EXECUTIVE SUMMARY

The American College of Obstetricians and Gynecologists (ACOG) and the Infectious Diseases Society of America (IDSA) offered guidelines for how physician offices, clinics, and other facilities can reopen to in-person, nonessential services in the next phase of the pandemic.

  • IDSA recommends testing for COVID-19 in asymptomatic individuals before major, time-sensitive surgeries, and deferring nonemergency procedures for patients who test positive.
  • According to ACOG, practitioners should use testing methods relevant to their patient populations.
  • Social distancing should continue through the summer, with clinics limiting the number of patients in waiting rooms.

Obstetrician-gynecologists should work collaboratively with hospitals and facilities to determine how quickly they will resume routine, in-person care, according to a position statement by The American College of Obstetricians and Gynecologists (ACOG).

ACOG recommends that practitioners develop testing methods relevant to their patient populations. More widespread testing, including testing of asymptomatic patients, might be necessary in the early phases of resuming routine care.

Clinics should maintain physical distancing as routine care resumes, ACOG said. “Practitioners and facilities will also need to develop policies for use of masks and facial coverings,” ACOG stated. “For example, in the early stages, policies should address whether all patients and clinicians will be masked during in-person encounters.” (The position statement is available at: https://www.acog.org/en/clinical-information/physician-faqs/~/link.aspx?_id=737EFABFEEC34D048E3A7516DD7D6A95&_z=z.)

The Infectious Diseases Society of America (IDSA) convened a panel of clinicians, microbiologists, and other experts to develop diagnostic recommendations for SARS-CoV-2 nucleic acid testing.

“The overarching goal was to give guidance about who should be tested, when they should be tested, and how to interpret the results,” said Kimberly Hanson, MD, MHS, chair of the IDSA’s COVID-19 diagnostic guidelines expert panel and an associate professor of internal medicine at University of Utah School of Medicine. Hanson spoke about the IDSA’s testing guidelines at a web conference on May 8.

The panel made 15 recommendations, mostly around testing for patients with symptoms or who were exposed to people with COVID-19. The panel also included a recommendation to test asymptomatic individuals, who have no known exposure to COVID-19, before they undergo major, time-sensitive surgeries. The testing should be performed within 48-72 hours of the procedure. (The guidelines are available at: https://www.idsociety.org/practice-guideline/covid-19-guideline-diagnostics/.)

The panel experts recommended that clinicians consider deferring nonemergent surgeries for patients who test positive for the virus. The panel recommends against testing patients who are asymptomatic, have not been exposed to the virus, and whose communities have a low prevalence rate of COVID-19.

“While there was relatively easy consensus around testing asymptomatic patients, there was a lot more discussion about asymptomatic patients,” noted Angela Caliendo, MD, PhD, FIDSA, a member of the IDSA COVID-19 diagnostic guidelines expert panel. She also spoke at the May 8 web conference.

The recommendations to test asymptomatic surgery patients are based on the desire to protect healthcare workers and to protect patients. “There is data in the literature about patients who underwent major surgeries and had COVID-19, and didn’t have as good of outcomes,” said Caliendo, professor and executive vice chair of Alpert Medical School’s department of medicine at Brown University in Providence, RI.

It is important for healthcare organizations to assess the effect of COVID-19 on their own cities, states, and regions before creating phase-in plans. For example, some regions have had better access to personal protective equipment (PPE) and supplies because of better planning.

“In my own region of Seattle, a lot of us have prepared for this, saw it coming, and we built capacity,” said John Lynch III, MD, MPH, a member of the IDSA board of directors. Lynch spoke at an IDSA web conference on April 17.

Regions with adequate COVID-19 testing kits likely have better data on infection rates. This information can help a clinic decide how quickly to phase in full clinic services.

“I see some level of social distancing moving on quite a ways into the future because we do not have all the data we need,” said Lynch, associate professor at the University of Washington department of medicine, division of allergy and infectious diseases, and associate medical director of Harborview Medical Center. “We do not have a coordinated process for this, so I do not know what proportion of people in my community have COVID-19.”

Summer 2020 likely will see decreased levels of social distancing. But from a healthcare facility’s perspective, there should be a slow and deliberate return to previous in-person services. PPE and more diligence with infection control measures are necessary, he noted.

“There is a risk we’ll bump back up [in COVID-19 cases] when we see a relaxing in social distancing, and we need to be able to respond to that,” Lynch predicted.

The Centers for Disease Control and Prevention (CDC) recommends that healthcare facilities monitor the CDC COVID-19 website and state and local resources for updated information about the pandemic in each state. (Find out more at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.html.) The CDC also recommended healthcare organizations take these steps:

The American Medical Association (AMA) also has created a checklist for reopening physician practices, including best practices and criteria that are helpful to any healthcare provider or clinic.

For example, the AMA recommended providers open incrementally. They should continue to provide telehealth and other modalities when feasible and begin opening with a few in-person visits a day, working on a modified schedule, the AMA suggested. Administrative staff could continue to work remotely and employees could be brought back in phases, such as working on alternate days or different parts of the day to reduce contact. (The checklist is available at: https://www.ama-assn.org/delivering-care/public-health/covid-19-physician-practice-guide-reopening.)

The AMA checklist includes safety measures for patients, as well as ways to ensure workplace safety for clinicians and staff. These include screening patients and employees for high temperatures and other symptoms of COVID-19, and minimizing staff contact. Clinics also could minimize the number of people touching the same equipment, and limit nonpatient visitors in waiting rooms.

Family planning clinics could continue to provide telehealth consultations and follow-up care, as they have during the crisis period. This will help reduce the number of in-person visits at each facility.

“In all areas of medicine, telehealth will play a larger role,” says Daniel Grossman, MD, professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco.

Telemedicine will continue partly because clinics, as they reopen, will need to continue social distancing and limiting the number of patients in the waiting room, Grossman says.

As the nation reopens to elective surgeries, nonemergency in-person clinic visits, and other nonessential business and shopping, reproductive health providers and others should keep in mind that the virus could easily resurge in various places.

Cities will be prepared for outbreaks, but these also could occur in more rural areas. Some of the earliest cases of COVID-19 occurred in small communities, including ski resort towns in Utah, and Native American communities. Rural areas and small cities are particularly susceptible to the pandemic because one infected person who attends a town event could infect many people in the area.

“What we’re seeing is a lot of disease in small cities that don’t have the medical care we have in big cities,” said Andrew Pavia, MD, FIDSA, chief of the division of pediatric infectious diseases at the University of Utah School of Medicine. Pavia spoke about COVID-19 outbreaks at an IDSA web conference on April 21.

“We’re not seeing one epidemic nationwide, or statewide,” Pavia explained. “In Utah, we’ve done a good job of clamping down on the rate of the rise, where it looked like cases were starting to decline, but now are back up to what it was because of micro-outbreaks that are occurring.”

Family planning clinics should keep this phenomenon in mind when scheduling and screening patients, especially if they are making decisions about when to require previsit COVID-19 testing.

Healthcare workers cannot assume patients arriving from less populated areas are safe from infection, says Angela Hewlett, MD, MS, FIDSA, associate professor in the division of infectious diseases at University of Nebraska Medical Center, and medical director of the Nebraska Biocontainment Unit.

“Living in a rural area has some advantages for battling a disease like this. People are naturally socially distanced and are living in single-family homes, spread out, and with no mass transit,” Hewlett explains. “But it also makes it a uniquely vulnerable population for an outbreak like this. The whole town might attend one large town gathering.”