How to Safely Provide In-office Care (MoH and OCFP Guidance).

This section integrates advice from the Ontario Ministry of Health, the OCFP and the Reopening Guide for Primary Care and Specialist Offices WO/SWO Pandemic Response Group

Ministry of Health COVID-19 Guidance: Primary Care Providers in a Community Setting set out guidance for in-person care.

The CEP Primary Care Operations in COVD-19 section is also a useful resource

Certain patients or acute conditions will require in-person visits. This includes vaccine administration for infants and children. Some helpful ‘In-Person Considerations’ related to in-person visits are available under the Ontario College of Family Physicians (OCFP)’s COVID-19 Tips for Family Doctors (updated Aug 21, 2021).

Primary care providers should exercise clinical judgement to determine whether an in-person visit is necessary and should consider providing some care virtually even if an in-person visit is needed in order to minimize the in-person time required (i.e., a prenatal visit could be divided into a virtual discussion of testing/screening options with a brief in person physical assessment).

Before the appointment

Let your patients know:

  • They and anyone accompanying them should bring a SURGICAL mask if they have one
  • There is a limit on who can attend to only those who require care and one caregiver/assistant if needed
  • Whether your restrooms are open or closed so they can prepare accordingly
  • If they will wait in the car, let them know how you will notify them to come in (e.g. if you will send a text message or use a restaurant-style buzzer system)

Screening on Arrival

Primary care providers should post information on their clinic website or send an email to all patients advising them to call prior to coming to the office/clinic where applicable. If an in-person visit is necessary and feasible, the primary care setting should undertake screening as defined below:

  • Patients should be screened over the phone for symptoms of COVID-19 before scheduling appointments. See:
  • Patients and those accompanying should be advised to wear their own SURGICAL mask to the clinic if they have one available to them.
  • Where patients present in-person, all patients and persons accompanying them should be screened again upon entry to the clinic to assess for symptoms and exposure history.
  • Staff conducting screening on site should ideally be behind a barrier to protect from droplet and contact spread. A plexiglass barrier can protect reception staff from sneezing/coughing patients. If a plexiglass barrier is not available, staff should maintain a 2-metre distance from the patient. If the office is unable to provide this physical barrier for those screening, the health care worker (HCW) doing the screening should use Droplet and Contact precautions. This includes the following PPE – gloves, isolation gown, a surgical/procedure mask, and eye protection (goggles or face shield).
  • Remind patients to put on their masks and use hand sanitizer as they arrive in the office.

Patients Who Screen Positive Over the Phone

Please see Diagnostic Testing and Clearance Pathways and Assessment Diagnosis and Management of COVID

Patients Who Screen Positive When Attending the Office

Patients who screen positive should be given a surgical/procedure mask and be advised to perform hand hygiene. Ensure patients do not leave their masks in waiting areas. As soon as the reception staff is aware that a patient screens positive, the patient should be immediately placed in a room with the door closed (do not cohort with other patients), where possible, to avoid contact with other patients in common areas of the office/clinic (e.g., waiting rooms).

If it is not possible to move a patient from the waiting room to an available exam room, the patient can be instructed to return outside (e.g. vehicle or parking lot, if available and appropriate) and informed that they will be texted or called when a room becomes available.

Patient should be provided with hand sanitizer (if available), access to tissue and a hands-free waste receptacle for their used tissues and used masks. All patients should be instructed to cover their nose and mouth with a tissue when coughing and sneezing, dispose of the tissue in the receptacle and to use the hand sanitizer right afterwards. Patients may also be instructed to take their surgical/procedure mask home with them with instructions for doffing masks. A sample patient handout from the OCFP on wearing and disposing of masks is available here. This is also available for patients to access in the Patient Resources tab, as well as guidance on how not to wear masks.

