Coronavirus Pandemic
Practice Guide Suggestions for Physicians
UPDATED 3/23/2020
As part of Southwestern Health Resources' commitment to providing physicians and other clinicians the latest information to deal the COVID-19 situation, we will continue to provide the latest resources from the CDC, CMS and other authoritative sources. Our goal for this series of communiques is to review and condense this information for you and give you practical guides that will enable you to continue to provide care for your patients while keeping you, your patients, and your staff safe.

In the interest of keeping you current, SWHR leadership will send out a series of communications over the next several weeks. This document will provide you recommendations on how to transition into a virtual office and handle common patient situations you may face during this COVID-19 crisis in new and unique ways.

Along with this document, please find at the end of this communication the latest updates on pharmacy suggestions and an infection prevention decision tree.

Office and Staff
The safety of the physicians and staff should always remain top priority. Our first recommendation is to make your office staff into coronavirus experts. Make sure that they stay well informed about the coronavirus and COVID-19 infection as well as the proper means to prevent infection. Useful references include the following websites:


Establish and continually reinforce a policy that any person on your office staff should stay home if he or she becomes sick, especially if there are signs of respiratory illness (fever, cough, sore throat, difficulty breathing). Any ill individual should contact his or her PCP for recommendations.

Heightened office safety must always be maintained. Use of hand sanitizer or wipes is critical before a patient goes to an examination room. Keep non-essential office personnel to a minimum. Sanitizing before and after contact with patients, or surfaces that have been touched by several individuals (doorknobs, elevator buttons, office pens, clipboards, countertops, etc.) is important for office personnel. Hand washing with soap and water several times a day, regardless of contact is a good idea.

Any office worker who is febrile and who has symptoms of a respiratory illness should be tested for COVID-19. Ill personnel working at the office are a risk to others and should be sent home. If an office worker contracts COVID-19, the local health department will make a determination as to office closure for face-to-face office visits.

Convert your office into a virtual office as much as you can - NOW . Telemedicine is an important component for delivering care safely during the COVID-19 epidemic. Office hours become a mix of patient visits, and telehealth interactions with new and established patients. Attempts should be made to transition from face-to-face office visits to telephonic and visual telehealth visits to the maximum extent possible. When that occurs, it should be possible to minimize hours in which patients are at the office. It is prudent to space out office appointments, so your waiting room has adequate distance between patients. Physicians, advanced practitioners and nurses can all use the remaining hours the office is open to treat patients remotely.

Below we have assembled recommendations for several types of interactions with patients. These are only suggestions that should be used in conjunction with your clinical judgement.

Responding to Established Patients who call the Office
  • Triage the call to establish if the condition is emergent, urgent or elective. CMS defines an urgent condition individual as one who may be at risk to life or limb, or for whom a delay in care could reasonably be expected cause inability to recover function. The State of Ohio added accommodation for those in whom a delay would likely cause an advancement in cancer stage. Additionally, access if the patient is at risk or displaying symptoms of COVID-19.

  1. Do you have a fever, sore throat, cough or difficulty breathing?
  2. Have you had contact with anyone known or suspected to have coronavirus/COVID-19?
  3. Do you live in a community with confirmed sustained community transmission of COVID-19?
  4. In the last 14 days have you traveled domestically or intern

If the patient responds affirmatively to any of the four questions above, he or she
should not be seen in the office.

  • If the condition is elective, we recommend setting an appointment date for after June 1, 2020f the condition changes, timing of the appointment can be changed. Discuss the increased risk to the patient of an office visit during COVID-19, the increased risk to the patient’s family, and the increased risk to the community in case the patient is an asymptomatic carrier. If the patient still insists on being seen, refer to your physician who can carry out a telehealth consultation with that patient.
  •  If the condition is urgent, not related to COVID-19, and the patient has no symptoms of COVID-19, consider a telehealth visit (telephone or video) to determine per clinical judgement appropriate next steps (virtual management, office visit, urgent/emergent care visit).
  • If the condition is emergent, handle the patient per usual office protocol to get the patient to a facility that can handle the emergency. If there is reasonable suspicion that the patient has COVID-19, call the facility to which the patient is going and inform it of the patient’s condition so personnel can prepare for a possible COVID-19 patient.  


Non-Urgent Referrals and Non-Urgent Procedures
The CDC and American College of Surgeons have recommended rescheduling appointments for routine medical and surgical care (e.g., annual physical, office follow-up visits, elective surgery). We detail below specific recommendations on how to accomplish this in a manner that should result in little objection from patients.

CMS defines an urgent condition individual as one who may be at risk to life or limb, or for whom a delay in care could reasonably be expected cause inability to recover function. The State of Ohio added accommodation for those in whom a delay would likely cause an advancement in cancer stage.

