THPG Operations
THPG Safe Return to Care Checklist


THPG Office Workflow for COVID-19


Cleaning Procedures

Aerosol

  • These procedures should only be done in order to save a life.
  • Consider administering treatment in a room used the least
  • Following a nebulizer treatment, close the door. The room should be left dormant until the next day and cleaned before use. Staff who must enter the room during the treatment should wear N95 respirators and eye protection. Stethoscopes, if not disposable, should be thoroughly cleaned after use.

Office

  • The Environmental Protection Agency (EPA) recommends the below guidance to ensure you are using an appropriate disinfectant.
  • At the end of the day clean all exam rooms, check-in & check-out counters and waiting room furniture. All areas where patients would have come into contact. 
  • Clean with the recommended disinfectant such as Citrace. Clean the exam table, cabinet countertop, cabinet and doorknobs, mayo stand, chair handles, jar tops, hot/cold water facets if you have a sink in the room and any other thing the patient may have touched.
  • A recommendation is to remove the jars of cotton swabs, tongue blades, etc. into a central area of the clinic to maintain your level of supplies. You could place those items in something like a shower caddy to carry with you to an exam room, so those things are not in the room. Supplies may go missing. Patients do go through drawers and cabinets, so we want to remove opportunity where possible. Do not leave a speculum on a mayo tray prior to an exam It can be carried into the room if a vaginal exam is necessary.

Post COVID Patient

  • After the patient leaves the exam room, close the door. The room should be left dormant until the next day and cleaned before use.
  • Clean the exam room with the recommended disinfectant such as Citrace. Clean the exam table, cabinet countertop, cabinet and doorknobs, mayo stand, chair handles, jar tops, hot/cold water facets if you have a sink in the room and any other thing the patient may have touched.
  • Reference Page Symptomatic: Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and or diarrhea. Likelihood of COVID is increased if patient resides in or has traveled within the previous 14 days to a location with severe COVID 19 infections/ has had close contact with confirmed COIVD 19 patient within last 14 days. Defining Self-Isolation: Stay home until it is safe to be around others. If you live with others, stay in a specific sick room or area and away from other people or animals, including pets. Use a separate bathroom, if available. Assumption: All clinic staff and patients are masked as of 3.25.20. All clinic staff in an exam room must wear complete PPE for tests producing aerosolized droplets. *Close contact: Less than 6ft away & greater than 5mins in a healthcare setting, 15 minutes and less than 6ft away in a community setting **10+3 day protocol: Isolate for 10 days after symptoms began or 3 days after last symptoms, whichever is longer ***On Lab Order Note: Specify if test is for healthcare worker or first responder ****Retesting Protocol: If two negatives are requested from employer (e.g. healthcare worker): you may wait until 1st test is resulted prior to ordering 2ndtest OR order both tests with note to schedule 2nd retest > 24hrs after 1st. Note: When appropriate, patients may need to be seen in person that have been tested for COVID 19. As with all patients, Providers and staff should be wearing eye protection (face shield preferred), gown, and gloves.*If Providers or staff are high risk, wear N95 respirator. If aerosol generating procedure, wear N95 respirator. Disinfect surfaces as usual. Key:

THPG Office Staff Script for COVID-19


EDS Triage Documents in 4 Languages

  • Please refer to 4/07/2020 (9:59am) Operations Update Email from Jennifer Stephenson

Virtual Visits

  • Video virtual visits can be conducted to complete HCC forms
  • For primary care providers using Skype, do not direct patients to the call center (682-236-6700) for Virtual Visit invite issues. If an invite is needed for an appointment in the next hour, or the patient is getting an error with the invite, the PM and only the PM should contact Kathy Lindler.

Vendor/ Pharm Visits for COVID-19

  • Pharmaceutical or sales representative are not allowed in the clinic nor are outside vendors.
  • Vendor partners who provide clinical care to our patients are allowed to be in the clinic such as Airrosti, Quest, etc.

Lunches Provided by Vendors

  • May be provided, must be individual lunches, not buffet style. The company representatives are not allowed to come to the clinic.




Employee Resources:

EAP

  • Visit https://www2.texashealth.org/eap/default.aspx.
  • Phone Number: 877-MyTHRLink (877-698-4754), select prompt 4, then select 4 again OR call 682-236-6861 to speak to a representative who can help you schedule an appointment or connect you to a counselor.

Childcare


Return to Work Letters in Epic

  • There are two THPG COVID-19 letters for patients available in the letter’s activity in Epic.
    • AMB THPG COVID-19 RETURN TO WORK (ID#58225)
    • AMB THPG COVID-19 WORK FROM HOME REQUEST (ID#58280)

  • Contact DL for further assistance: DLCareConnectTHPGtraining@TexasHealth.org
RL Tool for COVID-19
  • Reporting in the RL tool for COVID19 patients is only when there is a gap in procedure (PPE) for patients who are suspect or known positive for COVID19. 




