Operational Considerations for Infection Prevention and Control in Outpatient Facilities: Non-U.S. Healthcare Settings

Summary of recent changes

Updates as of July 23, 2024

• Updated the links to the references
• Removed the recommendations on alternate care sites and updated the language of the COVID-19 community level to align with current guidance

Background

This document outlines strategies to implement infection prevention and control (IPC) guidance in non-U.S. outpatient healthcare settings to prevent SARS-CoV-2 transmission and minimize the impact of the coronavirus disease-2019 (COVID-19) on essential health services. Clinics and other facilities that provide outpatient services play an important role in the care of patients with COVID-19 and are critical to provide continued essential health services. This information complements available guidance on essential health services and IPC for COVID-19 from the World Health Organization (WHO).

Target audience

These operational considerations are intended for use by health workers, including managers and IPC teams at outpatient facilities in non-U.S. healthcare settings. Outpatient facilities can include:

• Hospital-based outpatient clinics
• Non-hospital-based clinics
• Community health centers
• Physician offices

Objectives

The purpose of these IPC considerations in outpatient facilities during COVID-19 surges is to:

• Prevent outbreaks and transmission of SARS-CoV-2 at the facility
• Maintain essential health services to prevent indirect sickness and death from vaccine-preventable or chronic diseases
• Ensure that outpatient facilities remain safe places for patients to seek care for essential health services as well as acute illness

Responsible personnel to implement IPC in outpatient facilities

IPC activities in outpatient facilities should be planned, carried out, and supervised by designated health workers with IPC experience (i.e., IPC team or an IPC focal point). In accordance with WHO guidance on core components of IPC programs, district and national IPC management should support facility IPC focal points. For example, district- or national-level IPC management can help ensure availability of supplies to support good IPC practices, support education and training of the healthcare workforce, and provide feedback on outcomes. This role for district or national IPC programs is especially relevant during the COVID-19 pandemic. In settings with limited or no IPC infrastructure, establishing minimum requirements for national- and facility-level measures to protect patients and health workers is critical.

Key considerations for outpatient facilities

There are three operational steps to consider when planning outpatient service continuation in the context of COVID-19:

1. Prepare health workers and facilities to receive patients with suspected or confirmed COVID-19.
2. Rapidly identify and isolate patients with suspected COVID-19.
3. Modify outpatient service delivery to maximize patient and health worker safety.

1. Prepare health workers and facilities to receive patients with suspected COVID-19

Patients with suspected COVID-19 will likely present to outpatient facilities. Optimizing facility preparedness to receive patients with COVID-19 symptoms can help limit the exposure risk for other patients and health workers. When surges of SARS-CoV-2 are suspected in the community, facility leadership and the IPC focal point should review IPC guidance and operational considerations for healthcare facilities and follow national IPC guidance to prepare facilities to safely triage and manage patients with COVID-19 symptoms. Consider the following measures for infrastructure and healthcare workforce for IPC:

Designate a health worker who is trained in IPC to be the IPC focal point

The IPC focal point is responsible for implementing the facility's COVID-19 prevention measures. The focal point, in collaboration with other relevant people, should coordinate and apply various activities in the facility including:

• Communicate with local public health authorities to understand protocols for reporting suspected or confirmed COVID-19 patients and mechanisms to request supplies or other support.

• Determine the need for supplies for hand hygiene, personal protective equipment (PPE), and cleaning and disinfection, and the ordering frequency.
  • Assess availability of hand hygiene supplies and ensure supplies are readily accessible. Alcohol-based hand rubs with 60% to 95% alcohol should be used in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred to soap and water.
  • Determine amounts of PPE supplies needed to employ contact and droplet precautions for patients with suspected or confirmed COVID-19. These supplies include medical masksA, eye protection (face shields or goggles), gloves, and gowns.
  • Calculate supply quantities needed to clean and disinfect medical equipment (e.g., stethoscopes) and frequently touched surfaces (e.g., chairs and door handles) at the facility at least once a day.

