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Recommendations for Establishing Workflow and Safety as you Reopen your Clinics
4/29/2020

As many of you know, LAcs and other medical providers who had closed their practices in mid-March will be planning their return to work this week (5/1/20), based on Governor Brown’s updated position on elective medical care. More specific guidelines on how to do so here
 
There is a lot of information to go through to arrive at your clinic’s new workflow and safety measures in the era of COVD-19.  Each clinic will have to adapt in ways that work best for them while meeting the recommendations of the Governor’s office, the OHA, the OMB, the CDC and OSHA.

The OAA would like to be a resource as you make your plans and convey them to your colleagues and patients.  We have provided a basic outline of background and a possible workflow below.
Background:

At their Town Hall on 4/22, the ASA (American Society of Acupuncturists) recommended following state level guidelines for returning to practice as well as using the Centers for Medicare & Medicaid Services (CMS) Recommendation Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

They recommended using your best judgment based on local recommendations and encouraged dialogs between colleagues on how best to do this. Most importantly, they urge awareness of local viral patterns and statistics.  The next Town Hall is 4/29 at 5 pm PDT https://www.nccaom.org/asa-nccaom-joint-webinar/.

Oregon Stats:
As of 4/23/20, the latest Oregon statistics are as follows: 
You can find daily up to date numbers here.
 

  • 2059 cases
  • 78 deaths
  • 40,000+ negative tests
  • 4.8% test positivity
  • Emergency room visits have been down for 2 weeks. Of these, 1.4% are for COVID like illness. 
  • Testing:  policies regarding who gets tested and when were updated on 4/20 and continue to focus on front line workers in health care settings, grocery, delivery, pharmacy, long term facilities, etc. 
 
This information is presented weekly via the Extension for Community Health Outcomes Network (ECHO) webinars. On 4/23/20, the presenters stated that Oregon is “well under it’s capacity” and hospital projections are expected to remain flat.  Furthermore, ICU and hospital projections are both predicted to remain below capacity through 5/18. 
 
Note:  If you are interested in attending future ECHO presentations, simply sign up here.  The meetings often have 750+ attendees and serve to connect health care practitioners all over the state of Oregon.  Also, they offer CEU’s for their webinars.  While they are currently focusing on COVID-19, they offer many other interesting trainings.

CDC

On 4/16 the CCD issued “Interim Infection control and recommendations for Suspected or Confirmed Coronavirus Disease 2019 in Healthcare settings.”

Another helpful link:  Proper Donning and Doffing of PPE

OMB

"Oregon licensed acupuncturists restarting clinical services May 1st, must implement a strict screening process and adhere to social distancing measures and other precautions set out by the Governor's Executive Order and the Oregon Health Authority. Acupuncturists may continue offering telehealth services within Oregon if telehealth meets the standard of care for the particular patient and condition being treated. The Oregon Medical Board's information on COVID-19 is frequently updated at https://omb.oregon.gov/COVID-19."

Oregon acupuncture licenses can be renewed now through June 30 at https://omb.oregon.gov/renew. If you are unable to submit your renewal by June 30, the Oregon Medical Board (OMB) will waive the usual $80 late fee. For questions or assistance, please contact the Licensing Call Center at licensing@omb.oregon.gov or at 971-673-2700, Monday-Friday, 9:00 am - noon, and 1:00 - 3:00 pm. General information on license renewal is also available online at https://www.oregon.gov/omb/licensing/Pages/default.aspx.

OHA (Oregon Health Authority)  COVID-19 Page.   

On 4/8 the OHA determined a 4-tier strategy for PPE .  This was developed in response to the supply chain issues around PPE resulting in limited availability.  They also stress the idea of Standard Precautions.
 
Standard Precautions means approaching every patient or resident care situation in a way that prevents acquiring or passing on an infection, regardless of suspected or confirmed infection status of the patient or resident. 

The CDC's Heathcare-associated Infections website has excellent resources and training.

Standard Precautions include:
  • Hand hygiene - first and foremost!
  • Use of personal protective equipment (for example, gloves, gowns, facemasks), depending on the anticipated exposure
  • Respiratory hygiene and cough etiquette
  • Safe injection practices
  • Safe handling of potentially contaminated equipment or surfaces in the patient environment

OSHA

The OAA has been in ongoing conversations with Oregon’s OSHA office regarding PPE and best workflow clinic practices for LAcs moving forward.  They will not be issuing a formal document for us (or any medical practice) regarding workflow and clinic procedures. They are leaving the details up to clinicians based on the OHA, CDC and Governor’s office, but have been available for consultation. 
Please note: the OAA will host a webinar with our OSHA contact within the next few weeks.

