Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States

Key Considerations for Healthcare Facilities:

Currently there are no medications to treat or vaccines to prevent COVID-19. Therefore, community approaches to slowing transmission including appropriate hand hygiene, cough etiquette, social distancing, and reducing face-to-face contact with potential COVID-19 cases are needed to slow disease transmission and reduce the number of people who get sick. In each healthcare facility, the primary goals include:

Provision of the appropriate level of medical care
Protecting healthcare personnel and non-COVID-19 patients accessing healthcare from infection
Preparing for a potential surge in patients with respiratory infection
Preparing for potential personal protective equipment supply and staff shortages

Purpose of this document: This interim guidance outlines goals and strategies for all U.S. healthcare facilities to prepare for and respond to community spread of coronavirus disease-2019 (COVID-19). Although it is not possible to predict the future course of the outbreak, planning for a scenario in which many persons become ill and seek care at the same time is an important part of preparedness and can improve outcomes if an outbreak occurs. Therefore, preserving healthcare system functioning is paramount. It is critical for healthcare facilities to continue to provide care for all patients, irrespective of COVID-19 infection status, at the appropriate level (e.g., home-based care, outpatient, urgent care, emergency room, or hospitalization). Facilities may need to respond to a surge in patients requiring care. Concentrated efforts will be required to mobilize all aspects of healthcare to reduce transmission of disease, direct people to the right level of care, and decrease the burden on the healthcare system.

Public health guidance will shift as the COVID-19 outbreak evolves. All healthcare facilities should be aware of any updates to local and state public health recommendations.

Key Goals for the U.S. healthcare system in response to the COVID-19 outbreak are to:

Reduce morbidity and mortality
Minimize disease transmission
Protect healthcare personnel
Preserve healthcare system functioning

Actions to take now to prepare for an outbreak of COVID-19

Designate a time to meet with your staff to educate them on COVID-19 and what they may need to do to prepare. The following may be useful resources to share information about COVID-19:
- How COVID-19 spreads
- Clinical management of COVID-19 patients
- Infection prevention and control recommendations for COVID-19

Explore alternatives to face-to-face triage and visits. The following options can reduce unnecessary healthcare visits and prevent transmission of respiratory viruses in your facility:
- Instruct patients to use available advice lines, patient portals, on-line self-assessment tools, or call and speak to an office/clinic staff if they become ill with symptoms such as fever, cough, or shortness of breath.
- Identify staff to conduct telephonic and telehealth interactions with patients. Develop protocols so that staff can triage and assess patients quickly.
- Determine algorithms to identify which patients can be managed by telephone and advised to stay home, and which patients will need to be sent for emergency care or come to your facility.
- Instruct patients that if they have respiratory symptoms they should call before they leave home, so staff can be prepared to care for them when they arrive.

Plan to optimize your facility’s supply of personal protective equipment in the event of shortages. Identify flexible mechanisms to procure additional supplies when needed.
Prepare your facility to safely triage and manage patients with respiratory illness, including COVID-19. Become familiar with infection prevention and control guidance for managing COVID-19 patients.
- Visual alerts (signs, posters) at entrances and in strategic places providing instruction on hand hygiene, respiratory hygiene, and cough etiquette
- Ensure supplies are available (tissues, waste receptacles, alcohol-based hand sanitizer)
- Facemasks are available at triage for patients with respiratory symptoms
- Create an area for spatially separating patients with respiratory symptoms. Ideally patients would be >6 feet apart in waiting areas.

Plan to Take the Following Actions if COVID-19 is spreading in your community

Work with local and state public health organizations, healthcare coalitions, and other local partners to understand the impact and spread of the outbreak in your area.
Designate staff who will be responsible for caring for suspected or known COVID-19 patients. Ensure they are trained on the infection prevention and control recommendations for COVID-19 and proper use of personal protective equipment.
Monitor healthcare workers and ensure maintenance of essential healthcare facility staff and operations:
- Ensure staff are aware of sick leave policies and are encouraged to stay home if they are ill with respiratory symptoms.
- Be aware of recommended work restrictions and monitoring based on staff exposure to COVID-19 patients.
- Advise employees to check for any signs of illness before reporting to work each day and notify their supervisor if they become ill.
- Do not require a healthcare provider’s note for employees who are sick with respiratory symptoms before returning to work.
- In settings of widespread transmission, your facility may consider screening staff for fever or respiratory symptoms before entering the facility.
- Make contingency plans for increased absenteeism caused by employee illness or illness in employees’ family members that would require them to stay home. Planning for absenteeism could include extending hours, cross-training current employees, or hiring temporary employees.

