• Coronavirus

Guidance Relating to Non-Urgent, Non-Essential or Elective Non-Hospital Procedures Relative to the 2019-Novel Coronavirus (COVID-19)

Published:  May 18, 2020

On April 27, 2020, CPDH issued guidance for “Resuming California’s Deferred and Preventive Health Care.”  The Health Officer is issuing this guidance to assist local healthcare providers in resuming elective procedures. This guidance does not affect what facilities are allowed to operate under existing local or state shelter in place orders.

The Health Officer recommends that, prior to scheduling elective procedures, healthcare providers develop and implement COVID-19 elective procedure guidelines that addresses the considerations spelled out this in guidance.  The Health Officer recommends all healthcare providers regularly review and amend all evaluations in their COVID-19 elective procedure guidelines to make sure that their guidelines remains reliable.

All healthcare providers should comply with any applicable Federal, California, and local governmental regulations and guidance on COVID-19.  Healthcare providers may also look to guidance from Federal, California, and local healthcare associations for additional guidance.

The COVID-19 elective procedure guidelines should address:

General Considerations:

  1. An evaluation of the incidence and trends for COVID-19 in Sonoma County, including:
  1. An evaluation of the Personal Protective Equipment (PPE) supply in each facility, office, or any other places of healthcare service.  The evaluation should include a determination of how much PPE is needed by staff and the daily usage demand ( https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html).  PPE use should be consistent with OSHA requirements and Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommendations.  In planning to restart elective procedures, consideration should be given to how much PPE to reserve in the event that PPE is unavailable due to surges related to COVID-19 outbreaks.
  2. An evaluation of what prompt testing resources are available to the provider for employee or patient referrals.
    • Test sites as of May 6, 2020 are as follows:
      1. https://lhi.care/covidtesting or call 1-888-634-1123 for appointment.
        • All Sonoma County residents are eligible, regardless of age, economic or immigration status, or health symptoms.  Testing sites are located at Santa Rosa High School and the Petaluma campus of Santa Rosa Junior College. 
      2. Drive-through testing site for priority groups located at the county’s public health facilities on Chanate Road.  The site is open seven-days a week serving first responders and health care workers.  Call 707-565-4667 to schedule an appointment.
  3. An evaluation of available staff levels to safely perform procedures, provide care and needed follow up.  Workforce considerations should also take into account ancillary supports and downstream providers, such as potentially necessary referrals to SNFs.
  4. An evaluation of how quickly the provider is able to cease operations in anticipation of a COVID-19 surge, and when or what thresholds will trigger the provider to cancel all scheduled elective procedures.  (If surge status increases, access to non-urgent care should decrease so as to limit transmission, preserve critical supplies of PPE, and protect healthcare workers and the healthcare system).

Personal Protective Equipment:

  1. A determination for when is it clinically necessary for healthcare providers and staff to wear PPE, which should take into account OSHA requirements and Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommendations.
      1. OSHA – Guidance for Preparing Workplaces for COVID-19
      2. Centers for Disease Control and Prevention (CDC)
      3. California Department of Public Health Guidelines (CDPH)
      4. https://covid19.ca.gov/masks-and-ppe/

    • A plan for training all healthcare providers and staff on when and how to use specialized masks (i.e., N95), eye protection (face shield or goggles), gloves, and gowns.
    • All healthcare providers and staff should wear isolation medical-grade masks, if available to the provider, or facial coverings when not engaging in healthcare activities determined to require the use of PPE.

    Facility and Office Site Standards:

    1. Provision for screening all patients for COVID-19 testing prior to appointment.  Patient testing should include timing considerations to provide information as to COVID-19 status of patients prior to appointment.  Providers should use their judgment on advising patients (after testing) on isolating at home until date of appointment.  If there is uncertainty about patients’ COVID-19 status, PPE appropriate for the clinical tasks should be provided for physicians and nurses.
    2. Facilities and offices should have a plan in place to establish and implement Non-COVID Care zones, as outlined in CMS guidance.  https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf
    3. Post a notice at the entry to the office instructing patients to NOT enter if they are experiencing symptoms.
    1. All healthcare workers, staff, patients, and visitors should be temperature and symptom screened prior to entering the facility.
    2. Anyone demonstrating symptoms of COVID-19 during screening should be told to isolate at home, and follow up with their primary healthcare provide or public health for testing.
    3. Facilities and offices should have a plan in place for how to handle symptomatic employees, and how to handle employees with potential exposure to COVID-19.
    4. Patients and visitors should be warned, upon scheduling and prior to entering the facility, that they are required by Health Officer Order No. C19-07 to wear masks or facial coverings prior to entering the facility.
    5. Patients may remove facial covering when told to do so by a healthcare provider.
    6. Facilities and offices may provide masks and facial coverings to patients and visitors, or require patients and visitors to wear their own masks or facial coverings.
    7. Facilities and offices are encouraged to educate patients and visitors about proper use of facial coverings, consistent with the CDC and CDPH recommendations.
    8. Patients should be prohibited from bringing visitors to the facility unless the healthcare provider deems the visitor necessary for any aspect of patient care or comfort; these visitors should be pre-screened in the same way as patients.
    9. Social distancing should be implemented in work areas, common areas, and patient waiting room areas. 
      For example:
    • Posting visual reminders (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators) to provide patients and office staff with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette.  Visual reminders in multiple languages can be downloaded from the CDC website.
    • Limiting points of entry to the medical office or facility.
    • Arranging office flow such that patients enter and leave through separate doors.
    • Rotating staff breaks and lunches to prevent crowding in common areas, if possible.
    • Asking patients to check in by phone or text message and wait in their car until an exam room is ready.
    • Limiting both waiting and exam room access to the patient only, with the exception of visitor necessary for any aspect of patient care or comfort, such as parents of young children.
    • Rearranging waiting room chairs so that patients are separated by 6 or more feet.
    • Providing supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at practice entrances, waiting rooms, and patient check-ins.
    • Installing physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
    • Putting away items such as magazines, toys, water dispensers, or anything else that may be handled by infected patients.
    • Completing the check-out process in the patient room, rather than at the front or back desk.
    1. Facilities and offices should have a plan in place to clean and disinfect on an ongoing basis.  Care should be taken to disinfect high touch surfaces, such as door handles, chairs, countertop, medical equipment and exam tables between patients.