Visitor Policy for COVID-19

  • In an effort to reduce community spread, individuals accompanying patients to THPG practices must be limited to one person who is needed to assist the patient, either due to mobility or communication concerns.
  • Additionally, please discourage children less than the age of 16 from accompanying their adult parents or guardians to the office.




Test Result Notification for COVID-19

  • Following testing, please check in with patients frequently (daily if possible) to ascertain their status. Symptoms can change rapidly, and patients must be counseled to seek a higher level of care when symptoms are worsening.
  • COVID-19 test results will flow into MyChart for those orders placed in the practice setting. When speaking with patients regarding their results, the following information regarding self-isolation should be explained:
  • Persons with positive COVID-19 results who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:
    • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath)
    • And at least 7 days have passed since symptoms first appeared.
  • Persons with negative COVID-19 results should be advised as follows:
  • If they have had close contact with an individual known to have tested positive for COVID-19, they must remain in isolation until 14 days from their last contact with the individual.
  • If they did not have contact with an individual known to have tested positive for COVID-19, they must remain in isolation until 72 hours have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath)

PPE Requirement:

All Staff:

  • All employees and providers will now be required to wear face masks (formerly referred to as surgical or isolation masks) continuously while any building that provides patient care.
    • Mask should be changed daily, or when it is wet or soiled
    • Wash/foam hands before and after changing face masks
    • Remove and discard face masks after leaving an exam room of a patient suspected for COVID-19 and replace with a new mask before entering the next patient room.

Front Desk Personnel:

  • Email sent by THPG Leadership on 3.24.20 -1p
  • All employees and providers will now be required to wear face masks (formerly referred to as surgical or isolation masks) continuously while in any building that provides patient care. This includes caregivers, administrators, Food Services, Environmental Services and all other staff. Everyone has an important role in controlling the spread of the virus and keeping our employees and patients safe.
    • Wear gloves and use hand sanitizer (on the gloves) between patients at reception. Gloves should be changed daily or as soon as they torn or soiled.
    • Minimize exchange of items (Ex. Allow patient to insert credit card in the machine when possible)
    • Encourage patients to use hand sanitizer before handing objects to an employee and after taking the object back.
    • Always perform hand hygiene before and after glove use.

Patients and Guests:

  • All patients and individuals with patients are to be masked. As a reminder, there should be no more than one individual with each patient.




Plasma Donations

  • Contact Clinical Nurse Leader: douglasjohnson@texashealth.org or 214.345.5926
  • Email with the word ‘PLASMA’ in the subject line or leave a voicemail with your name and phone number

Ordering Chest X-rays

  • Our imaging partners are working to protect their staff and most have made the decision to not perform imaging on patients with cough or fever. Where clinically acceptable, guidance is to treat empirically for pneumonia and follow the patient closely for deterioration of symptoms. Only send those patients to the hospital emergency department that warrant emergency care.

Reporting COVID-19

  • ICD-10-CM Official Coding and Reporting Guidelines
  • April 1, 2020 through September 30, 2020
  • Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
  • Coronavirus Infections
  • 1) COVID-19 Infections (Infections due to SARS-CoV-2)
  • a) Code only confirmed cases
  • Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.
  • Presumptive positive COVID-19 test results should be coded as confirmed. A presumptive positive test result means an individual has tested positive for the virus at a local or state level, but it has not yet been confirmed by the Centers for Disease Control and Prevention (CDC). CDC confirmation of local and state tests for COVID-19 is no longer required.
  • If the provider documents "suspected," "possible," "probable," or “inconclusive” COVID-19, do not assign code U07.1. Assign a code(s) explaining the reason for encounter (such as fever) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.
  • b) Sequencing of codes
  • When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients as indicated in Section . I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium.
  • For a COVID-19 infection that progresses to sepsis, see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock
  • See Section I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium
  • c) Acute respiratory illness due to COVID-19
  • (i) Pneumonia
  • For a pneumonia case confirmed as due to the 2019 novel coronavirus (COVID-19), assign codes U07.1, COVID-19, and J12.89, Other viral pneumonia.
  • (ii) Acute bronchitis
  • For a patient with acute bronchitis confirmed as due to COVID-19, assign codes U07.1, and J20.8, Acute bronchitis due to other specified organisms.
  • Bronchitis not otherwise specified (NOS) due to COVID-19 should be coded using code U07.1 and J40, Bronchitis, not specified as acute or chronic.
  • (iii) Lower respiratory infection
  • If the COVID-19 is documented as being associated with a lower respiratory infection, not otherwise specified (NOS), or an acute respiratory infection, NOS, codes U07.1 and J22, Unspecified acute lower respiratory infection, should be assigned.
  • If the COVID-19 is documented as being associated with a respiratory infection, NOS, codes U07.1 and J98.8, Other specified respiratory disorders, should be assigned.
  • (iv) Acute respiratory distress syndrome
  • For acute respiratory distress syndrome (ARDS) due to COVID-19, assign codes U07.1, and J80, Acute respiratory distress syndrome.
  • d) Exposure to COVID-19
  • For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out.
  • For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the exposed individual tests positive for the COVID-19 virus, see guideline a).
  • e) Screening for COVID-19
  • For asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign code Z11.59, Encounter for screening for other viral diseases. For individuals who are being screened due to a possible or actual exposure to COVID-19, see guideline d).
  • If an asymptomatic individual is screened for COVID-19 and tests positive, see guideline g).
  • f) Signs and symptoms without definitive diagnosis of COVID-19
  • For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
  • R05 Cough
  • R06.02 Shortness of breath
  • R50.9 Fever, unspecified
  • If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, as an additional code. This is an exception to guideline I.C.21.c.1, Contact/Exposure.
  • g) Asymptomatic individuals who test positive for COVID-19
  • For asymptomatic individuals who test positive for COVID-19, assign code U07.1, COVID-19. Although the individual is asymptomatic, the individual has tested positive and is considered to have the COVID-19 infection.
  • Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
  • s) COVID-19 infection in pregnancy, childbirth, and the puerperium
  • During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of COVID-19 should receive a principal diagnosis code of O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, followed by code U07.1, COVID-19, and the appropriate codes for associated manifestation(s). Codes from Chapter 15 always take sequencing priority.

