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 for implementation of 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
• non-hospital-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 morbidity and mortality 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, implemented, and overseen 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 requirements pdf icon[1.48 MB, 70 Pages]external 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. Implement processes to 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 symptoms consistent with COVID-19external icon can help limit the exposure risk for other patients and health workers. When community transmission of SARS-CoV-2  is suspected in the area, 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 symptoms consistent with COVID-19. Consider the following measures:

Infection control infrastructure and healthcare workforce

• Designate a health worker who is trained in IPC to be the IPC focal point, responsible for implementation of COVID-19 prevention measures at the facility. The IPC focal point, in collaboration with other relevant persons, should coordinate and implement 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.
  • Facilitate implementation of 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).
  • Determine the type and quantity of existing supplies for hand hygiene, cleaning and disinfection, and personal protective equipment (PPE) as well as the ordering frequency.
    • Assess availability and accessibility of supplies needed to perform hand hygiene using either an alcohol-based hand rub or soap and water. 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
    • Assess PPE supplies needed to implement contact and droplet precautions for all 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; this information can be inserted into a PPE burn rate calculator to help plan and optimize the use of PPE
      2. Implement strategies for optimal and appropriate use of PPE following WHO rational use of PPE pdf icon[763 KB, 28 Pages]external icon guidance
      3. Develop contingency PPE plans in case of supply shortages
    • Assess supplies 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, including:
      1. When to use PPE
      2. What PPE is necessary
      3. How to properly put on, use, and take off PPE in a manner to prevent self-contamination
      4. How to properly dispose of or disinfect and maintain PPE
    • Cleaning and disinfectionexternal icon practices, including:
      1. Appropriate PPE use by cleaning staff
      2. Type of disinfectant and contact timeexternal icon
      3. Consider leveraging existing online coursesexternal icon to conduct virtual IPC trainings for facility and staff
• Develop a system to screen health workers for exposures to COVID-19 or signs and symptoms of COVID-19 before entering a building. A system may include self-reporting of symptoms suggestive of COVID-19 (e.g., cough, myalgias, fatigue, headaches), objective checks for fever (temperature >38^oC), or a combination of bothexternal icon.
  • If a health worker has had an occupational or non-occupational exposure to a person with suspected or confirmed COVID-19, consultation with an occupational health focal pointexternal icon is recommended. Based on an assessment of risk factors, recommendations for quarantine and testing can be made.
  • For example, health workers could be advised to report to their supervisor (or send a text message to their supervisor) before beginning their workday to confirm they have no symptoms that are consistent with COVID-19 (using a standard list of possible symptoms).
• Review sick leave policies for health workers and ensure that they are flexible and consistent with public health guidance to allow ill health workers to stay home.
• Establish policies and procedures for health workers who develop any symptoms or signs consistent with COVID-19. For example:
  • If a health worker becomes symptomatic while at work, he/she should be instructed to notify the supervisor and go home. If the health worker is unable to leave work immediately, he/she should be placed in an isolation area until he/she is able to go home.
  • The IPC focal point at the facility or supervisor should facilitate obtaining a COVID-19 test for the health worker because a positive test can guide how long the health worker will need to be excluded from work in accordance with national or sub-national 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 sub-national guidance.
• Prepare for health worker shortages by identifying alternative healthcare workforce pdf icon[199 KB, 11 Pages] members or extending work hours.

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

Despite modifications to outpatient operations to reduce the risk of SARS-CoV-2 transmission at facilities, patients with possible COVID-19 will still be seen.  Optimizing preparedness of facilities to receive patients with symptoms consistent with COVID-19 can help limit the risk of COVID-19 exposure to patients and staff.  Facility leadership and the IPC focal point should review WHO IPC guidance during health care when COVID-19 is suspectedexternal icon and follow national IPC guidance to begin preparing facilities to safely triage and manage patients with respiratory illness, including COVID-19.  Consider the following measures:

• Place visual alerts such as signs and posters at entrances and in strategic places providing instruction (in local languages) on hand hygiene, respiratory hygiene, cough etiquette, and maintaining physical distance of at least 1 meter from other patients and health workers based on WHO recommendations (which differs from CDC recommendation of ≥6 feet [1.8 meters]).
• Establish a separate registration desk for patients coming in with symptoms consistent with COVID-19. Place signs at the entrance directing patients to the designated registration desk.
• Registration desks should be stocked with supplies of medical masks. Hand hygiene stations (soap and water or alcohol-based hand rub) should be easily accessible.
  • Consider installing physical barriers (e.g., glass or plastic screens) for registration desk/reception areas to limit direct contact between registration desk personnel and potentially infectious patients.
  • If screening personnel are unable to maintain physical distance of ≥1 meter from patients (based on WHO recommendations, which differ from CDC recommendation of ≥6 feet [1.8 meters]), ideally separated by a physical barrier, they should wear a medical mask and eye protection (i.e., goggles or face shield).
• At registration, every patient should be asked if they have symptoms consistent with COVID-19image icon using a standardized questionnaire. Patients with suspected COVID-19 should be:
  • Given a medical mask for source control. If a medical mask is not available, patients should wear a non-medical mask as specified by WHOexternal icon or at least be given paper tissues to cover their nose and mouth when in the presence of others for source control;
  • Separated from patients without any of these symptoms in a different waiting area, ideally outdoors, if weather permits; and
  • Fast-tracked for clinical assessment to facilitate targeted referrals.

