As unlock 1.0 begins in the country, Prof. Dr. Sundeep Mishra writes on essential actions and precautions doctors looking to re-start their OPD should take to ensure smooth functioning of their practice.

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Many of us have drastically reduced the number of patients we see daily. While some of us have completely stopped seeing patients in the OPD, conducting net-based telemedicine visits from our offices or virtual-visits from home. In a recent US survey conducted among 2,600 primary physicians in mid-April, nearly half were struggling to remain open during the crisis. A majority had to limit the OPD visits and some were forced to shut down entirely. Another survey in the US reported that patient volume had decreased by 85%, 42% of health-care establishments had laid off their staff (and many had taken up salary cuts); 20% of primary health services were completely closed off (perhaps permanently).

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The situation in India is not clear but unlikely to be any better than this. The reason for this closure was a need to maintain social distancing because social distancing was the only known strategy to reduce the rates of hospitalisations and deaths in viral epidemics like this one.

We were all hoping that the peak of the COVID-19 pandemic will quickly pass and numbers will start declining so that we can open up our practices.

However, unfortunately for us, the COVID-19 numbers continue to pile up with no end-of-the-tunnel in sight. It seems that we will have to/and we are actually looking forward to “smart re-open” of our OPD practice completely in the near future. At the same time we realise that our practice probably won't be exactly the same as before. It seems that the practice has now changed fundamentally and likely remains so in the foreseeable future. The underlying principle of practice will be to keep patients and healthcare practitioners/staff safe.

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What are the foreseeable changes? Tips to smart-opening of OPDs

Remote monitoring abilities: It should be utilised more instead of in-person checks for vital signs, such as respiratory rate, oxygenation, blood glucose levels, heart rate etc.

Changes in the clinical practice:

1. Face-to-face time with patients should be limited. Regular follow-up visits just for the sake of periodic monitoring will decrease. Interval appointments or ‘follow-up/social visits' will be replaced by online 'virtual visits'. Thus, plan more of virtual visits in a way that improves patient health.
2. Prioritise interventional/surgical/procedural care and high-complexity chronic disease management and evaluate the necessity of the care based on clinical needs.
3. Use preventive strategies as much as possible.
4. Physicians and other health-care practitioners (HCPs) will have to be more acceptable of/compatible with latest technology. Every HCP will have to be conversant with smartphones and its apps, smart-watch, and monitoring devices (such as Fitbit) which allow more proactive, remote monitoring as also be a master in using recent technology of video conferencing such as skype, zoom etc.

Before opening up the OPDs:

1. Comply with governmental guidance: Different states have recently enacted, extended or modified lockdown orders and other guidelines. Generally, essential services are permitted including medical care but closely review and follow them especially in context with elective or non-urgent procedures.
2. Make a plan: Pre-opening planning is critically important to the success of your practice reopening. Sit down with a calendar and chart out your expected reopening day. Ideally, a period of 'soft-reopening' should be planned.
3. Assess your personal protective equipment (PPE) needs and alternatives such as cloth masks, what stockpile you have currently and will need in the future and place the necessary orders. If possible, have supplies delivered in advance before you reopen so that sporadic deliveries and other visitors do not disrupt the order of your daily plan.
4. Set up standard operating procedures (SOPs); staffing and cleaning, isolation/quarantine if an employee or patient or visitor is diagnosed with COVID-19 after being in the clinic.
5. Open incrementally: Consider a step-wise approach to reopening so that the practice may quickly identify and address any practical challenges if presented. Identify what visits are really required and what can be done via telemedicine. Begin with a few in-person visits a day, and then keep on incrementally increasing if you are able to handle it.
6. Administrative staff who do not need to be physically present may stay at home/work remotely. Bring employees back in phases as well (working on alternating days/different parts of the day).
7. Communicate HCPs weekly schedule clearly to the practice’s patients, clinicians and staff.

