AMGA CMO Council: Clinic Consolidation and Patient Triage Procedures

AMGA COVID-19 Resources

Discussion Summary
March 24, 2020

This summary is based on a discussion via AMGA’s Chief Medical Officer/Medical Director listserv as of March 24, 2020. For more information about the CMO Council, please click here.

Question: Has anyone else considered/activated the strategy of consolidating your primary clinics down for better infection control and to try to limit staff exposure to maintain a functioning care team across the organization?

  • Initially, have some of your primary care sites as respiratory clinics with focused care on COVID patients. These should be smaller sites with ground-floor access and in-car treatment where possible, and staffed from surrounding sites where needed. This allows your other clinics to still see low-suspect patients with lower chance of incidental exposure. Each of these clinics should have door greeters and respiratory areas for walk-ins with positive screening. Consolidate to larger sites (phase 2) as your COVID numbers increase, more staff is out on quarantine with smaller sites understaffed, and the worry of cross-exposure is less (COVID widespread in community).
  • Have large respiratory clinics and clinics that are non-respiratory to cover the reaches of your spread. The non-respiratory should only see essential visits. Triage and greeting at every location.

Question: Wondering about triage to onsite respiratory clinic visits vs. telemedicine/telephonic care and self-isolation at home. Are you testing? Or are you seeing the more vulnerable in your respiratory clinics?

  • Phone triage all respiratory and diarrhea complaints with three triage options:
    • Mildly ill: Self-treat at home
    • Moderately ill: Have a phone tele-video visit which is transitioned to face-to-face depending on severity
    • More ill: Patients should be seen face-to-face to test, assess for pneumonia, oxygen needs, hospitalization, etc.
  • Screen every patient upon entrance points. Those who screen positive should be directed to your urgent care/walk-in options. This will not capture every patient but hopefully help to protect those that are vulnerable. Have a few clinics that are remote and separate the waiting rooms or send positive-screened patients back to the car if a room is not readily available.
  • Vast majority (young/no co-morbids) treated over phone with home quarantine until the 72-hour afrebrile state per CDC recommendations. Moderate- to severe- and high-risk patients, and a significant number of those with flu as well, should be seen in clinic or ER (depending on severity). Flu presence and the ability to treat if positive is a driving force for clinic visits in high-risk patients.
  • Your phone triage system should be set up to:
    • Encourage asymptomatic patients to stay home
    • Mild/moderately symptomatic patients into televisits
    • Patients with severe symptoms to ER
  • Televisit clinicians should direct patients to urgent care for testing in certain circumstances (primarily more than mild symptoms, exposure to positive-test patient). Consolidate most testing supplies and PPE into UC and ER settings, leaving some available in primary care clinics. Don't anticipate significantly more supply for 10 days.

Question: Is anyone having COVID/respiratory clinics in primary care? What are you doing for patients who need to be seen for non-COVID care or to maintain immunizations to hopefully help prevent co-infection?

  • Launch a FURI (febrile URI) clinic and see patients face-to-face with full PPE. See less ill patients via tele-video visits. No patients with any respiratory symptoms or diarrhea are being seen at any primary care clinics, which are available for emergency non-COVID-related complaints only. All other visits are via tele-video.
  • Work to create the following workflow:
    • Upper respiratory infection symptoms via telehealth visit or via in-person visit as needed versus in the Emergency Department as needed.
    • The live site should have radiology capability and treat all patients as at risk. Test anyone along the way with material concern for COVID.
  • Create a respiratory clinic that’s open seven days a week. Staff it with five to six providers at a time; use one central clinic that has x-ray capability. Any patient with any sort of respiratory symptoms should be triaged there to keep them out of the rest of the practices. Even the patients with mild respiratory symptoms who are complaining of an acute symptom like knee pain or abdominal pain should be seen in that clinic. This helps to preserve PPE and cleaning supplies. All patients should be masked. All providers should wear gowns, gloves, goggles, and surgical masks. Patients should either be triaged to home, triaged to testing and home, or triaged to an appointment in the respiratory clinic.