Operational Considerations for Infection Prevention and Control in Outpatient Facilities: non-U.S. Healthcare Settings

Summary of Recent Changes

1. Background

This document outlines strategies to implement infection prevention and control (IPC) guidance in non-U.S. outpatient facilities in areas of widespread community transmissionexternal icon of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the coronavirus disease-2019 (COVID-19). Clinics and other facilities that provide outpatient services play an important role in a healthcare system’s response to COVID-19 and are critical to provide continued essential health services. This information complements available IPC guidanceexternal icon for COVID-19 from the World Health Organization (WHO).

2. Target Audience

These operational considerations are intended for use by health workers, including managers and IPC teams at outpatient facilities in non-U.S. healthcare settings. Outpatient facilities can include:

• hospital-based outpatient clinics
• nonhospital-based clinics
• community health centers
• physician offices
• alternate care sites

3. Objectives

The purpose of IPC in outpatient facilities during the COVID-19 pandemic is to:

• prevent outbreaks and transmission of SARS-CoV-2 at the facility,
• maintain essential health services to prevent indirect sickness and death from vaccine-preventable or chronic diseases, and
• ensure that outpatient facilities remain safe places for patients to seek care for essential health services as well as acute illness.

4. Responsible Personnel to Implement IPC in Outpatient Facilities

IPC activities in outpatient facilities should be planned, carried out, and supervised by designated health workers with IPC experience (i.e., IPC team or an IPC focal point). In accordance with WHO guidance on core componentsexternal icon of IPC programs, district and national IPC management should support facility IPC focal points. For example, district- or national-level IPC management can help ensure availability of supplies to support good IPC practices, support education and training of the healthcare workforce, and provide feedback on outcomes. This role for district or national IPC programs is especially relevant during the COVID-19 pandemic. In settings with limited or no IPC infrastructure, establishing minimum requirementsexternal icon for national- and facility-level measures to protect patients and health workers is critical.

5. Key Considerations for Outpatient Facilities

There are four operational steps to consider when planning outpatient service continuation in the context of COVID-19:

1. Prepare health workers and facilities to receive patients with suspected or confirmed COVID-19.
2. Rapidly identify and isolate patients with suspected COVID-19.
3. Modify outpatient service delivery to maximize patient and health worker safety.
4. Implement IPC for alternate care sites (e.g., community-based locations such as unoccupied schools, stadiums, etc.) and non-facility-based care (e.g., mobile medical units).

A. Prepare health workers and facilities to receive patients with suspected COVID-19

Patients with suspected COVID-19 will likely present to outpatient facilities. Optimizing facility preparedness to receive patients with COVID-19 symptoms can help limit the exposure risk for other patients and health workers. When community transmission of SARS-CoV-2 is suspected, facility leadership and the IPC focal point should review IPC guidanceexternal icon and operational considerations for healthcare facilities and follow national IPC guidance to prepare facilities to safely triage and manage patients with COVID-19 symptoms. Consider the following measures:

