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Preparing Ambulatory Care for COVID-19


Sylvia Garcia-Houchins, MSN, RN, CIC, director of infection prevention and control 

We’re very concerned for our ambulatory care organizations and the unique challenges they face in preventing transmission among patients. Two weeks ago, our Executive Director for Ambulatory Care Services, Pearl Darling, blogged about basic suggestions for addressing the COVID-19 outbreak. During the past few weeks, we’ve had more time to digest the situation and start planning for the days, weeks and months ahead. It’s important to stay in contact as the situation progresses.

Recognizing Symptoms
First of all, it’s critically important to keep your staff healthy. 

Even though COVID-19 is mild and moderate in most people, it’s essential to recognize the symptoms in your patients. It’s most crucial to know the common symptoms: a fever and dry cough. Close to 90% of cases had a fever and two-thirds had a dry cough. The third most common symptom was fatigue, which occurred in 40% of cases.

Per the Centers for Disease Control and Prevention (CDC), COVID-19 emergency warning signs include:

  • difficulty breathing/shortness of breath
  • chest pain/pressure
  • new confusion 
  • bluish lips and face

Social Distancing in Ambulatory Care Settings
By now, we’ve all heard about the importance of staying 6 feet from others. COVID-19 is transmitted via droplets and fomites during close, unprotected contact between an infector and infected. 

In China, airborne spread was not reported for COVID-19 and is not believed to be a major driver of transmission based on available evidence. However, it can be envisaged if certain aerosol-generating procedures are conducted in ambulatory care organizations.

Social distancing takes on a whole new meaning in ambulatory care settings and requires some planning. The goal of respiratory etiquette is to stop the dispersal of droplets with a mask, a tissue, an elbow or a sleeve. 

Here are some tips to minimize the chance of exposure in ambulatory care settings.

Before Arrival: 

  • Consider phone and virtual visits (more about telehealth below)
  • Plan for ill patients who need to be seen in person
  • Limit waiting room time or have patients wait outside or in their vehicle

At Arrival:

  • Provide signage and screen for symptoms
  • Ask patients to wait outside and sit at least 6 feet apart
  • Have masks, tissue and hand hygiene products available
  • Encourage respiratory hygiene and social distancing

After Visit:

  • Clean and disinfect surfaces
  • Open windows and doors to increase air circulation

Case Management and Telehealth
During this crisis, telehealth will be a more readily available option as certain HIPPA rules have been temporarily relaxed by the U.S. Department of Health and Human Services (HHS) to allow informal care between providers and patients who are socially distancing/quarantined. Patient encounters can now occur via Skype connections, for example, per the Telehealth 1135 waiver and expanded Medicare telehealth coverage. 

Going Forward
Your ambulatory care organization can provide reassurance and reduce stigma for your patients by addressing potential concerns, fears and anxieties regarding COVID-19 by reiterating these simple hygienic precautions and practices. Visit our COVID-19 site for important updates and resources.

Sylvia Garcia-Houchins is the Director of Infection Prevention and Control in the Division of Healthcare Improvement at The Joint Commission. Garcia-Houchins has over 30 years of experience in infection control in both hospital and long-term care settings, as well as eight years of clinical microbiology experience. Most recently, she served as the Director, of Infection Control at the University of Chicago Medicine and was also an intermittent consultant for Joint Commission Resources, Inc.