Safety/mitigation Guidance for Resuming Face-To-Face Clinical Contacts
As most states are gradually lifting stay-at-home orders and many businesses have begun to resume services to the public, there is a growing need for health care providers to resume in-office services as well. While the IOPC was rapid in its response to develop guidelines and recommendations regarding the transition to teleneuropsychology (TeleNP) services, we must also be cognizant of the need for a return to in-office evaluations in a way that will maximize patient and provider safety, while also ensuring the best possible services are provided. There are a number of guides for re-opening practice that have been put forth by several organizations, including the Center for Disease Control (CDC), World Health Organization (WHO), American Psychological Association (APA), American Medical Association (AMA), and others, and these were reviewed as part of the preparation of this material. Additionally, practice models and specific infection mitigation strategies submitted by neuropsychologists practicing in a variety of clinical environments were considered. Here we provide a general overview of safety considerations for those resuming in-person neuropsychological practice.
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Federal, State, and Local Guidelines, Policies, and Legal Parameters
Federal, state, and local governmental and regulatory guidelines should be reviewed as part of any initial plans to resume in-office clinical practices. These range from strict and specific requirements to more general guidelines. It is important to know the standards that apply to you and your practice and plan accordingly. Depending on your practice setting, there may be other institutional guidelines dictating the terms of your return to in-person practice that must also be considered. As governmental, regulatory, and institutional guidelines are subject to change as the pandemic situation evolves, providers should stay abreast of any such changes.
Infection Mitigation Plans
Prior to making a final decision to reopen the doors to your practice, it is important to have infection mitigation plans in place, along with contingency plans for possible scenarios where the planned procedures cannot be followed. Once a plan is in place, most guideline documents strongly recommend opening in an incremental, step-by-step fashion. This means starting with a very low volume of patients, following the plan that was developed as literally as possible. Once a few patients are seen, the plan can be modified as needed based on real-time patient contact activities. Increases in patient volume can occur incrementally, with maximum patient load determined by your setting and ability to follow pandemic mitigation processes.
Outline of Basic Needs Prior to Opening
There are basic commonalities noted across various federal, state, local, and professional organization regulations and guidelines that must be in place prior to re-opening for in-person services. These essential infection mitigation processes include but are not limited to:
Development of appropriate signage/posting in waiting areas, treatment rooms, and in paper form outlining the policies/procedures for infection mitigation in your office(s)
o Any posted material should be laminated or put in plastic sheets that can be cleaned
Pre-appointment screening for potential symptoms of COVID-19 (see example screening form)
o Repeat screening on the day of contact
Employ steps to maintain appropriate social distancing of a minimum of 6 feet as much as possible
Masks to be worn by patients, providers, and any office staff
Hand washing and/or use of hand sanitizer by all parties before and after any contact with a patient, caregiver, staff, or provider
o Hand washing (rather than hand sanitizer) is recommended after restroom use, blowing nose, and coughing into hands
Thoroughly clean/disinfect all office areas, furniture, surfaces, doors, and manipulative items (including writing utensils) before and after every patient contact (See link below for EPA list of disinfectants)
o Timing of cleaning – may benefit from at least a 30-minute waiting period before cleaning, to minimize airborne droplets
Additional general and neuropsychology-specific precautions strongly recommended for consideration include the following:
Designation of “clean” (i.e., unexposed) materials, areas, forms, etc. and a separate area for “dirty” (i.e., exposed) materials to avoid cross-contamination of items
Face shields or goggles or safety glasses that cover the eyes
Use of gloves by provider and/or patient (optional)
o If used, gloves should be discarded and replaced in any instance where hands would have been washed or sanitized (e.g., touching face, coughing into hands)
Clear barriers across a testing table with or without openings for stimuli to be presented (does not eliminate need for masks) when testing in small spaces where social distancing is not possible
Use of HEPA air filters in exam rooms
Use of UV light disinfection devices for a period of time prior to and after exam room use (optional)
Extended patient/provider/staff screening activities to include temperature readings