  • PCPs should consider postponement of non-emergent referrals to specialists, if they are comfortable treating and following the conditions (e.g. non-incarcerated inguinal hernia, leg claudication). If there is doubt, they should consider calling their specialist colleague. Similarly, PCPs should postpone referral to imaging centers or labs if possible, d consistent with clinical judgement. They should educate family and caregivers, so they understand the thought process of postponement and its advantage of minimizing risk of contracting COVID-19.
  • Specialists should consider an initial telephonic consultation for new referrals, and try to postpone non-emergent surgery, lab, and imaging, again consistent with clinical judgement. It is now permitted to charge for these telephonic visits. The initial telephonic visit establishes a physician patient relationship just as a face-to-face visit does.
  • The office should proactively call all patients who have existing appointments before June 1, 2020, and make a disposition: postpone the appointment, change the appointment to a telephonic one, or have the patient come to the office if the other options are not suitable.
  • No patient should go to the physician office without calling the office first.
  • Procedural specialists should be aware of the recommendations recently published by the American College of Surgeons (COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures):
HOPD - Hospital Outpatient Department
ASC - Ambulatory Surgery Center
  • As with postponement of appointments it is important for the patients to know that it is in their interest to postpone their operation or procedure. They are not likely to agree to postpone an operation for public health benefit only. If they are not clear on the health advantages to themselves, the patients may seek a health care provider who will perform their procedure or operation without postponement. It is helpful to educate family members and caregivers concerning the reasoning for postponement as well, privacy considerations permitting. 
  • If a patient needs an urgent procedure, consider location of procedure (ambulatory surgery center, hospital outpatient department).Things to consider: risk of exposure, availability of beds if needed, staff availability.

Responding to New Patients who call the Office
  • The general approach is the same as for an existing patient. Differences arise due to the lack of having established a relationship with the patient.
  1. If the condition is elective, a typical response to your attempt to postpone an appointment may be for the prospective new patient to seek care elsewhere, whether from another physician, or a facility. If the prospective patient does this, there is increased risk for that person, for the community, and for health care providers. It is therefore important to explain the rationale for a postponed appointment. Patients worried about a health condition may not respond to concerns of increased risk to the community and to health care personnel. They should respond to a realistic explanation of increased risk to themselves if they are scheduled for an early appointment, and lack of increased risk with postponement due to having an elective condition.
  2. If appropriate, even if the elective condition cannot be fully treated, offer to get started with a telephonic new patient visit.
  3. Offer to review the patient’s records and imaging, discuss the medical situation with the patient’s PCP as indicated, followed by a telephonic visit. If the condition is then determined not to be elective, and if an office visit is indicated, the appointment can be revised.
  • As this is a prospective new patient, you have the same discretion to not accept the patient into a physician-patient relationship as you would before COVID-19 (with the usual legal and ethical requirements that must be met). It is important to minimize the chances that a prospective patient will “doctor shop” if you are not going to accept the person as a new patient. This should help mitigation of public health risk from spread of COVID-19. Therefore, please attempt to provide guidance to the prospective patient concerning what type of physician would be appropriate to handle that person’s condition. Even better, recommend specific physician(s) and offer to call the physician to advise that the prospective patient may be calling. You might also consider relaying your COVID-19 office protocol for postponing appointments for elective matters to the accepting physician and communicate that you consider this an important public health measure.

Responding to Patients who arrive unannounced to your Office
  • Before the patient enters the office, establish if there is reasonable risk that the patient is infected or is a carrier of COVID-19.
  1. Ask the same questions that are in the telephonic survey above.
  2. Take the patient’s temperature.
  • If the patient is febrile, has symptoms of COVID-19, or answers any of the survey questions affirmatively, discuss with the patient that he/she should not be at your office as this presents a risk to other patients, to the office staff and physician. Have the patient go home unless symptoms warrant a hospital admission. Counsel against going to an ED or urgent care center, both from the standpoint of exposing others, and because your office will treat the patient faster and better by telephonic office visit than the care he or she would receive in the ED or urgent care center. Have the patient set up a telephonic office visit as soon as he or she returns home.
  • There have been cases in which the patient is not truthful in answering the survey questions due to a desire to be seen at the office regardless of consequences to others. If a patient is found likely to be infected by COVID-19 or thought to be a carrier after he or she is placed in the exam room, use your best clinical judgement. Consider terminating the examination and sending the patient home as in bullet point 2 above, for a telephonic office visit.

After Hours Information
After hours reference information is available for physicians through the Texas Health Resources Clinician COVID-19 Hotline: 682-236-2101 . Patients can talk to a nurse 24 hours a day, 7 days a week through the Texas Health Nurse Hotline: 682-236-7601.

References
Click here to access an article that discussed the current epidemiology of COVID-19 in many countries. It also has useful and interesting analogous epidemiological information from the “Spanish” Flu pandemic of 1918. It is a long read, but you will appreciate the need for aggressive public health measures after reading it. 

Additional Reference Documents
Southwestern Health Resources | www.southwesternhealth.com