The biggest concern from OSHA’s perspective for LAcs continues to be Hep B and blood born pathogens.  However, regarding COVID 19, pre-screening, hand washing, sanitation and social distancing are key components of a safe practice. 

Given that L.Acs are subject to close contact with patients (less than 6 feet) and that some COVID patients appear to be asymptomatic, PPEs in the form of surgical masks are recommended.  (N95 is recommended for ENT procedures or procedures that result in the aerosolizing of secretions). In addition, it is recommended that patients wear their own sourced cloth masks in the clinic.

List of Clinic Workflow and Safety Practices

We spoke with several clinicians (LAc) about workflow and have reviewed these practices with OSHA for feedback.  Here is a possible list of considerations.  Establishing and publishing your workflow to your staff and patients will help coordinate your efforts to practice safely.

I. Screen: Avoid treating sick, coughing, sneezing patients in the clinic
  • Day of or before appointment:
    • Confirm with patient (email or phone) that they have not been in contact with a sick person in 2 weeks, traveled outside the state in 4 weeks, or have any symptoms:  fever, sore throat, “tickly” throat, nausea, cough, loss of smell, taste.  (Many patients don’t own a thermometer…encourage them to get one)
    • Allow for last minute cancellation
    • Provide Telehealth or referral if they are symptomatic
  • Upon Arrival to Appointment:
    • Take forehead temperature.  If over 99 degrees, re-evaluate with auditory canal readings.  If confirmed, send home for Telehealth or referral
II.  Social distance & reduced surface touching
  • Reduce traffic flow in waiting area (even consider removing chairs to direct flow into treatments rooms immediately or consider having patients wait in their car until the appointment time)
    • Plan patient flow to allow for proper procedures
    • Consider taking patients directly to the treatment room and taking payments and scheduling in the treatment room
    • People accompanying the patient wait in the car
  • Sit 6 feet away for interview
  • Reduce patients touching of surfaces (consider leaving doors open if possible to avoid use of door handles)
  • Front desk: consider acrylic barrier for staff
  • Consider removing tea stations.  Or, have healthcare worker, staff, L.Ac. provide water or tea
  • Provide no touch trash receptacles
  • Remove all unnecessary decorations, magazines, etc. to decrease vectors of transmission and to allow for easy sanitation of surfaces
III.  PPE (presuming the treatment of asymptomatic patients, not active COVID-19)
  • Provider:  surgical masks all day.  Practice correct removal and disposal
    • Consider protective eyewear or face shield when in close proximity for pulse, abdominal exam, needling
  • Patient:  wear cloth or other available masks during visit
IV. Clothing
  • Consider scrubs for the clinic or at least for back up in the case of being sneezed or coughed on. Lab coats at a minimum should be worn
  • Change clothes immediately at end of day and launder clothing at that time or immediately upon arrival at home
V. Treatment Rooms
  • Consider vinyl massage table and vinyl pillow coverings for easy sanitation. If using paper or sheets on the tables, wear gloves and carefully remove from table without touching your clothes and fold in on themselves. Keep soiled laundry in a closed cabinet or hamper.
  • Have patients wear loose clothing for treatment that requires minimum contact to adjust
  • Isolate supplies, needles away from any patient contact
VI. Sterilizing and Disinfecting
  • Provide alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol throughout clinic
  • Provider/LAc:  wash hands before and after touching patients, supplies, providing treatment, and if possible upon leaving room
  • Adhere strictly to clean needle technique protocols
  • Bleach 1:9, or EPA approved disinfectant (use gloves to protect hands)
    • After each visit:  tables, face cradles bolster, stools, nobs of heat lamps, door handles, light switches, side tables, chairs
    • End of day:  clean field area (dispose of open needles, clean salves, essential oils, lighters, etc), all door handles, sinks, soap bottles, hand sanitizers, pens, keyboards, phones, floor, shoes
VII. Accidental Exposure
  • Immediately wash face and hands for 45 seconds and change clothes
  • Report to clinic director, file report with date/time, Patient ID, circumstances
  • 3 day self quarantine
  • If you become symptomatic, then 14 day quarantine
  • Return to work when no symptoms for 72 hours
VIII. Documentation
  • Document the patient was screened for and did not have COVID-19 symptoms, or were not exposed to their knowledge, in the last two weeks. Document patient temperature and that patient was made aware of possible risks of transmission, but that proper hygiene is observed, PPE worn and all surfaces routinely disinfected.  Can document verbal consent or have patient sign something.
IX. Other
  • Consider air purifiers or filter
  • Open doors and windows when able to circulate air
  • Have two weeks of cleaning and PPE supplies on hand
 
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