Guide to Safe Medical Practice in Outpatient Settings During COVID-19 Pandemic

 Presently, human kind is challenging with a highly contagious disease, COVID-19, caused by a newly emerged virus, SARS-COV2. Health care providers are at the front line of fighting, as well as, at the risk of getting infected.  Many attempts have been made to combat the disease are mostly focused on hospital settings rather than outpatient settings so far. Therefore, addressing the clinics and medical offices with numerous health care workers seems necessary.

 Using keywords COVID-19  OR SARS-COV-2 OR Corona virus, AND  Infection control OR Prevention  AND ( Outpatient settings) OR clinics OR (medical offices)  AND  (health care workers)  OR (health care personnel) in  databases and pertinent sites : PubMed, Cochrane Library, Scopus, Up - to-date, Clinical Key, Google Scholar, guidelines, and health organization like  CDC, W.H.O., high impact journals, and publications of Iran ministry of health related to outpatient settings, we searched  the medical literature for all published full text articles  pertinent to medical practice in clinics and medical offices and  COVID-19 disease. We collected all pertinent data, and then organized them in a step by step guide for health care workers. 

 Based on our findings, the majority of patients (80%) with COVID-19 have mild disease and no need to primarily be admitted to hospitals. Since these patients are the source of infection, referrals to all clinics and hospitals have the risk of transmission of the infection to medical staff as well as, other non-COVID patients. They could be quarantined at home, evaluated by physicians via telemedicine, receive appropriate medical advice, and followed up regularly.
Tele visit: Tele visit via telephone or video call eliminates unnecessary public or private transportation and the risk of transmission, as well as, face to face visits and exposing health care workers and other patients to the virus. Regarding limited health care resources, face to face unnecessary visits impose dual pressure upon an already overloaded health care system. Emergency departments and hospitals should be dedicated to the remaining 20% of COVID patients with moderate to severe disease.  Signs and Symptoms: Signs and symptoms of myriads of COVID-19 patients have been assessed. 27 signs and symptoms have been found common to patients. 4 out of 27 signs and symptoms most consistent with the disease are: fever, headache, fatigue, and myalgia/arthralgia. Moreover, one of the relatively characteristic symptoms of COVID-19 disease is, sudden and recently- onset loss of smell and taste in the context of other signs and symptoms. It should be differentiated from chronic and already present loss of smell, associated with chronic diseases like nasal polyposis, chronic sinusitis and neurologic problems. Other alarming Signs and symptoms that need to be sought are: hemodynamic instability (hypotension and reduced urine output), decreased level of consciousness, and chest pain. Patients with these conditions need to be admitted to hospitals. Approaching patients with dyspnea remotely, Physicians should consider differential diagnoses like exacerbation of asthma or chronic obstructive pulmonary disease (COPD), severe pneumonia, heart failure, pulmonary embolism, pericarditis, and anxiety.Oxygen saturation evaluation:   Patients could be instructed to monitor their oxygen saturation by home pulse oximeters twice a day and report it to physicians. If oxygen saturation is 95% or more with room air, and not having other risk factors, they could remain quarantined at home. Patients with oxygen saturation of 94% or less should be visited face to face in medical centers. Elevator etiquette: If you have flu-like symptoms, do not use the elevator. Keep a distance of 1.5 meter from other riders. If the space is not enough, wait for the next turn ride or use the stairs.  Don’t touch the buttons with naked hands; Touch them with tissue paper or your elbow instead. Have disinfectant available and disinfect your hands before and after touching the buttons. Do not touch your eyes, mouth and nose after touching the buttons. Stay facing the walls of the elevator. Wash or disinfect your hands with warm water immediately after getting off the elevator in case of touching buttons.At the entrance of the clinic: Place posters, and stands with alarming and educational matters about COVID- 19 disease.  Screen all patients, as well as, companions for the signs and symptoms of COVID-19. Limit the entrance of companions to the clinic and not allow those who were exposed to COVID patients in recent two weeks. Get all patients to wear masks and disinfect their hands with alcohol based disinfectant solutions before entering the clinic.Waiting room: Limit the number of patients at the waiting room. The distance between patients should be at least two meters. Put partition between them if it is possible. Open the windows and doors 6-12 times per hour. Have disinfectant solutions in the waiting room and soap in the washing closet available to all patients. Cough etiquette: Cover your mouth and nose with tissue paper or your internal surface of your elbow in case of coughing or sneezing. Discard the tissues in dustbin after coughing or sneezing and wash your hands. Physician’s room: Use a paperless system for transmitting data medical records between physicians and secretory or para clinics. The distance between physician and patient should be at least 2 meters. Physicians should change the gloves after each visit. The disposable table cloth should be changed and the table and all the surfaces touched by the patient should be disinfected after each visit. Follow up of patients at home: Patients at home should be first followed up regularly at daily basis and then setting up the frequency and duration of follow ups based on patient health condition.Personal protective equipment: Medical staff should wear full personal protective equipment including N95 Masks, goggles, face shields, gowns and gloves.Monitoring medical and allied health care staff: Signs and symptoms of COVID-19 should be monitored regularly and the test RT-PCR should be performed every 3 days for health care workers in close contact with suspected COVID-19 patients.Return to work place : Health care personnel could return to work from 10 to 20 days after onset of the disease, provided that symptoms have resolved and had been afebrile without the use of antipyretics for at least 24 hours.   Donning andDoffing: Errors in donning and doffing have been observed even among experienced personnel. Therefore, the order of donning and doffing of personal protective equipment should be followed for prevention of infection.Nebulizers and aerosol producing procedures: Given dispersing the virus particles by nebulizers around 10 meters, nebulizers and aerosol producing procedures, should not be used routinely in clinics unless the patient is isolated, the doors closed, and the personnel out of the room. 

 COVID-19 is a newly emerged and highly contagious disease. Its diagnosis is based on multiple signs and symptoms, as well as, laboratory and imaging findings. This disease has no approved treatment and all medications are used based on clinical trials so far. Therefore, the best practice policy is prevention. One of the available facilities that could help in prevention of the disease is telemedicine. Around 80% of patients, who have mild disease, could be followed up, quarantined and managed at home and managed by telemedicine. Those at home should be monitored daily and if their condition worsened need to be admitted to special centers dedicated to COVID-19 patients. They should not be referred to all clinics or admitted to all hospital wards. Unnecessary referrals lead to spread of the infection. Hospitals and clinics are already overloaded and medical personnel exhausted. Medical personnel, as national resources should be preserved for the remaining 20% of patients with moderate to severe disease. Since health care workers are exposed to the high load of the virus and they may receive the viral load from multiple sources, their disease is often more severe, the risk of mortality and the risk of transmitting the infection to others is higher than the general population. Therefore, providing them with full personal protective equipment and monitoring their health condition is essential.