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​During the COVID-19 pandemic both State and Local governments have worked together to respond to the pandemic. Stay-at-Home orders are in place and have supported the flattening of the curve in California. During this time, non-urgent health care has been deferred to support the State's efforts and to further prevent the spread of COVID-19. This deferral of services was essential in response to the surge of COVID-19 patients, but creates its own public health impacts, which must be addressed as soon as practicable.

Even though current evidence shows progress in suppressing the virus, there is much to consider for the future of the State and to protect against a surge, once Stay-at-Home orders are modified. One important focus will be resuming our existing health care system for non-emergent and non-COVID-19 health care, which has been deferred during this time. These services will include resuming elective and non-urgent procedures at hospitals; outpatient care including primary care and specialty care in physician offices and health centers; behavioral health, long term care, ancillary, pharmacy, and dental services. This is to restart the care that has been postponed including preventive care such as well-child visits and vaccinations, adult clinical preventive services, and routine dental services. Whenever appropriate for patient and condition, visits should maximize the use of telehealth/telephonic modality.

This guidance is intended to set a plan for California while understanding there may be local or regional circumstances that require different timelines for resumption of services.

The sections below outline considerations and guidelines that should be reviewed and met prior to resuming services. It is expected that specific regions of California may resume services before the entire State is able to; therefore, regional delivery systems will need to consult local public health officers in neighboring counties as they begin to resume services to non-emergent and non-COVID-19 patients.

It is important to continue to monitor COVID-19, including case counts and hospitalizations and their impact on the health care delivery system. It is also important to monitor local health officer orders and Governor's orders in the event that a different health care delivery system response is necessary.

General considerations for resuming services will include the following:

1. When preparing to resume services, a variety of indicators, including but not limited to the following, should be considered for a service area:
• COVID-19 infection rates [see consideration 3, below.]
• COVID-19 hospitalizations
  
• COVID-19 emergency room admissions
• COVID-19 Intensive Care Unit (ICU) utilization
  
• Skilled Nursing Facilities COVID-19 outbreaks
• Other COVID-19 factors that could increase the spread of COVID-19
2. Each facility, office, or any other place of health care services shall have an adequate stock of Personal Protective Equipment (PPE) in adequate supply for staff based on the type of care provided, risk level of patients, number of staff required to use PPE, and daily usage demand. PPE use should be consistent with Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommendations. In planning for PPE, consideration should be given for potential patient surges related to COVID-19 outbreaks.
   

3. Availability of testing with prompt results should be present for health care delivery situations when knowing the COVID-19 status of staff or patients served by the entity is important for clinical care and infection control.
   

4. Prior to resuming non-emergent and non-COVID-19 deferred services, offices and facilities should consult with local public health officers within counties served to determine if there are local COVID-19 patterns that could impact health care delivery.

5. Availability of qualified staff to safely perform procedures, provide care and needed follow up. 
6. Each facility and office should have patient flow systems and infection control precautions in place to minimize exposure and spread while caring for both COVID positive and non-COVID patients.
   

Guidelines for Resuming Services:

Personal Protective Equipment

Personal Protective Equipment (PPE) is essential to protect health care workers and patients; therefore, the following is recommended when resuming services. Facilities should have a plan for circumstances when patients or visitors when allowed arrive without face coverings.

PPE Minimum Requirements for outpatient settings:

1. All healthcare providers and staff must wear appropriate PPE at all times, consistent with CDC universal source control recommendations [reference #4]
2. All healthcare providers and staff treating COVID-19 positive patients must have appropriate training on, and access to, appropriate PPE, including the use of specialized masks (i.e., N95), eye protection (face shield or goggles), gloves, and gowns when appropriate
3. Patients and visitors when allowed should wear masks (including when provided by facility staff) or cloth face coverings. Practices are encouraged to educate patients about proper face coverings, consistent with the CDC and CDPH recommendations, and reserving specialized masks (i.e., N95) for the health care employees who are at increased risk
4. COVID-19 PPE policies and procedures should also be in place for health care workers who are not in direct patient care roles (i.e. Front desk registration, schedulers, environmental cleaning, etc.)
   