Changing fabric furniture to furniture that can be cleaned with recommended cleaning agents, or covering fabric furniture with wipeable protective covers
Use of foot-operated trash cans
Timeline of Infection Mitigation Activities for Neuropsychology practice
Activities Prior to Patient Arrival
COVID screening questionnaire at the time of scheduling and 48 hours prior to the appointment
o Determine policy regarding what happens when screening is failed
o Clearly convey to patients/caregivers any requirements for rescheduling (e.g., need to be cleared by their PCP)
o Sample Patient COVID Screening questionnaire that can be edited to fit individual clinic needs
Electronic registration forms that can be completed and submitted online prior to arrival
Instructions for patients regarding safety requirements for visit (masks, etc.) and any limitation on number of persons present (e.g., only one caregiver, no siblings)
Cleaning of rooms and materials (use of checklist with time and date recommended)
o Sample Daily Infection Mitigation Checklist that can be edited to fit individual clinic needs
Setting up a “virtual waiting room” – in-car or in an open area with sufficient space
o Phone check-in – patient/caregiver instructed to call on arrival
o Make sure you have a current telephone emergency contact number for family/caregiver if they will be waiting outside the clinic
Masks (required; gloves optional) available to patients/caregivers if they do not have their own or mask does not provide adequate protection
Stagger appointment times to minimize patient contact and to allow for additional cleaning/ventilation time in between
Remove some chairs in waiting as needed area to promote social distancing
Initial Entry and Forms
Patient and visitors screened again for symptoms and contacts
o Possibly temperature
o If family/caregiver is present, all checks apply to them as well
Hand sanitizer or hand washing upon arrival
Send forms for review in advance of appointment and completed online if possible
Complete forms in a controlled room rather than bringing forms from home
Consider use of verbal consent and related documentation
Use of “clean” and “dirty” folders or containers for forms
Interview
Consider pre-contact interviewing through telehealth or phone to minimize time in office
Social distancing as much as possible
Family/collateral interviews via phone or teleconference
o No more than one additional person present for interview
Use of masks, hand sanitizer, disinfection wipes for any touched items
o Minimize areas of possible touch (gloves optional)
Testing Activities
Have patients bring their own water/coffee/snack rather than providing, but area must be cleaned afterward
Maximize efficiency of test session to minimize time in office
Minimize testing where contact of materials is needed
“Clean” vs “dirty” side of the room (including folders of paper – clean and dirty)
o Wash hands after handling “dirty” test forms (e.g., when scoring)
Cleaning of manipulative stimuli with disinfecting wipes and/or separating them for cleaning after the assessment
Repeated use of hand sanitizer and hand washing during the session as needed (e.g., if touch face, sneeze, cough, etc.)
Laminate paper stimuli or cards or put them in plastic sheets for easy cleaning
Consider using orally administered measures of visual information processing to maximize social distancing and minimize contact with material
Place garbage can close to the patient – foot-operated or open, with plastic liner for easy removal
Separate pencils/pens for patients and examiner
End of Session
No hand shaking or physical contact!
Be mindful of social distancing as you leave the room
After the Session
Extensive cleaning of room, furniture, contact surfaces, materials, etc. (note that some disinfecting wipes require use of gloves)
o Timing of cleaning – may benefit from at least a 30-minute waiting period before cleaning, to minimize airborne droplets
Wash hands or use hand sanitizers after handling forms (e.g., when scoring) and/or allow a 24-hour waiting time before handling forms touched by the patient
Room HEPA air filter system and/or UV disinfecting light
o Readers are advised to do their due diligence regarding what devices are best suited for their clinics
Feedback Options to Consider
Same day, in same room, immediately following the testing or after a short break
Telehealth visit
If separate day in clinic, use the same precautions noted above for the return visit
Concluding Remarks
It is recommended that readers remain vigilant to local, state, federal, and professional organization guidelines regarding the resumption of in-person clinical practices. Regular monitoring of recommendations by the CDC, WHO, and other trusted sources is also recommended to stay as up to date as possible regarding infection mitigation strategies.
Additional Resources
American Professional Agency Preparing to reopen
American Medical Association – Re-Opening Guide AMA
Environmental Protection Agency List of Disinfectants for use against SARES-CoV-2
World Health Organization: Getting your workplace ready
OSHA guidance on preparing the workplace for COVID-19
Pediatric Practice Management Tips During the COVID-19 developed by the American Academy of Pediatrics.