Primary care providers may offer clinical assessment and examination to patients who screen positive only if they are able to follow Droplet and Contact precautions and are knowledgeable on how to properly don and doff PPE. This includes the following PPE: gloves, isolation gown, a surgical/procedure mask, and eye protection (goggles or face shield). If primary care providers are not able to follow Droplet and Contact precautions and/or are not knowledgeable on how to properly don and doff PPE, they should divert the care of the patient as appropriate. This includes to an assessment centre, for testing, if the medical reason for the medical visit is urgent, and cannot wait until testing is performed, to an Emergency Department or Urgent Care Centre

Setting up a Safe Clinic Environment

  • Signage should be posted at the entrance to the office/clinic and at reception areas requesting patients with symptoms to put on a surgical/procedure mask (if available and if tolerated), perform hand hygiene and then to report to reception to self-identify. Sample signage is available on the MOH COVID-19 webpage at the bottom of the page . If the office/clinic is in a shared building, signage should also be posted at the entrance to the building.
  • Where possible, primary care providers should have signage outside the office/clinic asking patients to call the clinic before entering to allow for appropriate screening and direction.

Physical distancing guidelines

Ensure that there is enough space to follow physical distancing guidelines of maintaining at least 2 meters from other people. Suggestions include the following:

  • Minimize the need for patients to wait in the waiting room (e.g. spreading out appointments, having each patient stay outside the clinic until the examination room is ready for them and then call in, by phone preferably).
  • Space out chairs by 2m in the waiting room to allow for physical distancing (consider vinyl/plastic for wiping).
  • Remove toys, magazines, remote controls, etc. from the waiting room.
  • Ensure that patients do not leave their masks in waiting areas.
  • Have tissues, alcohol-based hand rub and a waste basket available in the waiting room.
  • Consider ways to minimize traffic flow for common spaces by creating visual/physical cues, for example:
    • Make all aisles one-way with clear way-marks on the ground noting the flow of traffic (using using street traffic signs, as they are already familiar to people in other contexts).
    • Tape simple guides on the floor throughout the office to help people space by at least six feet throughout their time in the office.
    • Create physical cues such as a picture of feet on the floor at the reception window and other places you want patients to wait for clinic staff. Place a sign by the reception window to tell patients to wait six feet from the window until it’s their turn.
    • Create signage limiting the number of people in an elevator

Other tips for the physical office

  • If safe/private to do so, leave doors open to avoid repeated doorknob contact
  • For common areas used by multiple providers/staff (e.g. storage rooms, procedure rooms, weigh scales, etc.) consider limiting/dedicating staff who use those areas. Set up a disinfecting protocol for these areas.
  • Keep rooms “bare” – keep surfaces clear of equipment other than a computer monitor. Anticipate what you will need for the visit and bring into the exam room with you (e.g. tongue depressors, reflex hammers, swabs, etc.)
  • Reception: install plexiglass barrier if possible; don’t take health cards (verify online or do visual check of version code); encourage card tap payment where available.
  • Restrooms: if restrooms are open, they should be supplied with toilet paper, hot and cold running water, soap, paper towel or air dryer, plastic lined waste container, a hand sanitizer with 70-95% alcohol. Notify patients ahead of time if restrooms will not be available.

Scheduling tips

  • Reduce the number of examination rooms being used (consider one per provider to reduce cleaning duties).
  • Minimize staff in the office/clinic. Consider what tasks can be done from home or outside of regular hours to minimize staff interactions with each other and patients.
  • Stagger in person bookings among providers in multi-doctor practices so multiple patients are not arriving/leaving simultaneously
  • In a one-hour period, alternate between virtual visits and in person visits to spread out the time between in-person appointments and allow cleaning. Large clinics may consider having each provider pick a designated day in the office seeing their own patients who require in-person care, and any of the groups patients who require same-day in person care, and provide virtual care the remainder of the time
  • Change the number of physicians in the office at the same time.
  • For exam room turnover, factor in that cleaning products need ‘wet’ time so may not be ready right away.
  • Minimize the number of individuals in the office/clinic at one time. For example, limit the number of non-essential individuals that may accompany a patient for their appointment (excluding minors and support persons)

Where to buy scrubs