Reopening in the wake of Covid19
/By Dr. Raymond Zakhari
Since the hospital admissions are declining each day, and the ICU census continues to decline. Hospitals have demonstrated their ability to scale up: I propose the following path to reopening for business:
Healthcare going forward and reopening:
Just as most healthcare institutions require their health care providers to be trained in Basic Cardiac Life Support every 2 years further require training in Advanced Cardiac Life Support AND the Fundamentals of Critical Care Support as offered by the Society of Critical Care Medicine. Even though the skills are degradable with infrequent use, establishing and reviewing this foundation consistently will greatly reduce the learning curve when the need arises (as it most likely will again).
Train RNs, Respiratory Therapists, and physicians in point of care beside ultrasound and do away with the stethoscope.
Hospitals should develop a negative pressure tent contingency plan that can be rapidly deployed in the case of a local epidemic outbreak.
All patient care rooms have telehealth capabilities, and in house consult services develop remote access capabilities to reduce unnecessary foot traffic through patient care areas. The patient should be physically examined only when necessary.
All health care providers’ roles should wear surgical masks or N95 when caring for patients.
Visitors to healthcare institutions (hospitals, nursing homes, clinics, offices etc.) and patients should wear surgical masks upon entering the common areas.
Hand washing among healthcare workers should be strictly enforced and a chart notation should be made on every encounter if hand washing was done just as we are requiring notation as to the patient’s preferred language and if an interpreter was used.
All healthcare workers wear scrubs which are not worn outside the hospital unless covered
aggressive lab coat laundering
Neck ties strictly prohibited for any patient facing health care providers.
Initially, reopen outpatient elective healthcare practices, birthing centers, dental offices, dermatology, plastics, free standing procedure and surgical centers that are known to not to necessitate a hospital admission (in order to maintain/ retain hospital bed capacity and ongoing construction efforts for a turnkey pandemic response i.e. Murphy bed style expanded ICU capabilities).
Hospital’s receiving government funds should have a pandemic response plan in effect that should be integrated into daily operations to some degree to include their outpatient departments that includes:
Retain, maintain, and use telehealth for potential all cold and flu like symptoms. This will reduce fomite transmission to vulnerable person entering the health care environment. The virtual urgent care, eVisits, web-camera follow up visits for problems that do not actually require a hands on physical exam.
Virtual health kiosks similar to ATMs throughout the regional area to reduce unnecessary congregating in the emergency departments.
Free standing/ hospital affiliated offices for blood work, and radiological imaging with extend hours so that community providers can send electronic prescriptions to these places to facilitate tele-health work ups thereby exposing the patient and community as little as possible to communicable disease spread. (Pre pandemic shut down it was not uncommon for the community physicians to send their patients to the ER because their office was closed and they needed a test result sooner than later).
Any patient being managed for a chronic pulmonary condition or panic attack should be trained in pulse oximetry monitoring, the use of incentive spirometer, and peak flow monitoring with routine telehealth follow up.
Personal Responsibility
If you are high risk or vulnerable wear and an N95 mask when you are out and about.
Consider self-quarantine during times of increased risk
Practice proper hand hygiene
Carry hand sanitizer
If you are symptomatic or highly conscientious wear a surgical mask/ covering when out and about.
If you are symptomatic do not go to school or work
Consider removing handshakes from standard greeting and adopt another form such as a head nod, bow, salute, pat on the back. I would avoid fist and elbow bumps as we are all coughing and sneezing into them now.
Government controlled areas and buildings
Bring back and ramp up production of medications, personal protective equipment, ventilators, and other vital resources to the United States prescribing across state lines (if the patient establishes a relationship in the home state and travels they should easily be able to have their health care provider prescribe/ continue to treat them where they have traveled so as to not unnecessarily burden the local healthcare system).
Nurse Practitioners and Physician Assistants should be allowed to practice to the full scope of their training reducing the arbitrary regulations under the guise of patient safety. Amidst pandemic patient safety was not compromised because NPs and PAs were able to treat them independently. This increases the volume of trained healthcare providers at the ready and connects more people to care.
Continue to stockpile the strategic reserves of essential medical supplies, tent hospitals, medications etc., and National Guard medical response readiness for coordinated pandemic and mass casualty response.
Implement the use of electronic hands free doors, sinks and hand sanitizer dispensers
Surgical Masks available the entrances to be worn in elevators, and areas of potential crowding.
Hands free elevators with floor markings suggesting where to stand to reduce excessive crowding
Open State, and Federal parks and beaches simply encouraging social distancing of non-communal groups (families, roommates, etc. can be near each other).
Open up construction to allow for the implementation of these suggestions and other necessary pandemic response resilience initiatives.
Construction should include private homes who want to install saunas, steam rooms, hot tubs, cold plunge pools (research has shown these activities consistently boost the immune system and reduce the incidence of flu-like and common cold infections and symptom severity). Also, encourage landscaping that plants trees, bushes, shrubs etc. as “forest bathing” also boosts immunity.
Include in the public high school curriculum EMT –Basic training so that in times of national disaster people have a frame of reference for how they can be useful, and a trained volunteer force can be mobilized to free up healthcare professionals to handle more acute needs.
Allow food trucks to open for business and encourage take out and drive through options as this will encourage dining out again and allow people to regain livelihood. Incentive electronic ordering through mobile apps thereby decreasing lines and crowds.
Open hair and nail salons, and spas, bathhouses that have saunas, steam rooms, hot tubs, cold plunge pools. Workers worried about exposure can wear N95 masks.
These services can also be delivered privately in the form of a house call should it be feasible.
Any Private business can require their workers to wear N95 masks and or visitors to reduce risk of transmission from asymptomatic patrons etc.
Private business such as grocery and department stores can require patrons to wear a face mask while shopping. Patrons are free to choose where to shop.
Immunizations or titers should be required for attendance at any school or university.
Private Employers and Public Venues can decide to what degree they want to require this or what mitigation strategy they are taking i.e. no titers then surgical masks etc.
The health centers and school nurses offices should have point of care testing readily available for Respiratory Pathogen Panel, SARS-CoV2, Influenza, and Strep swab testing.
They should be allowed to perform these tests on a student or employee presenting with cold or flu symptoms.
Paramedics and EMTs should also be trained to conduct these point of care tests when responding to calls that have respiratory infection symptoms.
Students (parents) and Faculty can choose to wear or not wear a surgical mask or N95 mask while at school
Insurance Providers should be required to include antibody and titer testing for communicable disease which we currently vaccinate against and Covid 19.
Those who are not seroconverts should have the immunization cost covered at their healthcare provider’s office or pharmacy.
Most of the above should be implemented by Memorial Day weekend. After about 14-21 days (the longest known incubation period) the rest of the economy can be opened with the following measures:
Public Gatherings
Private venues can require patrons to wear face masks or coverings in sporting, theater and convention venues
The vulnerable remain personally responsible to self-quarantine.
Bars, Restaurants, Coffee shops, Cigar lounges: Waiters and Bartenders should consider wearing N95 masks, patrons should not be required to wear surgical masks.
The psychological toll due to loss of livelihood, life purpose, social isolation, etc. will likely yield more consequences than are currently known. Eventually herd immunity will develop and the group think mass hysteria should subside assuming people can reduce their consumption of the 24 hour news updates.