PPE Minimum Requirements for Hospital settings:

Implement policies for PPE that account for:

1. Adequacy of available PPE as needed for level of care and COVID-19 status
2. Staff training on and proper use of PPE according to non-crisis level evidence-based standards of care
3. Policies for the conservation of PPE should be developed (e.g., intubation teams) as well as policies for any extended use or reuse of PPE per CDC and CDPH recommendations and FDA emergency use authorizations
   

PPE Minimum Requirements for Skilled Nursing Facilities (SNF) settings:

Implement policies for PPE that account for:

1. All healthcare providers and staff must wear appropriate PPE at all times consistent with CDC universal source control recommendations
2. All healthcare providers and staff treating COVID positive patients must have appropriate training on, and access to, appropriate PPE, including the use of specialized masks (i.e., N95), eye protection (face shield or goggles), gloves, and gowns
3. Patients, while not in their rooms, and visitors when allowed must wear masks or cloth face coverings. Practices are encouraged to educate patients and visitors about proper face coverings, consistent with the CDC and CDPH recommendations, and reserving specialized masks (i.e., N95) for health care employees who are at increased risk
   

Health Care Services

Providers and facilities are encouraged to gradually resume full scope of services when possible and safe to do so, based on these guidelines. It is encouraged that as many services as possible and appropriate be delivered by telehealth/telephonic even after loosening of the Stay-at-Home restrictions to protect patients and health care workers. The physical layout and flow of care delivery areas may change in terms of patient movement and waiting areas so that physical distancing is maintained; and there should be a process for determining the priority of types of services delivered initially as delineated below. Services should be available for both COVID-19 negative and COVID-19 positive assuming systems are in place to provide adequate testing, appropriate separation of the patients, and adequate PPE and training to protect health care workers.

Facility and Office Site Standards

Safeguards at facilities and offices will play an important role in continuing the fight against COVID-19. Therefore, facilities and offices resuming services should take additional steps to protect the workforce and patients being served.

Guidelines

General

• Facilities should comply with all State, Local, and CDC guidelines to protect against further spread of COVID-19.
• Facilities should institute rigorous screening of their health care staff for symptoms of COVID-19 and have policies in place for removal of symptomatic employees from the workplace
• Follow physical distancing requirements in work areas and common areas.
• Require face coverings for all patients, with the exceptions of SNF patients while in their room, patients receiving services that would not allow for the use of a mask, or residents of facilities with personal rooms while in their room.
• Limit the number of patients in waiting areas and limit space between patients to a minimum of 6ft.
• When possible, the use of Non-COVID Care zones should be utilized in facilities that serve both COVID-19 and non-COVID-19 patients.
• All health care workers, staff, patients, and others. should be screened appropriately prior to entering a Non-COVID-19 Care zone as outlined in CMS guidance [reference #2]
• Patients should be screened telephonically for possible COVID-related symptoms prior to office visits
• Anyone demonstrating symptoms of COVID-19 during screening should be tested and quarantined
• Facilities shall have in place an established plan for cleaning and disinfecting prior to using facilities to serve non-COVID-19 patients and ongoing care.
• Facilities providing COVID-19 care should continue to be prepared for potential future surges. The plans for resumption of medically necessary care should include consideration of the impact on their ability to respond to future surges.
• Facilities should be prepared to modify resumption of clinical services in conjunction with surge status (as surge status increases, access to non-urgent care should decrease so as to not overwhelm the healthcare system). Staff can then be re-purposed to urgent care roles.

Health Care Staff

• Screen all workers and staff entering the facility for symptoms of COVID-19, prior to entering the facility.
• Health care staff should take measures to avoid rotating between care of COVID-19 positive/persons under investigation and non-COVID-19 patients as outlined in CMS guidance [reference #2]

Care Prioritization and Scheduling

Facilities and offices shall establish a prioritization policy for providing care and scheduling. Extended hours should be considered to limit the number of patients in an office at any given time. Facilities and offices should also consider scheduling special or reserved hours for elderly or immunocompromised patients, to minimize the risk of infection to vulnerable patients.

Clinical prioritization should consider clinical impacts of treatment delay and the current surge status of the health care infrastructure in a community. 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 [reference #1,5,6] on care prioritization, scheduling, and outpatient guidelines.

Outpatient Visit Guidelines

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.
  

**Telehealth/telephonic modality should be used for all appropriate patients and conditions.

Dental Guidelines

With respect to dental services, the California Department of Public Health will update the current guidance regarding the prioritization and delivery of following non-urgent dental services:

• Previously cancelled or postponed patients
• Preventive services
• Dental Procedures
• Routine dental services
  

Hospital and Outpatient Surgery Guidelines

Priority scheduling should consider principles and considerations from the Joint Statement released by the American Hospital Association (AHA), American College of Surgeons (ACS), American Society of Anesthesiologists (ASA) and Association of periOperative Registered Nurses (AORN) providing key principles and considerations. All facilities should consider opening in phases to allow for any necessary staff training or adjustments to new policies.

