key: cord-272630-2na1gndu
authors: Benito, Daniel A.; Pasick, Luke; Mulcahy, Collin F.; Rajasekaran, Karthik; Todd-Hesham, Hosai; Joshi, Arjun S.; Goodman, Joseph F.; Thakkar, Punam
title: Local spikes in COVID-19 cases: Recommendations for maintaining otolaryngology clinic operations
date: 2020-08-20
journal: Am J Otolaryngol
DOI: 10.1016/j.amjoto.2020.102688
sha: 
doc_id: 272630
cord_uid: 2na1gndu

The Coronavirus Disease-2019 (COVID-19) pandemic has created an unprecedented economic and public health crisis in the United States. Following efforts to mitigate disease spread, with a significant decline in some regions, many states began reopening their economies. As social distancing guidelines were relaxed and businesses opened, local outbreaks of COVID-19 continue to place person on healthcare systems. Among medical specialties, otolaryngologists and their staff are among the highest at risk for becoming exposed to COVID-19. As otolaryngologists prepare to weather the storm of impending local surges in COVID-19 infections there are several practical measures that can be taken to mitigate the risk to ourselves and our staff.

The first confirmed case of COVID-19 in the United States was reported in northern Washington on January 20, 2020 [1] and by March 11, 2020 , the World Health Organization declared COVID-19 a pandemic. [2] COVID-19 has since created an unprecedented economic and public health crisis in the United States. As healthcare system strain became imminent, the Centers for Medicare and Medicaid Services (CMS) 3 , the Surgeon General, and the American College of Surgeons (ACS) [4] recommended postponing elective procedures in efforts to mitigate the spread of disease and preserve personal protective equipment (PPE). Along these lines, the American Academy of Otolaryngology put forth recommendations for urgent and nonurgent patient care on March 20, 2020. These recommendations included delaying all elective procedures, rescheduling elective and non-urgent visits, rescheduling elective and non-urgent admissions, delaying inpatient and outpatient surgical and procedural cases, and postponing routine dental and eyecare visits. [5] Further, due to the high risk nature of the examination of the ear, nose, and throat [6] , otolaryngology outpatient visits have been drastically reduced throughout the country.

Such measures have restructured otolaryngology practices with telemedicine playing a crucial role in the continuing care. CMS continues to encourage telehealth modalities, however,

The ACS released guidance for the resumption of elective procedures on April 17, 2020. [4] While aspects of these guidelines are relevant for the outpatient setting, they do not address all outpatient clinic workflow issues. Further, given that otolaryngologists and clinic staff are at unique risk due to close contact with mucous membranes of the upper respiratory tract [6] , there is a need for specialty specific recommendations for the resumption of otolaryngology clinics. A recent report from a group in northern Italy (an area severely affected by COVID-19) provides guidance on reorganizing outpatient otolaryngology services in light of the current pandemic. [8] Many states began reopening businesses and healthcare centers within the context of these guidelines, however regionally there have been significant differences in implementation of masking and social distance mandates, leading to a reimplementation of restrictions. Our goal is to provide recommendations focused on outpatient otolaryngology clinics in the United States. It is important to note that these recommendations should not supplant evolving United States Centers for Disease Control (CDC), and relevant federal, state and local public health guidelines.

The increased emphasis placed on telemedicine presents specific challenges for the otolaryngologist, given the wide scope of practice that entails both procedural and medical management of ailments. While some chief complaints require in-person office evaluation, many patient consultations can be conducted and reimbursed via telemedicine.[9.10] Increasingly, however, otolaryngology practices have been opening for in person office visits in accordance with published guidelines. Although universal COVID-19 screening has not been widely adopted, strategies such as universal masking and staggered approach to appointments to reduce waiting room occupancy have been effective. Accordingly, it is imperative that patients are J o u r n a l P r e -p r o o f Journal Pre-proof triaged by administrative or nursing staff prior to clinic arrival. Further, it is important to know if the patient or an accompanying family member is at high risk for severe COVID-19 illness, as defined by the CDC. [11] When the decision is made for an in-person evaluation, patients should be screened for COVID-19 symptoms prior to their arrival. [12] In addition, patients who may require office-based procedures should be screened and should be strongly considered to undergo COVID-19 testing prior to arrival, if possible ( Table 2 ).

In-person examinations pose obvious risks of SARS-CoV2 (novel coronavirus) transmission among patients, family and friends of patients, and clinical staff. As such, implementing strategies to mitigate this transmission is critically important. Overall, we have implemented strategic reorganization of patient flow (scheduling, waiting room interactions, check-in process, and physical barrier placement) and adaptations within the examination room to protect both patients and clinical staff alike ( Table 2) . Considerations for endoscopic examination are also presented in Table 3 , should clear indications such as difficult airway management or malignancy be present. Adjunct use of transcutaneous laryngeal ultrasound may be a rapid noninvasive method well suited for evaluation of vocal fold motion [13] , however an aerosol-generating procedure was performed. [14] [15] [16] [17] [18] [19] [20] These recommendations should be used in conjunction with current guidelines for patient care and public safety [21] [22] [23] [24] and are adaptable to meet the needs of specific practice environments.

