Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic

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Purpose

To provide healthcare systems with a framework to deliver non-COVID-19 health care during the COVID-19 pandemic.

Background

At the onset of the COVID-19 pandemic, CDC recommended that healthcare systems prioritize urgent visits and delay elective care to mitigate the spread of COVID-19 in healthcare settings. A consequence of the pandemic has been the under-utilization of important medical services for patients with non-COVID-19-related urgent and emergent health needs [1-3]. As the pandemic continues, healthcare systems must balance the need to provide necessary services while minimizing risk to patients and healthcare personnel (HCP). Because the effects of COVID-19 vary among communities, healthcare systems will also need to consider the local level of COVID-19 transmission when making decisions about the provision of medical services. This document provides a framework for the delivery of non-COVID clinical care during the COVID-19 pandemic. Given the dynamic nature of the pandemic, considerations may change over time and vary by practice type and setting.

Key considerations

Be prepared to rapidly detect and respond to an increase of COVID-19 cases in the community.
- Stay informed. Consult regularly with your state or local health department for region-specific information and recommendations. Monitor trends in local case counts and deaths, especially for populations at higher risk for severe illness.
- Before expanding to provide elective services, healthcare systems must operate without crisis standards of careexternal icon. Ensure adequate HCP staffing and bed capacity, availability of personal protective equipment and other supplies, and access to other important tools to respond to a surge in cases if needed. Learn how healthcare systems can operate effectively during the COVID-19 pandemic.
Provide care in the safest way possible.
- Optimize telehealth servicesexternal icon, when available and appropriate, to minimize the need for in-person services.
- Follow recommended infection control practices to prevent transmission of infectious agents, including screening all patients for COVID-19 signs and symptoms, universal source control, and infection control practices specific to COVID-19. Be familiar with COVID-19 healthcare infection prevention and control recommendations specific to your setting.
Consider that services may need to expand gradually.
- Make decisions for expanding necessary care based on the local epidemiology and in concert with recommendations from state and local officials.
- Prioritize services that, if deferred, are most likely to result in patient harm.
- Prioritize at-risk populations who would benefit most from those services (for example, those with serious underlying health conditions, those most at-risk for complications from delayed care, or those without access to telehealth).

The following table provides a framework for considering some of these factors. The examples are not exhaustive; decisions that healthcare systems ultimately make may depend on local factors not addressed in this table.

Table. Framework for provision of non-COVID-19 health care during the COVID-19 pandemic, by potential for patient harm and degree of community transmission

Framework for provision of non-COVID-19 health care during the COVID-19 pandemic, by potential for patient harm and degree of community transmission
Potential for patient harm	Examples	Substantial community transmission Large scale community transmission, including communal settings (e.g., schools, workplaces)	Minimal to moderate community transmission Sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases	No to minimal community transmission Evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting
Highly likely Deferral of in-person care highly likely to result in patient harm	Signs/symptoms of stroke or heart attack Dental emergencies Acute abdominal pain Treatment for certain cancer diagnoses Well-child visits for newborns	Provide care without delay; consider if feasible to shift care to facilities less heavily affected by COVID-19.	Provide care without delay; consider if your facility can provide the patient’s care, rather than transferring them to a facility less affected by COVID-19.	Provide care without delay while resuming regular care practices.
Less likely Deferral of in-person care may result in patient harm	Pediatric vaccinations Change in symptoms for chronic conditions Musculoskeletal injury Certain planned surgical repairs Physical or occupational therapy	If care cannot be delivered remotely, arrange for in-person care as soon as feasible with priority for at-risk* populations. Utilize telehealth if appropriate.	If care cannot be delivered remotely, work towards expanding in-person care to all patients in this category. Utilize telehealth if appropriate.	Resume regular care practices while continuing to utilize telehealth if appropriate.
Unlikely Deferral of in-person care unlikely to result in patient harm	Routine primary or specialty care Care for well-controlled chronic conditions Routine screening for asymptomatic conditions Most elective surgeries and procedures	If care cannot be delivered remotely, consider deferring until community transmission decreases. Utilize telehealth if appropriate.	If care cannot be delivered remotely, work towards expanding in-person care as needed with priority for at-risk* populations and those whose care, if continually deferred, would more likely result in patient harm. Utilize telehealth if appropriate.	Resume regular care practices while continuing to utilize telehealth if appropriate.

*Those with serious underlying health conditions, those most at-risk for complications from delayed care, and those without access to telehealth services.

References

De Filippo O, D’Ascenzo F, Angelini F, et al. Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy. N Eng J Med. 2020 Apr 28. doi: 10.1056/NEJMc2009166.
Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020 Mar 16. doi:10.1016/j.jds.2020.02.002.
Metzler B, Siostrzonek P, Binder RK, et al. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: The pandemic response causes cardiac collateral damage. Eur Heart J. 2020 Apr 16. doi: 10.1093/eurheartj/ehaa314.