Reopening Clinics: Ensuring a Healthy Facility and Staff Safety
Bryan Connors | May 14, 2020
As public health experts determine that it is safe to see patients and stay-at-home restrictions are relaxed, ambulatory care centers, physician clinics and dental clinics should strategically plan when and how best to reopen. The physical environment is part of the foundation of providing a healthy workplace so properly preparing your facility prior to re-occupancy will be important. When facilities sit idle with little to no use, it can actually create potential issues that need to be evaluated and addressed. As always, staff and patient safety are of the utmost importance and COVID-19 presents some new issues for many clinics that they will have to plan to navigate.
Your physical facility, its layout, HVAC system, and work area play a major role in the health and safety of your staff and patients during the COVID-19 crisis. It is essential that appropriate measures are taken to ensure a healthy environment prior to reopening your clinic.
Optimize HVAC Systems and Ventilation
Clinics will want to verify optimal performance of their HVAC systems and maximize air exchange rates. Air exchange rates are important to remove any infectious airborne droplets containing the virus, from infected patient or staff (that maybe asymptomatic). HVAC filtration should also be reviewed to ensure that it’s suitable and recommended filtration (or better) is in place for each occupancy type. Commonly, dental clinics and some medical clinics are located in commercial office spaces which means there may be more “office-type” (less efficient) filters in place serving the HVAC system. In settings such as this with lower air exchange rates, clinics may want to use small, free standing HEPA filters. The use of these units can increase the “effective” air exchange rate, which gives similar benefits of higher air exchange rates.
When making any modifications to HVAC systems and ventilation, clinics should ensure they are compliant with the Facilities Guidelines Institute and state building codes.
Layout and Flow of Workspace
Review the configuration of your workspace, waiting room, corridors, and patient care areas to consider ways to modify the space to allow for social distancing where possible or creation of barriers. For example, can corridors be made one directional? Is there the ability to install plexiglass at check-in areas to better protect patients and staff?
Water Management to Prevent Waterborne Microorganisms
For several weeks now clinics have been empty or had very limited use and occupancy due to the cease of non-essential procedures. This presents a significant concern for clinics since stagnant water creates ideal conditions for Legionella bacteria growth. The Centers for Disease Control and Prevention recommends “flushing” of outlets until all water is “replaced” within the building and until the hot water reaches the maximum temperature at every outlet in the building. This should be in combination with implementation of an effective Water Management Plan.
Dental clinics will also need to address the potential for mycobacterium abcessus in water lines, which can cause serious infections in the mouth during dental procedures. Mycobacterium is slow growing and notoriously difficult to get rid of. Testing water systems for mycobacterium is not as simple as it sounds and obtaining test results from a laboratory can take as long as 30 days. Therefore, taking mitigation steps is the recommended approach.
Dental lines are smaller making the flushing process less effective than in plumbing systems because enough water cannot get through the lines. “Shocking”, a disinfection treatment using chemicals, is recommended by the CDC. Shocking waterlines typically involves an initial treatment followed by additional treatments for maintenance.
The infection risks from mycobacterium and Legionella bacteria are serious and clinics are advised to employ the guidance of a qualified industrial hygienist to ensure measures are implemented effectively to mitigate these risks.
Space Cleaning and Disinfection
Clinics will need to enhance their regular cleaning and disinfection practices, for example, the frequency may need to be increased and routine cleaning of fixed equipment such as furnishings and fixtures. For most, this is a contracted service so you’ll need to coordinate with your vendor on the frequency and areas for enhanced cleaning. Make sure that EPA approved methods and products are being used.
It will be important to consider high-touch surfaces and areas. This commonly includes items such as doors, elevator buttons, stair handrails, faucet handles, keyboards and the like but you’ll want to consider other areas in your environment that get frequent use such as supply closets.
A proactive indoor air quality program is always a best practice to ensure a healthy environment. The need for enhanced and more frequent cleaning and disinfection of the overall space and individual work areas may introduce unwanted chemicals into the environment that could be irritating to occupants. Wipes are preferable to sprays because they are less irritating to occupants from an indoor air quality perspective, but options for what your clinic may be able to obtain could be limited due to the high demand.
Personal Protective Equipment for Staff
The intention may be to serve only patients not infected with COVID-19, but the reality is that clinics will have to face this at some point. We know that persons infected with COVID-19 can be asymptomatic. Supplying personal protective equipment (PPE) and training for staff on its proper use will be necessary. For many, this will include a surgical mask and face shield.
How to Know If an N95 Respirator is Real or Counterfeit
N95s are appropriate for use if the person will be in close contact with a person who is confirmed or suspected to be COVID-19 positive. From a general public health perspective, the CDC does not require them. However, we’ve found that some clinics want to use N95s as a precaution, particularly dental clinics where staff will be working with patients who are not wearing masks. The first obstacle will be obtaining a supply given the current shortage and that supplies are being directed to hospitals and first responders. If you do provide N95s for staff, you will need an Occupational Safety and Health Administration (OSHA) compliant Respiratory Protection Program. Additionally, staff will need to be medically cleared, fit tested and trained on proper use and donning and doffing procedures. Given the supply shortage, you will also need to implement correct measures for storage and reuse of N95s. If an N95 is to be stored for reuse, it should be stored in a container that is able to be closed but vented to allow moisture to escape.
Plan in Advance How to Manage a Positive Case of COVID-19
It is not a matter of if, but when, will you be faced with managing a positive case of COVID-19 (staff or patient) in your practice. Planning for this situation needs to happen before you reopen. Also consider what steps will be taken if an employee has come in “close contact” (as defined by the CDC) with a person who is COVID-19 positive. Your policy should include these essential steps:
- Virtual interview with the infected employee/patient
- Contact tracing
- Notification of close contacts
- Cleaning and disinfection plan
- Communication notifying employees of the confirmed case and steps taken by the clinic to manage the risks
Also, decisions will need to be made as to when an employee can return to work, taking into account their role (essential or non-essential). You’ll also need to consider any human resources or legal implications related to The CARES Act. Detailed written policies and procedures will be important so that actions can be undertaken quickly.
Communication with Staff and Patients
Across the country people have been under stay at home orders for several weeks. Naturally, people will have concerns about returning to work and buildings. Communicating the measures your clinic has taken to ensure a safe environment for your staff and patients to give them piece of mind will be essential. Providing staff and patients with confidence in your clinic and their safety will have a positive impact in helping you return to normal operations and, ultimately, your bottom line. Many clinics will need to think about COVID-19 health screenings with patients before entering the practice, potentially via text message or other technology, fever screening and signage. Though these issues may appear simple, advanced planning will be necessary, so you can confidently serve your patients and protect your staff.
Careful planning will be critical to the success of your practice reopening and there are many areas that need to be addressed. Taking the right steps to prepare your facility to provide a healthy environment, combined with effective policies and training to help ensure staff and patient safety are two key components in your overall plan. Successful implementation may require specialized expertise in industrial hygiene, engineering and infection control to avoid setbacks and minimize disruptions.