• Coordinate and ensure training for relevant health workers on the following:
  • Standard and transmission-based precautions
  • Appropriate use of PPE
  • Cleaning and disinfection practices

Develop a system for healthcare workers to report signs and symptoms of COVID-19 and be prioritized for testing

If a health worker has been exposed to someone with suspected or confirmed COVID-19, they should consult with an occupational health focal point. Based on an assessment of risk factors, the health focal point can recommend quarantine and testing.

Review sick leave policies for health workers

Review sick leave policies for health workers and ensure they are flexible and consistent with public health guidance to encourage health workers who are ill to stay home.

Establish policies and procedures for health workers who develop symptoms or signs of COVID-19

For example, when health workers become symptomatic while at work, they should notify their supervisors and go home to avoid having contact with others in the workplace.

• Each facility's IPC focal point or supervisor should help health workers get tested for COVID-19 because positive tests can guide how long health workers must be excluded from work in accordance with national or subnational guidelines.
• In settings with limited testing availability, health workers suspected of having COVID-19 who are not tested should also be excluded from work for a period determined by national or subnational guidance.

2. Rapidly identify and separate patients with suspected COVID-19

Despite facility prevention measures to reduce the risk of SARS-CoV-2 transmission, patients with possible COVID-19 will still be seen. Preparing facilities to receive patients with COVID-19 symptoms can help limit the risk of exposure to patients and staff. Facility leadership and the IPC focal point should review WHO's guidance, Infection prevention and control in the context of COVID-19, and follow national IPC guidance to begin preparing facilities to safely triage and manage patients with respiratory illness, including COVID-19.

3. Modify outpatient service delivery to maximize patient and health worker safety

Modifying outpatient operations is important to reduce crowding and to prevent the mixing of infectious with noninfectious patients at facilities and prevent transmission of SARS-CoV-2. Coordinating with local public health authorities can expand strategies available to an individual facility (e.g., identifying alternate care sites for essential health services). Additionally, in communities experiencing COVID-19 surges, implementing source control for patients, visitors, and health workers at facilities through universal use of masks can also reduce transmission of SARS-CoV-2 in health care facilities.

Strategies to reduce risk of SARS-CoV-2 transmission

Modifications to outpatient operations for essential health services

• Identifying essential health services such as vaccinations, maternal and child healthcare, HIV testing and treatment, tuberculosis testing and treatment, and others
• Detailed considerations for modifying delivery of essential health services, including disease-specific considerations. Examples of such strategies include:
  • Dedicating certain days and times for services, for example, vaccinations on Mondays, obstetric patients on Thursdays.
  • Dispense additional doses of medications for patients with stable, chronic disease to reduce number of times a patient needs to visit the pharmacy.
  • Identify alternative locations, such as schools and churches, for providing services such as well visits for children.
  • Consider non-facility-based settings, such as outreach or mobile services, for delivery of select services (e.g., immunizations) based on the local context and ability to ensure IPC practices and safety of health workers and the community.

Modifications to outpatient operations for non-essential health services during COVID-19 surges

• Identify nonessential health services that can be delayed or canceled in accordance with local or national guidance. Postponing nonessential health services frees health workers to provide COVID-19 care and reduces crowding in waiting rooms.
  • Examples of such services include routine vision or dental checkups and annual physical exams.
• Explore alternatives to in-person encounters, described below.

Modifications to outpatient operations for patients who are acutely ill or have symptoms consistent with COVID-19

• Consider alternatives to in-person triage such as conducting visits using telemedicine (e.g., telephone consultations or cell phone video conference) to provide clinical support without direct contact with the patient. For example, establish a hotline that:
  • Can be used as telephone consultation for patients to determine if they need to visit a healthcare facility.
  • Can inform patients of preventive measures to take as they come to the facility (e.g., wearing a nonmedical mask or having tissues to cover coughs or sneezes).
• Encourage and support home care when appropriate for patients with COVID-19 symptoms.
  • Provide clear instructions to caregivers and people who are sick regarding home care and when and how to access the healthcare system for face-to-face care or in the case of urgent or emergent conditions.
  • If possible, identify health workers who can monitor those patients at home with daily check-ins using telephone calls, text, or other means.