California Department of Health
February 28, 2020
TO:Outpatient Healthcare Facilities
SUBJECT:Outpatient Healthcare Facility Infection Control Recommendations for Suspect COVID-19 Patients
Suspect COVID-19 infection in patients with: fever or signs/symptoms of respiratory illness AND a history in the prior 14 days of contact with a laboratory-confirmed COVID-19 case or travel to an affected country or area as per the latest CDC recommendations.
If COVID-19 infection is suspected, please use the infection control measures below.
Planning ahead: If an outpatient facility can reasonably expect to evaluate suspect COVID-19 patients, the facility should be prepared to do so. Preparedness activities include:
- Ensuring that sufficient patient care staff have been fit-tested for the N95 respirator that will be used.
- Ensuring that N95 respirators, gowns, gloves, and eye protection (face shield or goggles) are available.
- Ensuring that synthetic fiber swabs with plastic shafts and sterile tubes containing 2-3 ml of viral transport media are available for specimen collection.
- Knowing how to contact your local health department local health department if you suspect COVID-19 in a patient.
Facilities without an airborne infection isolation room (AIIR)
If patient calls facility BEFORE arrival AND COVID-19 infection is suspected
- Refer patient to facility with an AIIR, if possible (know where such facilities are in your area). Before referring patient to another facility, contact facility to ensure that they can safely evaluate patient.
- If referral elsewhere is not possible and medical evaluation is necessary, but not urgent, try to:
- Schedule the patient at the end of the day when few staff and no other patients are present; or
- Evaluate patient and collect specimens (if necessary) in patient’s car, or otherwise outside of facility. See below for personal protective equipment (PPE) needed.
- Ask patient to call after arrival at facility but before entering the facility.
- If patient can’t be roomed immediately, ask patient to wait outside facility, call patient when room is available, and meet patient prior to facility entry to provide patient a surgical mask to put on before entry.
- If patient cannot wear a surgical mask, other practical means of source containment should be implemented (e.g., place a blanket loosely over the heads of infants and young children suspected to have COVID-19 as they transit through common areas).
- Prior to interacting with patient inside or outside the facility, staff should don PPE for Standard, Contact, and Airborne Precautions, plus eye protection, i.e., N95 respirator or powered air purifying respirator (PAPR), face shield or goggles, gown and gloves.
- Bypass the waiting area if possible, and do not allow patient to remain in the waiting area or other common areas.
- Immediately place patient in a private room and keep the door closed.
- Only essential staff should be in the room.
- Patient should be immediately evaluated for clinical signs and symptoms of COVID-19. If the patient fits the current COVID-19 Person Under Investigation (PUI) criteria, or if the patient’s PUI status is unclear, consult the Local Health Department to determine if testing for COVID-19 is indicated and for support in submitting specimens if testing will be performed.
- Limit transport and movement of the masked patient outside of the room to medically-essential purposes or discharge.
If patient does NOT call before entering facility AND COVID-19 infection is suspected
- Mask patient immediately when COVID-19 is suspected.
- If patient cannot wear a mask, other practical means of source containment should be implemented, e.g., place a blanket loosely over the heads of infants and young children suspected to have COVID-19 while they are transiting through common areas.
- Do not allow patient to remain in the waiting area or other common areas; if patient cannot be transferred to a facility with an AIIR or roomed immediately have patient wait in car or otherwise outside of facility, call patient when room is available, and meet patient at facility entry.
- Follow steps 1. d – i above.
If COVID-19 is suspected AND facility has an airborne infection isolation room (AIIR)
- Mask the patient immediately when COVID-19 is suspected, preferably before facility entry.
- If patient cannot wear a surgical mask, other practical means of source containment should be implemented (e.g., place a blanket loosely over the heads of infants and young children suspected to have COVID-19 while they are transiting through common areas).
- Do not allow patient to remain in the waiting area or other common areas; if patient cannot be roomed immediately have patient wait in car or otherwise outside of facility, call patient when AIIR is available, and meet patient at facility entry.