Changes in in-person visit practice

1. Limit the number of patients in the waiting room (fixed number allowed depending on size of the waiting room): Patients/caregivers may be asked to wait elsewhere (maybe car) till their allotted time/number is called.
2. Limit the number of non-patient visitors in the hospital premises: Post the changed OPD policy at the hospital/clinic/OPD entrance as also on the hospital/practice's website.
3. Maintain social distancing in the waiting room.
4. Consider a flexible schedule, with perhaps a longer span of the day with more time in between visits to avoid backups.
5. Housekeeping and repairs should be undertaken outside of normal operating hours.
6. Shared objects like magazines or toys have to be done away with. Instead, install video content.
7. Wipes, hand sanitisers, and the wearing of masks have to be made mandatory.
8. Screen patients/care-givers before in-patient visit. Temperature monitoring of patients/care-takers has to be undertaken before they enter premises and patients enquired about presence of COVID symptoms.
9. Dedicated time and OPD/examination room should be allotted for patients with respiratory symptoms/fever/symptoms suggestive of COVID-19. These patients should be examined utilising the PPEs and other protective equipment. The rooms should be thoroughly sanitised after these exams are done and in between visits.
10. Co-ordinate COVID testing with appropriate centres/testing sites. Many health systems have instituted the practice of testing all patients who are being scheduled for elective or high-intensity procedures (such as outpatient surgeries or services requiring close contact).

Routine screening of staff and other facility workers

1. Regular stocking of COVID-19 screening tests is required.
2. Doctors, healthcare workers and all others who work in the facility (housekeeping, delivery personnel, and anyone else who enters the area) should be routinely screened for high temperature and other symptoms of COVID-19. Records of employee screening results should be kept in a confidential file (separate from the personnel file).
3. SOPs and guidelines may have to be followed if any of the staff tests positive
4. Staff schedules will need to be adjusted and rotating clinical personnel directly involved in patient care activities will have to be undertaken
5. The available staff will be required to be cross-trained so that one can step in for another if temporarily required (if somebody falls ill).
6. An open mechanism to employ more staff should be set up in case critical staff get sick or quarantined.
7. Personal health requirements should be clearly communicated to clinicians and staff. They should know that they should not present to work if they have a fever, have lost their sense of taste or smell, have other symptoms of COVID-19 or have recently been in direct contact with a person who has tested positive for COVID-19.
8. Establish open communication with facilities management regarding cleaning schedules.
9. Keep adequate social distancing between employees and develop protocols for sharing spaces (e.g. kitchens, bathrooms, canteens).

Deal with patient backlog:

1. Once restrictions ease, an enormous backlog of patients is likely and there will be a need to select more serious cases who will need immediate help.
2. A plan of triaging should be ready.
3. Healthcare workers should be ready to work longer hours and even on weekends to catch up. Maintaining a healthy work-life balance would be essential

Change patient expectations:

1. Patients will also be more comfortable with ‘remote’ examination. Telemedicine will become an essential part of practice.
2. Local source for some services (tests and procedures); blood tests, ECGs, x-rays, CT/MRI etc. would have to be utilised.
3. Patients will be more comfortable with technology, IT and artificial intelligence which might ultimately not only decrease costs associated with hospital visits but also empower patients enabling them to take care of themselves better.

Change in financial re-imbursement:

1. The way payments are made would also be changed. There will be more of online (bank transfers, PayTM etc).
2. Be careful of how healthcare is paid for, re-imbursements, insurance etc.
3. For lone-workers it may be a good idea to join some larger group or academic institution temporarily.
4. Check for re-imbursement for COVID-19 testing.

Establish confidentiality/privacy: Institute or update confidentiality, privacy, and data security protocols. Results of any screenings of employees/patients should be kept confidential as far as possible. Co-workers and patients can be informed that they came into contact with an employee who tested positive for COVID-19, but the identity of the employee and details about an employee’s symptoms cannot be shared with patients or co-workers without consent.

Legal implications:

New legal issues and obligations may arise as the practice reopens.

1. Regarding forced lock-down for inter-city employees: While government employees will get ‘full pay,’ the situation with those privately employed is uncertain.
2. Legal implication of telemedicine will have to be re-worked in light of need for social distancing
3. Issues of confidentiality of COVID-19.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The writer, Dr. Sundeep Mishra is a Professor of Cardiology.