When possible, manage mildly ill COVID-19 patients at home.
- Assess the patient’s ability to engage in home monitoring, the ability for safe isolation at home, and the risk of transmission in the patient’s home environment.
- Caregivers and sick persons should have clear instructions regarding home care and when and how to access the healthcare system for face-to-face care or urgent/emergency conditions.
- If possible, identify staff who can monitor those patients at home with daily “check-ins” using telephone calls, text, patient portals or other means.
- Engage local public health, home health services, and community organizations to assist with support services (such as delivery of food, medication and other goods) for those treated at home.

Considerations for specific settings (In addition to above)

Outpatient facilities
- Reschedule non-urgent outpatient visits as necessary.
- Consider reaching out to patients who may be a higher risk of COVID-19-related complications (e.g., elderly, those with medical co-morbidities, and potentially other persons who are at higher risk for complications from respiratory diseases, such as pregnant women) to ensure adherence to current medications and therapeutic regimens, confirm they have sufficient medication refills, and provide instructions to notify their provider by phone if they become ill.
- Consider accelerating the timing of high priority screening and intervention needs for the short-term, in anticipation of the possible need to manage an influx of COVID-19 patients in the weeks to come.
- Symptomatic patients who need to be seen in a clinical setting should be asked to call before they leave home, so staff are ready to receive them using appropriate infection control practices and personal protective equipment.
- Eliminate patient penalties for cancellations and missed appointments related to respiratory illness.

Inpatient facilities
- Reschedule elective surgeries as necessary.
- Shift elective urgent inpatient diagnostic and surgical procedures to outpatient settings, when feasible.
- Limit visitors to COVID-19 patients.
- Plan for a surge of critically ill patients and identify additional space to care for these patients. Include options for:
  - Using alternate and separate spaces in the ER, ICUs, and other patient care areas to manage known or suspected COVID-19 patients.
  - Separating known or suspected COVID-19 patients from other patients (“cohorting”).
  - Identifying dedicated staff to care for COVID-19 patients.

Long term care facilities
- Limit visitors to the facility
- Post visual alerts (signs, posters) at entrances and in strategic places providing instruction on hand hygiene, respiratory hygiene, and cough etiquette
- Ensure supplies are available (tissues, waste receptacles, alcohol-based hand sanitizer)
- Take steps to prevent known or suspected COVID-19 patients from exposing other patients
- Limit the movement of COVID-19 patients (e.g., have them remain in their room)
- Identify dedicated staff to care for COVID-19 patients.
- Observe newly arriving patients/residents for development of respiratory symptoms.

Shifting Healthcare Delivery Modes during a COVID-19 Outbreak in the United States

Several major impacts can be anticipated during a severe outbreak that could affect the operations of healthcare facilities. These include surges in patients seeking care, the potential for workforce absenteeism from personal or family illness, and effects from social distancing measures such as school closures. Healthcare facilities will likely need to adjust the way they triage, assess and care for patients using methods that do not rely on face-to-face care.

Shifting practices to triaging and assessing ill patients (including those affected by COVID-19 and patients with other conditions) remotely using nurse advice lines, provider “visits” by telephone, text monitoring system, video conference, or other telehealth and telemedicine methods can reduce exposure of ill persons with staff and minimize surge on facilities. Many clinics and medical offices already use these methods to triage and manage patients after hours and as part of usual practices. Recent reports suggest that approximately 80% of COVID-19 patients (of all ages) have experienced mild illness[i]. Managing persons at home who are ill with mild disease can reduce the strain on healthcare systems—however, these patients will need careful triage and monitoring.

Promoting the increased use of telehealth

Healthcare facilities can increase the use of telephone management and other remote methods of triaging, assessing and caring for all patients to decrease the volume of persons seeking care in facilities.
If a formal “telehealth” system is not available, healthcare providers can still communicate with patients by telephone (instead of visits), reducing the number of those who seek face-to-face care.
Health plans, healthcare systems and insurers/payors should message beneficiaries to promote the availability of covered telehealth, telemedicine, or nurse advice line services

Shifts in the way that healthcare is delivered during a COVID-19 outbreak response will be complex. Thorough and consistent communications between all components of the public health and healthcare system will be needed in every community. For example, providers in medical offices, clinics, and other outpatient settings must be informed and know their roles. Pre-hospital care by emergency management services (EMS) and public-safety answering points (PSAPs) will also need to be aware of any altered transport guidance so they can conduct in-home assessments and triage per local guidance.

Reference:

[i] Wu Z, McGoogan JM. Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China. JAMA [Internet] 2020; available from: https://jamanetwork.com/journals/jama/fullarticle/2762130