risk factors for severe COVID-19 illness, consider calling an ambulance or referring to the ED. Advise the 911 dispatcher or ED that you are referring a suspected patient with COVID-19. 

Isolation:

Several options can be considered for isolating a patient who arrives in an outpatient practice or clinic and the initial screen is positive for symptoms consistent with COVID-19 (fever, cough, shortness of breath, new loss of taste or smell), the patient has had recent contact with anyone who has tested positive for COVID-19 or is awaiting their test result, or there has been close contact with others who have symptoms of COVID-19 but have not been tested. These options include having the patient wait outside, in their car, or in a separate private area, if medically appropriate. They should be moved as quickly as is reasonable to a private exam room with the door closed. Staff should use appropriate PPE (facemask and face shield at a minimum, gown and gloves if avail-able) when in contact with the patient. After the patient is seen and evaluated, the room should be cleaned with EPA- registered disinfectants. Staff should make sure to wash their hands, adhering to effective hand washing technique.

Quarantine and isolation can increase stress, anxiety, and feelings of loneliness that may serve as triggers for increased substance use. Patients who are quarantined or isolated due to COVID-19 may well benefit from increased outreach by phone or other telehealth technology from clinic staff. Keeping in touch with patients also allows for coordinating when patients may be eligible to return for any necessary in-person visits.

Increased understanding of COVID-19 infection indicates that once a patient tests positive for the COVID-19 virus, that test may remain positive for a number of weeks. This does not necessarily indicate continued infectiousness. Therefore, testing based strategies for determining when a patient may return to an outpatient setting are no longer recommended by the CDC. Rather, most patients who developed milder severity COVID-19 illness may discontinue isolation 10 days after symptom onset and with symptom improvement, including the absence of fever without the use of fever-reducing medications for at least 24 hours. Patients with a positive COVID-19 test result who never developed symptoms may discontinue isolation 10 days after the date of their first positive RT- PCR test for SARS-CoV-2 RNA. Only patients with severe COVID-19 illness may need isolation for up to 20 days after symptom onset due to the longer duration of infectiousness. If in doubt, contact your local Department of Public Health.

 

Waiting rooms should be appropriately supplied with tissues, trash receptacles, alcohol-based hand sanitizer not containing methanol, and patients and staff should have access to sinks with soap. Fomites such as toys, reading materials, and other communal objects should be removed or regularly cleaned in accordance with CDC disinfection guidelines. For example, toys and reading materials could be available upon request and cleaned between each use. Seats should be placed 6 feet apart with barriers between them, if this is possible.

Facilities should provide patients and staff with instructions on hygiene and cough etiquette and information related to signs and symptoms of COVID-19. Instructions should include how to use facemasks (ensuring cover- age of nose and mouth), how to use tissues to cover nose and mouth when coughing or sneezing, how to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.

Messages could include warning about avoiding hand sanitizers containing methanol as this can lead to significant harm and poisonings if ingested. (see the CDC’s Clinic Preparedness Recommendations and warnings from the Food and Drug Administration (FDA).

Monitoring Staff for COVID-19 Symptoms: All staff should be screened for COVID-19 symptoms and referred for testing as appropriate to prevent transmission within the facility. Self-screening apps have been used by some employers; whether using an app or simply through self-assessment, staff should be aware of their own symptoms and health status prior to proceeding to work with patients.

The CDC recommends that:

  • Personnel who develop respiratory symptoms (e.g., cough, shortness of breath, new loss of taste or smell) should be instructed not to report to work.
  • Facilities and organizations providing healthcare should implement sick leave policies for healthcare providers that are non-punitive, flexible, and consistent with public health guidance.
  • Movement and monitoring decisions for healthcare professionals (HCPs) with exposure to COVID-19 should be made in consultation with public health authorities. Refer to the Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Health- care Setting to Patients with Coronavirus Disease 2019 (COVID-19) for additional information.

Testing based strategies to determine return to work are no longer recommended for healthcare professionals. Rather, symptoms and an understanding of the immune status of a healthcare professional should drive return to work decisions. See the CDC’s updated return to work criteria for healthcare providers: https://www.cdc.gov/ coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html

Staff use of Personal Protective Equipment: While staff not providing physical care to patients should maintain distance and wear a face covering (either cloth-based or surgical mask) while in the healthcare facility, according to the CDC, the PPE to be worn when providing physical care for a patient with known or suspected COVID-19 includes:

  • Respirator or Facemask covering nose and mouth
  • Eye Protection (i.e., a disposable face shield that covers the front and sides of the face; goggles are no longer recommended by the CDC)
  • Gloves
  • Isolation Gowns

Staff should be trained and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

Given increased community transmission of the COVID-19 virus, including that by asymptomatic individuals, in progressively larger parts of the country, strong consideration should be given to the adoption of universal precautions when caring for all patients, not only those with known or suspected COVID-19. Universal precautions for staff caring for patients should include at least a surgical mask or other medical-grade mask that covers the nose and mouth. A face shield, if available, in addition to a facemask, will also protect the eyes and mouth. At minimum PPE should include a surgical mask. Masks with exhalation valves or vents are not recommended as they do not provide source control of respiratory droplets.

Data increasingly demonstrate the effectiveness of facemasks and coverings in reducing transmission of the COVID-19 virus (See NEJM’s article about PPE use and COVID-19 and WHO’s guidance on Safety of Health Workers).

Signs in staff lounges, restrooms, conference rooms, or other common areas can help remind staff about the importance of wearing face coverings and washing hands immediately before and especially after any contact with their face covering.

See CDC’s updated Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings for more details: https://www.cdc.gov/ coronavirus/2019-ncov/infection-control/control-recommendations.html

See the CDC’s guidance on optimizing supplies of PPE: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ ppe-strategy/index.html

The short-term risk of morbidity and mortality from an untreated SUD should be balanced against the risk of potential COVID-19 exposure when considering whether to take on new patients into a SUD treatment practice or program. Recognition should be given to the possibility of worsening SUD in light of heightened stress, anxiety, and isolation caused by the COVID-19 pandemic. Telehealth-based strategies for new intakes should be consid- ered when possible and appropriate.

See Supporting Acess to Telehealth for Addiction Services Guidance

When clinically appropriate, based on the acuity of the individual patient’s SUD treatment needs and medical risk factors, non-urgent visits should be deferred and/or converted to telehealth or telephone visits if appropriate and if the technology is available. Recognition should be given to the possibility of worsening SUD in light of heightened stress, anxiety, and isolation caused by the COVID-19 pandemic.

See Supporting Access to Telehealth for Addiction Services Guidance

1This resource was developed by a Task Force appointed by ASAM’s Executive Council. To enable more rapid development and dissem- ination it was not developed through ASAM’s normal process for clinical guidance development that is overseen by the ASAM Quality Improvement Council.

 

CONTENT DISCLAIMER

This Clinical Guidance (“Guidance”) is provided for informational and educational purposes only. It is intended to provide practical clinical guidance to ad- diction medicine physicians and others caring for individuals with substance use disorders during the COVID-19 pandemic as it unfolds. Adherence to any recommendations included in this Guidance will not ensure successful treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results.

The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances pre- sented by the individual patient, and the known variability and biological behavior of the medical condition.

This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies may require revisions to the recommendations in this Guidance to reflect new data. ASAM does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.