Treatment for COVID-19

  • There have been many references to the use of azithromycin and chloroquine for treatment of COVID-19. There are studies in support of this for hospitalized patients, although the studies have been small. Due to the emerging nature of this disease, the studies are not randomized controlled trials. Furthermore, the studies indicate reduction in viral load but there is no clear correlation with clinical outcomes. The risk of prescribing these medications as empiric treatment or prophylactic and “just in case” treatment for concerned patients is that supplies of these medications will be diminished and unavailable for acutely ill hospitalized patients. Patients will ask/demand for these prescriptions and it is incumbent upon each provider to be good stewards of our precious resources.
  • Should you or your patients be interested, there is a trial seeking research volunteers who are:
    • Health care workers or household contacts with known exposure to someone with COVID-19 within the last 4 days and who are currently asymptomatic.
    • People who are symptomatic with confirmed PCR+ COVID-19 diagnosis within the first 4 days of symptoms starting.
    • Health care worker with compatible symptoms with exposure to known PCR+ COVID-19 case within 14 days AND compatible symptoms of fever, cough, or shortness of breath and no available testing or pending testing for the individual.

THPG PPE Guidelines
All staff

All employees and providers are required to wear face masks (formerly referred to as surgical or isolation masks) continuously while in any building that provides patient care.

The mask should be changed daily, or when it is obviously wet or soiled.
Wash or foam hands before and after changing face masks
Remove and discard the face mask after leaving the exam room of a patient suspected for COVID-19 and replace with a new mask before entering the next patient room.

All staff are screened upon arrival to the practice and upon return to the practice if they have left the premises. After December 7, 2020, employees will be screened once per day if they are utilizing the HCP COVID symptom checker app.

Patients and visitors

All patients and visitors will be required to wear clinic-provided face masks while inside THPG practices.

All patients and visitors are screened upon arrival, including temperature checks.

Providers and patient-facing staff

All providers and patient-facing staff should wear gown, gloves, face mask and eye protection during direct patient care.

Gown, gloves and masks should be discarded after an encounter with a patient with a respiratory illness or is COVID positive.

All providers and staff should wear face masks at all other times (when not in direct patient care).

All THPG staff with patient-facing roles should wear eye protection, including front desk staff, until acrylic barriers are installed.

Receptionists/ Front-desk staff

Wear gloves and use hand sanitizer (on the gloves) between patients at reception. Gloves should be changed daily – sooner if they become torn or soiled.
Minimize exchange of items.  For example, allow patient to insert credit card in the machine where possible.
Staff should also encourage patients to use hand sanitizer before handing objects to an employee and after taking the object back.
Staff should always perform hand hygiene before and after glove use.

Aerosolizing procedures (Nebulizers and spirometry)

Spirometry should not be done in the clinic setting.

Nebulizer treatments performed in the clinic are reserved for patients in severe distress. If possible, have the patient perform nebulizer treatments in the home.

For those patients who are in severe distress and the decision is made to provide the nebulizer treatment, consideration should be given to doing the treatment in a lesser-used room.

Following a nebulizer treatment, close the door. The room should be left dormant until the next day, and cleaned before use. Staff who must enter the room during the treatment should wear N95 respirators and eye protection. Stethoscopes should be thoroughly cleaned after use, or disposable stethoscopes may be used.

If provider has not been fit tested, AND YOU MUST DO LIFE SAVING NEBULIZER TREATMENT, start the patient on the nebulizer after you exit the room. When the treatment is complete, have the patient mask and exit the room, and move the patient to another exam room to complete the encounter. During the treatment, monitor the patient to the best of your ability from outside the room.