Prioritization scheduling should consider:

• Objective priority scoring (e.g., MeNTS instrument)
• List of previously cancelled and postponed cases with priority scoring
  
• Specialties' prioritization (cancer, organ transplants, cardiac, trauma)
• Strategy for allotting daytime "OR/procedural time" (e.g., block time, prioritization of case type [i.e., potential cancer, living related organ transplants, etc.])
• Identification of essential health care professionals and medical device representatives when necessary for procedures
• Plan for phased opening of operating rooms
• Identify capacity goal prior to resuming
• All operating rooms and post operating ICU beds simultaneously – will require more personnel and material
• Strategy for increasing "OR/procedural time" availability (e.g., extended hours before weekends)
• Issues associated with increased OR/procedural volume
• Ensure primary personnel availability commensurate with increased volume and hours (e.g., surgery, anesthesia, nursing, housekeeping, engineering, sterile processing, etc.)
• Ensure adjunct personnel availability (e.g., pathology, radiology, etc.)
• Ensure supply availability for planned procedures (e.g., anesthesia drugs, procedure-related medications, sutures, disposable and non-disposable surgical instruments)
• Ensure adequate availability of inpatient hospital beds and intensive care beds and ventilators for the expected postoperative care
• New staff training
  

Skilled Nursing Facilities (SNF) Guidelines

Priority for SNF should focus on admission and protecting existing patients and new patients from the spread of COVID-19.

Scheduling should consider:

• Admission of confirmed non-COVID-19 patients in particular from acute facilities to maintain acute bed capacity
• Admission of confirmed COVID-19 positive patients only to facilities that have been designated or configured to manage these patients
• Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for 14 days, per the CDC universal source control recommendations [reference #4]
• Non-COVID-19 patients who become symptomatic must be isolated from the general resident population
  

Workforce Availability

The health care workforce and staff are essential to resuming the delivery of deferred and preventive health care services. All facilities and offices should be aware of the impact COVID-19 has had on many health care workers including fatigue and the impact of stress and should ensure they have an adequate workforce available prior to resuming services and that they provide needed resources to support health care workers.

Workforce considerations should take into account ancillary supports and downstream providers, such as potentially necessary referrals to SNFs.

Guidelines

• Facilities should ensure adequate staffing levels are in place to provide services, including staff to support additional safeguards at facilities
• Workforce considerations should not impact the ability to respond to surge needs in the future

Additional considerations for Hospitals

Hospitals are encouraged to consider the need to take additional precautions to protect against the spread of COVID-19.

Guidelines

• As possible, adopt Non-COVID Care zones to assist in the prevention of COVID-19, per CMS guidance [reference #2]
• Have appropriate levels of PPE, staffing, ventilators, and other critical resources in order to properly separate patient flow and care for both COVID-19 positive and non-COVID-19 related patients
• Prevent the rotation of health care workers, staff and patients between COVID-19 and non-COVID-19 zones
• Pre-op COVID-19 testing as indicated in the Joint Statement [reference #1]
• Policies on managing entry and exit points
• Physical distancing policies
• Screening requirements for staff and visitors
• Limit number of visitors per patient allowed
• Post-Acute care policies taking into account COVID-19 testing prior to placement in skilled nursing facilities
• Considerations for principles and considerations documentation from the Joint Statement released by the AHA, ACS, ASA and AORN providing key principles and considerations
• Discharge planning considerations, including considerations for Home Health, SNF placement and alternative care facilities.

Additional considerations for Skilled Nursing Facility care

Skilled Nursing Facilities (SNF) have had higher rates of COVID-19 cases and extra precautions will continue to be necessary when considering placement. Special considerations should be considered to protect high risk patients residing in SNFs.

Guidelines

• Continue to review all State, Local, and Federal guidelines, including the CDC guidelines
• Limit visiting but provide video communication between residents and their loved ones
• Screen all those entering the SNF
• Require facial coverings for visitors when allowed and staff
• Patients being admitted or re-admitted should be tested for COVID-19 prior to admission
• Ensure adequate infection control training for staff
• Particular focus on adequacy of staffing with contingency plans for staff illness, or resignations
• Limit group activities and communal dining to meet physical distancing guidelines 
  

References and additional guidance to consider

Additional materials are provided here to support the health care systems in resuming deferred and preventive services during this time.

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