Infrastructure and healthcare workforce for IPC

• Designate a health worker who is trained in IPC to be the IPC focal point, responsible for implementing the facility’s COVID-19 prevention measures. The IPC focal point, in collaboration with other relevant people, should coordinate and apply various activities in the facility:
  • Communicate with local public health authorities to understand protocols for reporting suspected or confirmed COVID-19 patients and mechanisms to request supplies or other support.
  • Establish engineering controls or structural changes to the facility that reduce SARS-CoV-2 transmission (e.g., installing physical barriers like glass or plastic shields at screening and triage stations, improve indoor ventilationexternal icon).
  • Determine the need for supplies for hand hygiene, personal protective equipment (PPE), and cleaning and disinfection, and the ordering frequency.
    • Assess availability of hand hygiene supplies and ensure supplies are readily accessible. Alcohol-based hand rubs with 60% to 95% alcohol should be used in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred to soap and water.
    • Determine amounts of PPE supplies needed to employ contact and droplet precautions for patients with suspected or confirmed COVID-19. These supplies include medical masks, ^[1] eye protection (face shields or goggles), gloves, and gowns.
      1. Monitor the use of these supplies. The information can be inserted into a PPE burn rate calculator to help plan the use of PPE.
      2. Apply strategies for optimal use of PPE following WHO rational use of PPEexternal icon.
      3. Develop contingency PPE plans in case of supply shortages.
    • Calculate supply quantities needed to clean and disinfect medical equipment (e.g., stethoscopes) and frequently touched surfaces (e.g., chairs and door handles) at the facility at least once a day.
  • Coordinate and ensure training for relevant health workers on the following
    • Standard and transmission-based precautionsexternal icon
    • Appropriate use of PPEexternal icon
    • Cleaning and disinfectionexternal icon practices
• Develop a system to screen health workers for exposures to COVID-19 or signs and symptoms of COVID-19 before entering a building. The system may include self-reporting symptoms that suggest COVID-19 (e.g., cough, myalgias, fatigue, headaches), objective checks for fever (temperature higher than 38^oC), or a combination of bothexternal icon.
  • If a health worker has been exposed to someone with suspected or confirmed COVID-19, they should consult with an occupational health focal pointexternal icon. Based on an assessment of risk factors, the health focal point can recommend quarantine and testing.
  • To ensure consistent reporting of COVID-19 symptoms, health workers could be advised to report to their supervisor (or send a text message to their supervisor) before beginning their workday to review a standard list of symptoms and confirm they do not have any.
• Review sick leave policies for health workers and ensure they are flexible and consistent with public health guidance to encourage health workers who are ill to stay home.
• Establish policies and procedures for health workers who develop symptoms or signs of COVID-19. For example,
  • When health workers become symptomatic while at work, they should notify their supervisors and go home. When health workers are unable to leave work immediately, they should be placed in isolation areas until they are able to go home.
  • Each facility’s IPC focal point or supervisor should help health workers get tested for COVID-19 because positive tests can guide how long health workers must be excluded from work in accordance with national or subnational guidelines. In settings with limited testing availability, health workers suspected of having COVID-19 who are not tested should also be excluded from work for a period determined by national or subnational guidance.
• Prepare for health worker shortages by identifying alternative healthcare workforcepdf icon members or extending work hours.

B. Rapidly identify and separate patients with suspected COVID-19

Despite facility prevention measures to reduce the risk of SARS-CoV-2 transmission, patients with possible COVID-19 will still be seen. Preparing facilities to receive patients with COVID-19 symptoms can help limit the risk of exposure to patients and staff. Facility leadership and the IPC focal point should review WHO’s guidance, Infection prevention and control during health care when coronavirus disease (‎COVID-19)‎ is suspected or confirmedexternal icon, and follow national IPC guidance to begin preparing facilities to safely triage and manage patients with respiratory illness, including COVID-19.

C. Modify outpatient service delivery to maximize patient and health worker safety

Modifying outpatient operations is important to reduce crowding and to prevent the mixing of infectious with noninfectious patients at facilities, and prevent transmission of SARS-CoV-2. Coordinating with local public health authorities can expand strategies available to an individual facility (e.g., identifying alternate care sites for essential health services). Additionally, in communities with widespread community transmission of COVID-19, implementing source control for patients, visitors, and health workers at facilities through universal use of masks can also reduce transmission of SARS-CoV-2. While nonmedical masks are recommended for the general population, medical masks per WHO recommendationsexternal icon should be prioritized for health workers or vulnerable populations, including people aged 60 years or over, those with underlying conditions, such as cardiovascular disease, diabetes, chronic lung disease, cancer, cerebrovascular disease, or people with immunosuppression.

Strategies to reduce risk of SARS-CoV-2 transmission in outpatient facilities by modifying service delivery are described below.

Modifications to outpatient operations for essential health services

• Identifying essential health services such as vaccinations, maternal and child healthcare, HIV testing and treatment, tuberculosis testing and treatment, and others.
• Detailed considerations for modifying delivery of essential health services, including disease-specific considerations, can be found hereexternal icon. Examples of such strategies include
  • Dedicating certain days and times for services, for example, vaccinations on Mondays, obstetric patients on Thursdays.
  • Dispense additional doses of medications for patients with stable, chronic disease to reduce number of times a patient needs to visit the pharmacy.
  • Identify alternative locations, such as schools and churches, for providing services such as well visits for children. See section D for detailed guidance.
  • Consider non-facility-based settings, such as outreach or mobile services, for delivery of select services (e.g., immunizations) based on the local context and ability to ensure IPC practices and safety of health workers and the community.