- Follow steps 1. d – e above.
- Immediately place patient in AIIR and close the door.
- Follow steps 1. g – i above.
- Patient may remove mask when in AIIR but should don mask again prior to leaving the room when being transported within the facility, when receiving care in other parts of the facility, during transit to another facility, and when exiting the facility after discharge.
Avoid Performing Aerosol-Generating Procedures
Some procedures performed on known or suspected COVID-19 patients could generate infectious aerosols. Procedures that are likely to produce aerosols, e.g., nebulizer treatment, sputum induction and open suctioning of airways should be avoided if possible, and if performed, should be performed cautiously.
If such procedures must be performed they should take place in an AIIR, and staff should use gown, gloves, eye protection, and a PAPR as respiratory protection per the CalOSHA Aerosol Transmissible Diseases Standard. If need for procedure is urgent, and an AIIR is not available, patient should be in private room with door closed, and the PPE above should be used. In addition, the number of staff present during the procedure should be limited to those essential for patient care and procedural support.
If testing for COVID-19 is approved, obtain respiratory samples from PUI per current CDC guidance
- All PUIs: Collect two upper respiratory samples.
- Nasopharyngeal (NP) swab AND oropharyngeal (OP) swab*.
- Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inhibit PCR testing.
- Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. NP and OP specimens should be kept in separate vials. Refrigerate specimens at 2-8°C and ship overnight to testing lab on ice pack.
- PUIs with lower respiratory tract symptoms only: Collect lower respiratory tract specimen only if clinically appropriate.
- Non-induced sputum or other lower respiratory tract specimens, such as bronchoalveolar lavage and tracheal aspirate (unlikely to be performed in outpatient setting).
- To rule out other potential viral pathogens, collect additional NP swab for viral respiratory panel PCR testing, if possible. Do not perform non-PCR based influenza testing, i.e., rapid influenza diagnostic tests, as results are not reliable.
*NP wash/aspirate or nasal aspirate are also acceptable; collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate sample at 28°C and ship overnight to testing lab on ice pack.
For all PUIs
- Immediately report all suspect COVID-19 patients to your local health department.
- When evaluation is complete, determine next steps for disposition and possible isolation with guidance of LHD, based on clinical needs of patient.
- Depending on the number of air changes per hour (see Table below), do not use or clean and disinfect the examination room for up to one hour after the suspect COVID-19 patient leaves. If the number of air changes per hour is not known, do not use the examination room for one hour after the suspect COVID-19 patient leaves.
- After room has been empty for appropriate time period, use routine procedures to clean and disinfect room. Those performing this task should wear a disposable gown and gloves. A face shield or facemask and goggles should also be worn if splashes or sprays during cleaning are anticipated.
- Notify any location where the patient is being transferred or referred for additional clinical evaluation or laboratory testing about the patient’s suspect COVID-19 status. Do not refer such patients to other locations unless appropriate infection control measures can be implemented.
- Instruct suspect COVID-19 patients and exposed persons to inform all healthcare providers of the possibility of COVID-19 infection prior to entering a healthcare facility so that appropriate infection control precautions can be implemented.
- If a suspect COVID-19 patient is confirmed as a case, all patients, visitors and staff who were in the same area during the time the case was in your facility and for up to one hour after the case left the area (see Table below) will need to be assessed for risk of exposure even if case was masked.
- If it will be difficult to identify potentially exposed staff and patients later, make note of staff and patients who will need to be identified if the suspect COVID-19 patient is found to be a case.
For more information on COVID-19, please see:
- CDC COVID-19 Information for Healthcare Professionals
- CDPH Immunization Branch COVID-19: What You Need to Know
Table. Air changes/hour (ACH) and time required for airborne-contaminant removal by efficiency*
|ACH||Time (minutes) required for removal 99% efficiency||Time (minutes) required for removal 99.9% efficiency|
CDC Airborne Containment Removal Table B.1
+ Denotes frequently cited ACH for patient-care areas.