Safe Reopening After Covid-19 Peak

Safe Reopening After Covid-19 Peak

Background:

We will reopen our office and sleep and EEG labs for on-site patient care effective May 18, 2020, while following Covid-19 mitigation and preventive procedures. Patients must wear a mask covering their nose, mouth and chin. They must come alone. One companion is allowed for children, and patients with disability, cognitive impairment, or language difficulty.

We closed our offices and testing areas on March 23, 2020 in response to the Covid-19 crisis at that time. At that time, new Covid-19 cases were rising rapidly in SE Michigan, the Governor had ordered that all non-essential procedures be cancelled and had issued a stringent stay-at-home order. Hospitals anticipated they would run out of ICU beds and ventilators. We anticipated Covid-19 cases and deaths would rise rapidly. Beaumont Health had begun closing most of its ambulatory services. There was no clear guidance on mitigation procedures. Things looked grim.

The State of Michigan shows a steady decline in new cases in Region 2 North (Oakland, Macomb and St Clair counties), to below 200 every day since April 23, below 100 every day since May 2. Beaumont Health announced on May 2, 2020, that new Covid-19 cases have been falling for 14 days. It has begun to close re-purposed ICU beds. It is concerned about the backlog of cancelled procedures. It announced it is opening its services, including ambulatory services. It is performing screening mammograms. There is clearer guidance on mitigation procedures, from various authorities including the CDC, WHO, AASM, Beaumont Health, and others. On May 3, Michigan’s Chief Medical Executive, Dr. Khaldun, strongly encouraged Michigan physicians to resume services that are important for patient health and well-being, while adopting procedures to ensure staff and patient safety. Of course, the health care industry realizes that there may be a second wave sometime in the future. We may then have to restrict services again then.

We have carefully considered mitigation procedures and created appropriate policies to ensure patient and staff safety. We also have a backlog of cancelled cases, as well as new patients who have been calling over the past six weeks. Sleep apnea is a potentially life-threatening disorder. Central disorders of hypersomnolence may lead to potentially fatal accidents. Now that there are grounds for optimism with respect to Covid-19. Community transmission is way down. Hospital resources are no longer stretched thin. Therefore, it is time to take care of our patients’ essential health care needs.

Policies:

We will implement the following mitigation and preventive policies to mitigate risk of Covid-19 transmission within the Sleep and Attention Disorders Institute. They are for the good of each patient and staff member, as well as those around the patient or staff member.

A.    Staff:

1.      Upon arrival at the beginning of their shift, as well as upon return from the mid-shift break, all staff must sanitize their hands with sanitizer at the entry door. They must then don a surgical mask or a cotton cloth mask with at least two layers. The mask must cover the nose, mouth and chin.

2.      All staff with then fill out a Covid-19 questionnaire upon arrival. It asks about exposure to Covid-19 (being within 6’ of a confirmed diagnosed Covid-19 person for ≥10 min without face mask) over the last 14 days, fever (≥38 C oral), new onset or change in cough or shortness of breath, or flu-like symptoms such as body aches. The questionnaire is adapted from that used by Beaumont Health, and we will use Beaumont Health written guidance on whether it is appropriate to stay at work. Any staff reporting symptoms may not work unless they have been symptom free for 3 days and it has been 10 days since onset of symptoms (or have two negative Covid-19 tests 24 hours apart). Staff that has been exposed but is asymptomatic may work but must wear a mask at all times with no exceptions.

3.      The staff member must complete the questionnaire before clocking in.

4.      All staff must have temperature taken (using contact less thermometer) by another staff member (preferably a manager), as soon as possible after arrival and after return from mid-shift break. A forehead (temporal) temperature ≥37.5 C (99.5 F) will be considered a fever. If the staff member had the forehead wrapped or was out in the sun, the temperature reading may be an anomaly, and may be repeated after sitting inside for 5 minutes. If a staff member develops a fever, or a significant cough or new onset breathing difficulty, then the staff member must leave work in a safe manner, and go home.

5.      All staff must wear a mask while at work. This may be a surgical mask or a cloth mask with at least two cotton layers. The mask must be worn at all times, but may be removed if the staff member is alone in own work area, with no one else present in the vicinity. However, a staff member with Covid-19 exposure must wear a mask at all times while at work.

6.      CPAP use may aerosolize the Covid-19 virus. Therefore, when entering a room of a patient during CPAP (including BPAP, ASV, etc.) use at the time, staff must wear an N95 mask, goggles, and gloves.

7.      When interacting within 6’ of a patient with mask removed (such as during physical examination, testing or hook-up procedures), staff must wear an N95 mask, goggles, and gloves.

8.      Staff must maintain a distance of 6 feet from other staff to the extent possible. We have reconfigured work areas so that this is possible most of the time. Staff will have to confer together or work together at times, and must wear masks at such times.

9.      To the extent possible, staff should endeavor to maintain a distance of 6 feet from patients.

10.  Staff will continue to be required to wear lab coats as personal protective equipment. Launder these daily.

B.     Patients:

1.      We will not be providing in-office services at this time to patients with Covid-19 or those likely to have Covid-19.

2.      All patients will be advised that, unless otherwise necessary, they alone are allowed entry into the office. Companions are not allowed to enter unless necessary (such as one parent of a child, one companion of a disabled patient or a patient with significant cognitive impairment or difficulty with English). Other companions may wait in the car, not in the waiting room. All patient policies also apply to the companion.