Modifications to outpatient operations for non-essential health services during COVID-19

• Identify nonessential health services that can be delayed or canceled in accordance with local or national guidance. Postponing nonessential health services frees health workers to provide COVID-19 care and reduces crowding in waiting rooms.
  • Examples of such services include routine vision or dental checkups and annual physical exams.
• Explore alternatives to in-person encounters (see section below).

Modifications to outpatient operations for patients who are acutely ill or have symptoms consistent with COVID-19

• Outpatient facilities may consider alternatives to in-person triage such as conducting visits using telemedicine (e.g., telephone consultations or cell phone video conference) to provide clinical support without direct contact with the patient.
  • For example, establish a hotline that
    • Patients can call or text notifying the facility that they seek care due to acute illness, including symptoms consistent with COVID-19.
    • Can be used as telephone consultation for patients to determine if they need to visit a healthcare facility.
    • Can inform patients of preventive measures to take as they come to the facility (e.g., wearing a nonmedical mask or having tissues to cover coughs or sneezes).
  • Provide information to the public through local mass media and social media platforms about availability of a hotline, signs and symptoms of COVID-19, and when to seek care.

• Encourage and support home care when appropriate for patients with COVID-19 symptoms
  • Assess the patient’s ability to engage in home monitoring, their ability to safely isolate at home, and the risk of their transmitting the virus to others in their home.
  • Provide clear instructions to caregivers and people who are sick regarding home careexternal icon and when and how to access the healthcare system for face-to-face care or in the case of urgent or emergent conditions.
  • If possible, identify health workers who can monitor those patients at home with daily check-ins using telephone calls, text, or other means.

D. Implement IPC for alternate care sites and non-facility-based care

To minimize the risk of SARS-CoV-2 transmission at outpatient facilities, the use of alternate care sites or non-facility-based models of healthcare delivery may be considered to separate patients in need of essential health services from patients seeking care for acute illness. Alternate care sites include community-based locations, such as unoccupied schools or stadiums, that might be temporarily out of use due to local mitigation measures. Such sites offer the benefit of space to allow appropriate physical distancing of health workers and patients. However, since these sites are not primarily intended for the delivery of healthcare, their structure might not be suitable for outpatient services that require physical exams and are best used to deliver single-purpose care (e.g., drug pick-ups, immunizationspdf iconexternal icon, or well-child visits). Similarly, non-facility-based care, which includes outreach services to people’s homes or mobile services, help minimize crowding at healthcare facilities while maintaining essential health services.

IPC is always needed wherever healthcare is delivered, including alternate care sites and non-facility-based care. At a minimum, health workers delivering care in these settings require education and training in good IPC practices, including standard and transmission-based precautions. Patients and health workers should maintain physical separation of at least 1 meter from others at all times based on WHO recommendationsexternal icon, which differ from CDC recommendation of ≥6 feet (≥1.8 meters). Additional IPC considerations for specific situations are below:

• Alternate care sites
  • Establish a system of COVID-19 screening and triage for patients arriving at alternate care sites as described in section B.
• Outreach to patients’ homes
  • Practice frequent hand hygiene before and after each patient encounter using portable alcohol-based hand rub.
  • Consider consultation outside of the household to ensure adequate ventilation.
  • Consider wearing medical masks and eye protection (e.g., face shields or goggles) throughout the shift instead of changing PPE in between each household, if PPE supplies are limited.
  • For healthcare services that require gloves or gowns, special considerations are needed to appropriately put on, safely take off, and dispose PPEexternal icon.
• Mobile medical units
  • Increase ventilation by opening windows when conditions allow.
  • Stock vehicle with adequate supplies of alcohol-based hand rub for frequent hand hygiene and recommended PPE.
  • Bring visual alerts or signs to encourage patients to take appropriate IPC precautions while waiting in queues, including maintaining physical distance of 1 meter from others (based on WHO recommendationsexternal icon, which differ from CDC recommendation of more than 6 feet [more than 1.8 meters]) and practicing hand hygiene, respiratory hygiene, and cough etiquette.
  • Clean and disinfect commonly touched surfaces in the vehicle at the beginning and end of each shift and between transporting passengers who are visibly sick. For visibly soiled surfaces, use soap and water before applying disinfectant (e.g., alcohol at 70%).

Footnote

[1]If they are not near aerosol-generating procedures, WHO recommendsexternal icon that health workers providing direct care to COVID-19 patients should wear a medical mask (in addition to other PPE that are part of droplet and contact precautions). Health workers involved in aerosol-generating procedures require N95s, not medical masks.