Infection Mitigation in Outpatient Settings

COVID-19 - Infection mitigation in outpatient settings

Infection Mitigation in Outpatient Settings

This provides guidance to outpatient addiction treatment providers 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.

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Updated: 6/30/20

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Infection Control and Mitigation 

This provides guidance to outpatient addiction treatment providers 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 is likely to increase risks associated with substance use and substance use disorder – due to the anxiety, social isolation, and stress associated with the pandemic 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.

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.
  3. Likelihood of spreading Covid-19 to other persons.

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

Topics:

Reopening

While many places across the country are starting to relax physical distancing restrictions, the COVID-19 pandemic is not over. Communities and treatment programs across the country remain at risk for increasing population prevalence over time.

Phone Screening Before Arrival: When possible, scheduled patients should be pre-screened by phone for symptoms consistent with Covid-19 (fever, cough, and shortness of breath), recent contact with anyone who has tested positive for COVID-19, or close contact with others who have symptoms of COVID-19 but have not yet been tested. Appointment may be deferred or converted to telehealth if clinically appropriate. If an in-person visit is deemed clinically necessary for 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 recommendations below.

Screening and Triage Upon Arrival: All patients should be screened for symptoms consistent with Covid-19 (fever, cough, shortness of breath) recent contact with anyone who has tested positive for COVID-19, or close contact with others who have symptoms of COVID-19 but have not yet been tested on arrival to their appointment prior to entering a waiting area. Screening may include checking temperatures for fever if this is feasible. Patients should also be screened for known contacts with individuals who have either screened positive for COVID-19 or have symptoms of COVID-19 but have not yet been tested.

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 the items above should be isolated from other patients/staff (as below), if seen, or have their visit deferred (or transitioned to telehealth), if clinically appropriate. Patients with cough should be provided a mask, if available, or tissues to cover their nose and mouth.

If a patient screens positive for symptoms refer them to be evaluated by a medical provider, ideally over the phone.

Depending on testing in your area, consider referral to a testing center. If no testing is available, and the patient has mild symptoms and has no high-risk factors, 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 high risk factors, consider referring to the ED. Advise the ED that you are referring a suspected patient with COVID-19.

If in doubt, contact your local Department of Public Health.

Isolation: When a patient arrives in an outpatient practice or clinic and the initial screen is positive for symptoms consistent with COVID-19 (fever, cough, and shortness of breath), recent contact with anyone who has tested positive for COVID-19, or close contact with others who have symptoms of COVID-19 but have not yet been tested. 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 when in contact with the patient. After the patient is seen and evaluated, the room should be cleaned with EPA-registered disinfectants.

Waiting rooms should be appropriately supplied with tissues, trash receptacles, alcohol-based hand sanitizer, 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. Instructions should include how to use facemasks (when needed), 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. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinic-preparedness.html

The CDC has several handouts and posters designed to educate patients about COVID-19 and good hygiene practices. https://www.cdc.gov/coronavirus/2019-ncov/communication/factsheets.html

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. The CDC recommends that:

See the CDC’s 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, according to the CDC, the PPE recommended when providing physical care for a patient with known or suspected COVID-19 includes:

  • Respirator or Facemask
  • Eye Protection (i.e., goggles or a disposable face shield that covers the front and sides of the face)
  • Gloves
  • Gloves

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.

See CDC’s 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 through intake into a SUD treatment practice or program. Telehealth-based strategies for new intakes should be considered when possible and appropriate.

See Telehealth 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.

See Telehealth Guidance