Outside the Facility (Community)

• This will have National, Regional and Local Implications. Intervene where you can!

• Avoid travel

• Limit social gathering

• Practice social distancing

• Your community may decide to close itself off to outside visitors except emergency workers.

Inside the Medical Facility

Unlike a Code Orange event...

In a Pandemic, infected patients will transmit to non-infected patients and exponentially increase patient load.

Rural Facilities:

Unless very lucky - your facility was NOT DESIGNED for Pandemics. Therefore you will not have a lot of Good choices. You will often be choosing the LEAST BAD option.

You may have the unique challenge of providing acute, outpatient and inpatient care in the same immediate physical space. This will pose challenges as you must provide outpatient alternatives while maintaining acute services.

Decrease all unnecessary exposures:

Entry Control

Every hour or 1/2 day that is delayed doing this is putting your Staff, Patients and your Community at needless increased risk. See the previous section.

Normal flu: 10 iterations of infecting on average 1.3 people = (1.3)¹⁰ = 14 cases of flu.

Coronavirus: 10 iterations of infecting on average 3 people = (3)¹⁰ = 59,000 people

Coronavirus: 6 iterations of infecting on average 3 people = (3)⁶ = 729 people

1. Do Not become the Source of Infectious spread.

   • Limit or Restrict Entry i.e. the number of people coming in.

   • Doors may need to be Locked to Protect patients and Provide the best care. Patients may need to call before coming.

     • Have Security for this.

2. If Costco has better Access Control than you do - YOU HAVE A PROBLEM

3. Your Pre-Triage will be very imperfect at first. If you do not control Entry - your staff and other patients will be put at needless risk

4. Ensure the public knows to NOT come to the facility unless they have called ahead for outpatient.

5. Switch to Telephone Consultations. This will require planning and resources.

6. Stop all non-urgent Appointments.

7. Implement Physical Distancing at Work. Source Control with Cloth Masks.

8. Pharmacy Rx by fax only, no old pill bottles to be brought to the clinic.

9. Pharmacy Deliveries - Avoids visits to the facility which increases Covid Risk.

   • Coordinate with Public Security or other means for delivery.

Separate Patient Streams

Pre-Triage, Source Control, Zones

After controlling the number of People Entering, focus on:

1. • Separating Infected/Suspected patients from Non-infected patients with Pre-Triage

   • Create Zones for these patient categories

1. Ensure only 1 or 2 controlled points of entry to the Facility.

2. Set Up Pre-Triage Immediately At or even Before Entry (e.g., set up a Tent outside)

   • you can use written question slips for each person entering about Resp/other symptoms and Travel. ie Have some way to relay this info to frontline staff so they can use appropriate PPE if needed.

   • Flag severe or High Risk patients and keep them separate

   • At some point you will have Telephone Triage, but you should Always have a backup at the Entry points.

3. NO Individual enters without Pre-Triage.

4. YOU MUST Monitor and TEST PRE-TRIAGE. At least EVERY DAY, better 2X/day

   • Installing new systems is complicated. There is always a learning curve and multiple points of failure exist.

   • Just because you set it up does NOT means it works.

   • In a best case it might take 7 days to make it solid.

   • Compounding this is the fact that Information is changing q2days

   • Be aware that your system has holes in it that put staff and patients at risk of exposure. You need to plug those holes.

   • Be kind and collaborative in your testing and make changes. Ask for feedback. If your front end staff are not able to do it - YOU need to make it better for them.

5. Source Control. Growing evidence of Asymptomatic spread.

   • Put a mask (cloth to save PPE) on everyone in the facility - Staff and Patients.

   • Make SURE they understand this is NOT PPE. It is their contribution to decreasing spread.

   • Consider making cloth masks for asymptomatic patients that can then be laundered in HOT water and detergent.

6. Zones - Inside the facility, separate the patient streams so COVID Positive or COVID Suspected (Red, Yellow respectively) are not mixing with Non COVID (Green). Due to resources you may decide to collapse Red and Yellow into just Red. See details in next section.

Local Spread - If local spread occurs Pre-Triage criteria may change and only require questioning about symptoms.

Please see Pre-Triage section.

Stay informed via public health, emergency medicine, and your colleagues.

Ideal Pre-Triage SetUp

Below is a sample of a dream Pre-Triage & Facility setup with unlimited nursing, medical, support staff & buildings.

Logistics of Patients

Keep in mind that you have different patient Categories:

1. Outpatient (Stable)

2. Emergency (Acute issue)

3. Inpatient (This guide does not address inpatients in any detail)

Each Category of patient also has a COVID status: Red, Yellow or Green. That makes a lot of combos.

You will need Red, Yellow & Green Zones for Emergency patients.

You could also have full Outpatient Green, Red and Yellow zones.

• This will require a lot of staff - which you will not have (if you do - go for it!).

In general:

• • Outpatient visits should decrease dramatically and become telephone visits. You can then eliminate having to setup 3 different outpatient zones with full volume.

  • Some outpatients however, will need to be seen - e.g., pregnant patients.

One approach is to:

1. Have a separate outpatient area for Green

2. In your existing acute area, set aside some space for any outpatients deemed Yellow or Red (they have been identified because outpatients are being PreTriaged by Telephone too).

3. In the case of specialized care - eg Obstetrics - staff from that service may spend the day or part of it in the acute area to see their Yellow/Red outpatients.

You will have to play with different ideas and work closely with the other healthcare professionals and support staff to make it work.

Be ready to try, fail and try something new.