3.      Upon arrival in the office, all patients (and companions, if allowed) must sanitize their hands at the sanitation station in the waiting room. They must properly wear a mask or face covering that covers their nose, mouth and chin. If they do not have a mask, we may provide them a cotton double-ply mask, which we will collect when the patient is leaving, and launder daily. Patients (and companions, if allowed) will complete a questionnaire asking about exposure to Covid-19 and Covid-19 symptoms. Patients/companions will have their forehead temperature taken. A forehead (temporal) temperature ≥37.5 C (99.5 F) will be considered a fever.

4.      Reschedule appointments for patients who have Covid-19 symptoms or a fever, for a date at least 3 days after their symptoms are gone and at least 10 days after onset of symptoms. Patients with Covid-19 exposure must wear a surgical mask or a double-layered cotton mask, and not an alternative mask. We may supply them with a double-ply cotton mask for office visits, or a surgical mask for testing. However, if the appointment is for testing involving use of CPAP, reschedule appointments for patients with Covid-19 exposure.

5.      Patients (and companions) must wear their mask properly during hookup and testing, if possible. Patients undergoing sleep testing may remove the mask while in their own room. If they are awake, ask them to put their mask back on before entering their room. Patients must put the mask on and sanitize their hands if they leave their room. Staff must wear an N95 mask, goggles, and gloves when working within 6’ of the patient, if the patient mask has to be removed during hookup or testing.

6.      Before making a new patient appointment or testing appointment, staff will ask about:

a.       Exposure to confirmed Covid-19 patient (≥10 min within 6’ without mask) during the last 14 days.

b.      Fever, new cough (out of the norm), loss of taste or smell, shortness of breath (out of the norm) or flu-like symptoms like body aches.

If these are absent, make an appointment, with advice to reschedule if any of these develop. If exposure is present, make appointment for 14 days past exposure. If symptoms are present, ask patient to contact us 3 days after symptoms are gone (and at least 10 days after onset of symptoms). It is not necessary to ask these screening questions for patients seen that day in the office, since these patients have already been screened earlier.

7.      Telehealth services will continue to be available (for established patient but not for new patient or testing follow-up appointments) and may be scheduled during established patient slots. However, insurance companies currently plan to stop covering them sometime in June (with exact date depending on insurance company), so patients will then have to pay.

C.    Facilities:

1.      The purpose of masks (surgical or cloth) is to prevent the wearer from infecting others. Cloth masks should preferably be cotton with at least two layers. Launder our cloth masks. Surgical masks are considered disposable, but may be reused and may be sanitized in times of shortage, such as currently.

2.      The purpose of N95 masks and goggles is to prevent the wearer from being infected. These are considered disposable but may be reused, and may be sanitized in times of shortage.

3.      We will provide staff with surgical masks (or two-ply cotton masks) to wear at all times. When clinically indicated, we will provide staff with N95 masks. Surgical masks and N95 masks may be worn continuously or intermittently all day, and then placed in a paper bag with the staff member’s name. N95 masks may be reused five times (that is, for five days). Thereafter, they may be sanitized by steam (no more than three times) and then reused. Surgical masks may be reused and sanitized till they break or become soiled. Replace any masks with broken bands or clips or with torn or soiled fabric.

4.      We will remove and store enough chairs to allow a distance of about 6 feet between individuals, to the extent possible. This will mean removing the chairs in the exam rooms, 50% of the chairs in the waiting room, 67% of the chairs in the conference room, and a couple staff chairs.

5.      To the extent possible, we should endeavor to keep patients about 6 feet away from others (excluding their allowed companion). In the sleep lab, patients must stay in their rooms.

6.      We will open and close doors to the extent possible, so that patients do not have to touch door handles.

7.      We will continue our room cleaning procedures using Super Sani-cloth (2 min contact time for  low or intermediate level disinfection) or Opti-cide Max spray (1 min contact time for low-level disinfection, 2 min contact time for intermediate level disinfection), allow to air dry, may wipe after 1 or 2 min depending on level of disinfection), with increased diligence. Reported drying time for these is 3 minutes, so disinfection occurs before drying.

8.      We have installed several hand sanitizing stations throughout the facilities. These will allow patients and staff to sanitize their hands frequently.

9.      We have purchased six air purifiers with HEPA filters and UV-C light. These claim to purify the air in a 336 sq. ft. room and to capture and/or destroy viruses such as the SARS-CoV-2 (the Covid-19 virus). We will use these in patient bedrooms at night (and during the day for MSLT) at low speed and UV on during sleep testing. Upon the patient leaving, we must turn them to high speed with the timer set for two hours and the room door closed.

10.  Used clipboards will be placed in an open bin and reused after 72 hours (since SARS-CoV-2 may survive on hard surfaces for 48 hours). Used pens will be placed in an open bin and undergo low-level disinfection at the end of the day before reuse.

11.  We will continue high level disinfection of CPAP masks and tubing, intermediate level disinfection (using Super Sani-Cloth) of thermistors, and low level disinfection of  HSAT devices, and other testing materials, following our established protocols, and be even more diligent. Low-level disinfection kills the SARS-CoV2.

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