    Healthcare Staff:

    1. Healthcare staff should be encouraged to avoid rotating as much as possible between care of COVID-19 positive/persons under investigation and non-COVID-19 patients as outlined in CMS guidance.
    2. Healthcare workers with a potential exposure to COVID-19 should be encouraged to follow CDC guidance.  https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.
    3. Healthcare workers are encouraged to implement the following best practices to reduce the risk of transmission:

      Preparing for work:
      • Consider wearing scrubs every day.  Always have a clean set ready.
      • If you wear a white coat, wash it every day.
      • If you typically wear jewelry, a tie, a watch, or other nonessential accessories, leave them at home.
      • If you have medium or long hair, wear it pulled back.
      • If you wear contacts, consider wearing glasses to decrease the need to touch your face and to offer a barrier.
      • Prepare clean clothes and shoes to change into after work.  Take them with you if you can change at work.
      • Remove nonessential items in your car, and stock the car with disinfecting wipes to make it easy to wipe down key surfaces after traveling home.
      • If taking mass transit, have hand sanitizer available and use it after touching any surfaces.
      • If you have extra disposable gloves, take them with you in case you need to touch potentially contaminated surfaces as you travel to work.  Be sure to carefully remove and dispose of them.

      Before leaving work:
      • If possible, shower and change into clean clothes and shoes before heading home.
      • Put dirty clothes and shoes into a bag for soiled clothing.  Consider using a cloth bag you can wash along with your dirty clothes each day.
      • Wash your hands or use hand sanitizer after removing work clothes and before touching clean clothes.

      When you arrive home:
      • If you were unable to change clothes before leaving work, change in an isolated location (e.g., garage, mudroom, laundry room).
      • Do not wear shoes from work into your home.  Clean them, top and bottom, with disinfecting wipes.
      • Wash clothes worn at work using your usual laundry detergent.
      • Wash or safely discard dirty clothes bag.
      • Wash hands after handling dirty clothes and shoes.
      • Shower before interacting with your family.
      • If you choose to isolate from your family:
        • Identify a room and bathroom to be used exclusively by you.  Have another family member leave needed food and items for you outside your isolation area so that you don’t have to move throughout your home to meet your needs.  Consider using disposable plates, cups, and utensils.
        • Consider obtaining a short-term lodging facility, such as a short-term rentals, vacation rentals, timeshares, hotels, motels, and other short-term lodgings that can be used to isolate alone or with other co-workers.

    Care Prioritization and Scheduling:

    • Facilities and offices should establish a prioritization policy for providing care and scheduling.
    • Priority scheduling should consider:
      • Patients with acute illnesses that cannot be handled through telehealth.
      • Patients with chronic illness, including behavioral health conditions that have not been seen due to Stay-at-Home rules and need in person visit.
      • Preventive services including well child and vaccinations, as well as adult clinical preventive services.
      • List of previously cancelled or postponed patients.
      • Other patients needing in person visit to monitor status or assess illness, etc.
      • Clinical impacts of treatment delay and the current surge status of the healthcare infrastructure in a community.
    • Telehealth/telephonic modality should be used for all appropriate patients and conditions.
    • At the time of scheduling, patients should be asked if they are experiencing common COVID-19 symptoms – dry cough, fever, etc.  Patients reporting COVID-19 symptoms should be screened telephonically and referred for testing, if possible, before coming to the office.
    • Schedule patients such that only a few are in the office at any one time.
    • When scheduling appointments instruct patients to call ahead and discuss the need to reschedule their appointment if they develop symptoms of a respiratory infection (e.g., cough, sore throat, fever) on the day they are scheduled to be seen.
    • Extended hours should be considered to limit the number of patients in an office at any given time.
    • Facilities and offices should consider scheduling special or reserved hours for elderly or immunocompromised patients, to minimize the risk of infection to vulnerable patients.
    • When considering community surge status, consideration should be given to capacity across the continuum of care.  Consider additional guidance, including Joint Statement, California Medical Association and American Academy of Pediatrics guidance on care prioritization, scheduling, and outpatient guidelines.

    References and additional guidance to consider:

    1. CDPH Resuming California’s Deferred and Preventative Health Care
    2. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic (PDF)
    3. CMS Guidance (PDF)
    4. California Medical Association Guidance on Reopening the Health Care System (PDF)
    5. CDC Universal Source Recommendations
    6. AAP COVID-19 main page
    7. AAP Pediatric Ambulatory Services

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