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Managing COVID-19 in Our Ambulatory Care Environments


Darla VanPutten Adams, MD, ambulatory care surveyor

Editor’s note: The information provided below is also available in webinar format at this link.

I’ve had 20 plus years of experience as a family physician and 17 years as an ambulatory care surveyor, and it’s safe to say COVID-19 has challenged almost every aspect of our practice.

As we’re all aware, COVID-19 has now spread through all 50 states and worldwide. Ambulatory care organizations are at different points in the spectrum of the pandemic impacting their geographic area. Sooner or later, COVID-19 will impact your community.

Protecting Health Care Workers
Since health care workers are exposed at much greater levels to respiratory droplets, their infection risk with COVID-19 can be up to 20% higher than the general population.

There’s been a tremendous amount of emphasis on the types of personal protective equipment (PPE) needed as well as lack of it. However, PPE is just one component of the controls needed to manage the spread of COVID-19 and overall, it’s the least effective means of preventing virus transmission. 

We’ve reached the point in this crisis that we need to assume all patients entering facilities are potentially infected with COVID-19. The best solution to this infection prevention dilemma is, when practical, to keep most individuals out of your facility. Delaying and rescheduling elective and non-emergency procedures will help your ambulatory care organization preserve much-needed PPE.

Consider utilizing tools such as:

  • advice lines
  • patient portals
  • online self-assessment tools 
  • video or telehealth triage pre-screening 
  • outdoor triage

Admittedly, this can become complicated with different patient conditions and special populations such as:

  • prenatal patients
  • patients with HIV
  • undocumented, homeless, migrant and seasonal patients without access to smart phones or other communication options

Encouraging Masking for Patients
Anytime a patient enters your organization, be they symptomatic or asymptomatic, it is important to practice source control.

Source control is a term used to describe measures intended to prevent infected individuals from spreading disease. In the context of COVID-19, source control includes the practice of wearing a mask to reduce the likelihood of transmitting the COVID-19 virus.  

Ambulatory care organizations are caught in a tough spot. On one hand, they need to preserve PPE so they have adequate supply to protect staff AND on the other hand, they need to make sure people entering their facilities are appropriately masked so they are not unknowingly spreading infection to staff or other patients. 

Some organizations will no longer permit entry to unmasked patients. Others are reaching out to local churches and charitable groups for mask donations, providing online instructions or handing out instruction sheets and supplies on how to make masks while waiting in the car for an appointment. Organizations are also purchasing bandanas and showing patients how to fold them for use upon arrival.

Make sure the signage in your facility has the most updated guidance on masking and social distancing. Many materials were developed earlier in the pandemic and don’t include current guidance on masking.

PPE Considerations
Leaders need to ensure that staff is familiar with different isolation levels and what that means in terms of required PPE.

Once your staff is knowledgeable about appropriate PPE, leaders need to ensure staff is comfortable regarding how to don and doff PPE (as shown in this video). Numerous studies have shown it is during the doffing of PPE that many staff end up exposing themselves and possibly others. In addition, if staff members don’t feel comfortable donning and doffing PPE, they may waste supplies, making actual or perceived mistakes, and/or use items unnecessarily. The key is ensuring all employees within your organization are receiving the same message about PPE.

Choosing PPE Based on Exposure
PPE should be chosen based on anticipated exposure. Aerosol-generating procedures are likely to induce coughing and result in the release of high numbers of respiratory droplets. Ambulatory care organizations need to be mindful of providing nebulizers, which were recently shown in a Centers for Disease Control and Prevention (CDC) report to have been the source of infection for staff who then went on to develop COVID-19.

Consider whether a nebulizer treatment is necessary, or if an inhaler with a spacer will suffice for your patient. Alternatively, it’s possible to start treatment and delay entry back into the room until droplets have had time to settle. More severe asthmatics may need to be set up with a home nebulizer with strict criteria for follow up. Each organization must consider what works for their specific patient population.

Respiratory Protection
The Joint Commission has released mask considerations when caring for known or suspected COVID-19 patients as well as has offered support statements for health care workers bringing masks from home.

We’ve also received lots of questions regarding the reprocessing of N95 masks. Well-intended health care leaders are jeopardizing staff safety by decontaminating these N95 masks inappropriately, based on incorrect information in the media. Actions such as spraying masks with disinfectant may be harmful  to the wearer of the mask and should only take place if approved by the manufacturer.  

The Joint Commission has published more information on disinfecting and decontaminating single use respirators here.

There is a great deal of information circulating in the media about COVID-19 and it’s easy to get caught up in hypothetical situations. The key is using credible sources for information and planning.

Even after an effective vaccine for COVID-19 is realized, organizations will need to implement all these strategies to prevent or mitigate the spread of emerging infectious diseases. This pandemic has been a “trial by fire,” but the skills we’re learning today will serve us for many years to come. Stay strong!

Dr. Darla VanPutten-Adams has been a Joint Commission surveyor since December 2003. She is trained under the Accreditation Manuals for Ambulatory Care and Office-Based Surgery. She is also trained to conduct unified ambulatory care surveys (relative to the Federal Bureau of Primary Health Care program’s expectations under the BPHC Accreditation Initiative), as well as deemed status, AHC systems, sleep centers, teleradiology, and mobile imaging surveys. Upon completion of her residency in Family Medicine at St. Medical Center in South Bend, Indiana, she worked for nearly 20 years at Southern Dominion Health Systems in Victoria, Virginia, a community health center funded under the 330-grant program. She held the position of Medical Director for 15 years prior to joining The Joint Commission.