Clinical assessment would ideally occur in a single-person room. During clinical assessment, ensure that windows, if present in the room, are opened as fully as possible to optimize ventilation, and close doors that lead to hallways. Before entering the room, perform hand hygiene, using a station that should be located near the outside of the room, and wear all recommended PPE.

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

Modifications to outpatient operations are important ways to reduce crowding and mixing of potentially infectious and non-infectious patients at facilities, preventing transmission of SARS-CoV-2 in the process. Coordination with local public health authorities is helpful to 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 all patients, visitors, and health workers at facilities through universal use of masks can also reduce transmission of SARS-CoV-2.  While non-medical masks are recommended for the general population, medical masks per WHO recommendationsexternal icon should be prioritized for health workers or vulnerable populations, including persons aged ≥60 years or persons with underlying conditions, such as cardiovascular disease, diabetes, chronic lung disease, cancer, cerebrovascular disease, or persons 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 to prioritize is a necessary first step and includes 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/times for services (e.g., vaccinations on Mondays, obstetric patients on Thursdays, etc.).
  • Dispense additional doses of medications for patients with stable, chronic disease to reduce number of times a patient needs to visit the pharmacy.
  • Identify separate locations (e.g., schools, churches, etc.) for holding well visits for children.
  • Consider non-facility-based settings (e.g., 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 non-essential health services that can be delayed or canceled in accordance with any local or national guidance. Postponing non-essential health services allows health workers to be available to provide COVID-19 care and reduces crowding in waiting rooms.
  • Examples of such services include routine vision or dental check-ups 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-19external icon

• Outpatient facilities may consider alternatives to in-person triage such as conducting visits using telemedicine (e.g., telephone consultations or cell phone videoconference) 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 are seeking 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 non-medical mask or having tissues to cover coughs or sneezes).
  • Provide information to the general public through local mass media such as radio, television, newspapers, and social media platforms about availability of a hotline, signs and symptoms of COVID-19, and when to seek care.

• If a patient with symptoms consistent with COVID-19 can be managed by telephone and advised to stay home:
  • Assess the patient’s ability to engage in home monitoring, their ability to safely isolate at home, and the risk of them transmitting the virus to others in their home environment.
  • Provide clear instructions to caregivers and sick persons regarding home careexternal icon and when and how to access the healthcare system for face-to-face care or urgent/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 healthy 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, immunizations pdf icon[842 KB, 3 Pages]external 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 in 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 ≥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 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 all windows.
  • Stock vehicle with adequate supplies of alcohol-based hand rub for frequent hand hygiene and all 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 ≥6 feet [≥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.

References

1. Operational considerations for case management of COVID-19 in health facility and community. Geneva: World Health Organization; 2020external icon.
2. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, updated June 2020. Geneva: World Health Organization; 2020external icon.
3. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 pdf icon[2 MB, 91 Pages]external icon.
4. Minimum requirements for infection prevention and control programmes pdf icon[1.4 MB, 70 Pages]external icon.
5. Standard operating procedure (SOP) for triage of suspected COVID-19 patients in non-U.S. healthcare settings: early identification and prevention of transmission during triage. Centers for Disease Control and Prevention; 2020.
6. Personal Protective Equipment (PPE) Burn Rate Calculator. Centers for Disease Control and Prevention; 2020.

7. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. Geneva: World Health Organization; 2020 pdf icon[763 KB, 28 Pages]external icon.
8. Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-S. Healthcare Settings. Centers for Disease Control and Prevention.
9. Cleaning and disinfection of environmental surfaces in the context of COVID-19. Geneva: World Health Organization; 2020external icon.
10. COVID-19: How to put on and remove personal protective equipment (PPE)external icon.
11. Operational Considerations for the Identification of Healthcare Workers and Inpatients with Suspected COVID-19 in non-US Healthcare Settings. Centers for Disease Control and Prevention; 2020.
12. Prevention, identification and management of health worker infection in the context of COVID-19. Geneva: World Health Organization; 2020external icon.
13. Considerations for integrating infection prevention and control into national pandemic preparedness and response planning for coronavirus 2019 (COVID-19). Centers for Disease Control and Prevention; 2020 pdf icon[199 KB, 11 Pages].
14. Clinical management of COVID-19. Geneva: World Health Organization; 2020external icon.
15. Mask use in the context of COVID-19; 2020external icon.
16. Maintaining essential health services: operational guidance for the COVID-19 context. Geneva: World Health Organization; 2020external icon.
17. Home care for patients with COVID-19 presenting with mild symptoms and management of their contacts. Geneva: World Health Organization; 2020external icon.
18. Guiding principles for immunization activities during the COVID-19 pandemic. Geneva: World Health Organization; 2020 pdf icon[841 KB, 3 Pages]external icon.
19. Water, sanitation, hygiene, and waste management for SARS-CoV-2, the virus that causes COVID-19. Geneva: World Health Organization; 2020external icon.
20. Cleaning and disinfection for non-emergency transport vehicles. Centers for Disease Control and Prevention; 2020.
21. How to protect yourself & others. Centers for Disease Control and Prevention; 2020.
22. Text Illness Monitoring. Centers for Disease Control and Prevention; 2020.