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AMGA CMO Council: PPE Protocols at Respiratory Clinics and Reopened Ambulatory Sites

AMGA COVID-19 Resources
 

Discussion Summary
April 13, 2020

This summary is based on a discussion via AMGA’s Chief Medical Officer/Medical Director Council listserv as of April 13, 2020. For more information about the CMO Council, please click here.

Question: For practices/medical centers which have kept open a dedicated respiratory clinic, are the physicians and other providers wearing full personal protective equipment (PPE) (gown, gloves, N95 and face shield) and changing gown and gloves between every patient?

  • They are following full droplet and contact precautions. Surgical mask is sufficient as this is not airborne disease. We assign one staff member to be the "swabber" of the day—they wear N95 if the patient cannot self-swab. We have implemented self-swabbing which allows our staff to stand six feet or more away and wear a surgical mask instead of N95. They change between every patient. We have resorted to using non-disposable gowns, changing between every patient, as we do not have enough disposable.
  • Our clinicians are wearing full PPE for all patient encounters (viral and non-viral sessions). They are wearing N95, gown, and gloves. We are following CDC guidelines around reuse of PPE to optimize its lifecycle—but obviously disposing of anything worn, soiled, or damaged. Staff are wearing standard ear-loop mask and gloves the entire time they are in the office. Everyone is wearing a mask while at work, even during breaks. Our viral attack rate in the staff and clinicians has been quite low, but again, we are full PPE all sessions, masks and lots of hygiene during sessions. We have also been able to remove all "high-risk" clinicians and staff out of direct patient care in office (to phones, telemedicine, outreach, etc.)
  • Our respiratory assessment clinics are wearing PPE as follows: gown, mask, and eye covering (usually face shield or mask with shield, ​rather than goggles)—not N95 as our ID specialists and the state health department have reassured us that collection of the nasopharyngeal swab is not an aerosolizing procedure. These items can be worn continuously throughout the session as long as they are not visibly soiled. Gloves are changed with each patient, usually multiple times with the same patient. If a patient coughs or sneezes directly at the provider or staff member within six feet, then all PPE is changed. Masks are not reused if taken off. Patients are masked at all times, except when they are having a swab sample taken.

Question: For those opening up ambulatory practices, are there plans for PPE for the healthcare workers once the patient passes through screening and is in the exam room?

  • We are anticipating surgical masks and gloves for each patient encounter, and only changing the surgical mask if it becomes soiled or damaged. At the same time, some discussion has arisen about using N95 masks for providers, given the high viral shedding that occurs in asymptomatic patients.
  • If there is no fever or respiratory symptoms, then surgical mask for both patient and healthcare provider is sufficient, without the need for the rest of PPE. We also anticipate using surgical masks and gloves for each patient encounter and only changing the surgical mask if it becomes soiled or damaged. We know that asymptomatic patients can have viral shedding, but I am not clear that they have "high" viral shedding—all studies point to this being a large droplet disease, not airborne.
  • We are starting to discuss opening up the regular clinic to more face-to-face visits, but will likely utilize the patient's car as the waiting room as much as possible. All staff in patient-facing positions in all locations are masked. We have not yet required patients to be masked, but may start doing this if we open up the clinics to more patients. Our respiratory assessment clinics will likely continue to operate, even with lower numbers, to try to keep symptomatic patients out of other offices, and we are doing screening questions at the doors to try to keep these practices "clean."
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