As operations in the otolaryngology clinic have resumed, considerations for workforce availability, staffing ratios, sanitation protocols, and HCW screening must be maintained to ensure a safe working environment for both patients and staff. Strategies can be focused on maintaining the lowest staffing ratio available in order to efficiently check-in patients, triage calls, escort patients and record vitals, and assist in any planned procedures ( Table 2 ). This may require day-to-day alterations in ratios. Moreover, staff should be advised to follow CDC recommendations for social distancing from other staff and patients in order to avoid "close contact." Large viral droplets (greater than 5µm) can remain in the air for only a short time and travel distances generally less than 1 meter. [25] [26] [27] Virus-laden small (less than 5µm) aerosolized droplets can remain in the air and travel distances greater than 1 meter. [28] This is defined as greater than 6 feet distance between oneself and a COVID-19 case. As the highest degree of viral shedding from the nasopharynx is thought to occur up to 48-72 hours prior to symptom onset [29] , patients should be assumed to be asymptomatic carriers until testing capacity is sufficient to perform point-of-care testing prior to the patient visit should use of laryngoscopy be needed. Many institutions have moved to testing patients between 24-96 hours prior to elective surgery or laryngoscopy [30, 31] . Temperature screening of all patients and staff through a non-contact temperature check at the entrance should be instituted, however should not be relied upon to rule out COVID-19. Use of barrier glass, such as glass or plastic windows at the front desk are recommended for protection against droplet infection. [32, 33] As J o u r n a l P r e -p r o o f Journal Pre-proof state re-opening and restrictions evolve, it will become increasingly important for the otolaryngologist and team to monitor the COVID-19 incidence rate in their area, and develop a threshold for re-entering the mitigation phase when a resurge is evident. [4] Self-protective measures for both the otolaryngologist and staff begins with preparation prior to the work-day, continues with prudent use of PPE in the clinic, and ends with a practical hygiene routine upon returning home (Table 5 ). [34] 

With a growing body of evidence, the transmission of SARS-CoV-2 is becoming better understood. Face masks or face coverings should be worn by everyone in an otolaryngology clinic and clinicians in direct contact with patients should wear full droplet precaution PPE.

Airborne precaution should be donned for aerosol-generating procedures (Table 5) . While N95 respirators are the minimum level of respiratory protection recommended for airborne precautions, higher level respirators (N99, N100, elastomeric respirator, PAPR, CAPR) may offer greater protection from virus transmission. [19, 35] In practice, however, use of an N 95 mask with a face shield has become standard for all procedures where there is a potential exposure to respiratory droplets and the provider is in close proximity to the patient. In our experience, patients who were asymptomatic at the time of visit but developed symptoms and a positive COVID test within days of the office procedure, did not transmit the virus to staff or other patients using these precautions.  UV-C light should be utilized for 15 minutes following a standard visit [15, 16, 45] Patient Visit with Aerosol Generating Procedure  Delay entering examination room to disinfect and remove soiled instruments J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

First Case of 2019 Novel Coronavirus in the United States

World Health Organization. WHO director-general's remarks at the media briefing on

CMS adult elective surgery and procedures recommendations: limit all non-essential planned surgeries and procedures, including dental, until further notice

American College of Surgeons. Local Resumption of Elective Surgery Guidance

New Recommendations Regarding Urgent and Nonurgent Patient Care

COVID-19 and the Otolaryngologist: Preliminary Evidence-Based Review

How to Reorganize an Ear, Nose, and Throat Outpatient Service During the COVID-19 Outbreak: Report From Northern Italy

Mitigation of head and neck cancer service disruption during COVID-19 in Hong Kong through telehealth and multi-institutional collaboration

Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: An invited commentary

COVID-19: People Who Are at Higher Risk for Severe Illness

COVID-19): Phone Advice Line Tool for Possible COVID-19 Patients

Laryngeal Evaluation during the COVID-19 Pandemic: Transcervical Laryngeal Ultrasonography. Otolaryngol Neck Surg

Is Office Laryngoscopy an Aerosol-Generating Procedure?

Evaluation of an Ultraviolet C (UVC) Light-Emitting Device for Disinfection of High Touch Surfaces in Hospital Critical Areas

Perioperative COVID-19 Defense

Effectiveness of Ultraviolet-C Light and a High-Level Disinfection Cabinet for Decontamination of N95 Respirators

Evaluation of a Pulsed Xenon Ultraviolet Disinfection System for Reduction of Healthcare-Associated Pathogens in Hospital Rooms

High-Risk Aerosol Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations. Otolaryngol -Head Neck Surg

Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol -Head Neck sick/social-distancing.html

Precautions for Operating Room Team Members During the COVID-19 Pandemic

COVID-19 Outbreak Associated with Air Conditioning in Restaurant

Environmental factors affecting the transmission of respiratory viruses

Transmission routes of respiratory viruses among humans

Aerobiology and Its Role in the Transmission of Infectious Diseases

Temporal dynamics in viral shedding and transmissibility of COVID-19

Developing Perioperative Covid-19 Testing Protocols to Restore Surgical Services. NEJM Catal Innov Care Deliv

Overview of COVID-19 testing and implications for otolaryngologists

Protecting patients and healthcare personnel from COVID-19: considerations for practice and outpatient care in cardiology

Centers for Disease Control and Prevention. Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response

How to train health personnel to protect themselves from SARS-CoV-2 (novel coronavirus) infection when caring for a patient or suspected case

Letter: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic

Infection Control Measures for Operative Procedures in Severe Acute Respiratory Syndrome-related Patients

In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic

Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic

Illness in Intensive Care Staff after Brief Exposure to Severe Acute Respiratory Syndrome

Possible SARS Coronavirus Transmission during Cardiopulmonary Resuscitation

Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear

Symptom Screening at Illness Onset of Health Care Personnel With SARS-CoV-2 Infection in King County

Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with

United States Environmental Protection Agency. Disinfectants for Use Against SARS-CoV-2

Cost-effectiveness of transfacial glandpreserving removal of parotid sialoliths

Centers for Disease Control and Prevention. Evaluating and Testing Persons for Coronavirus Disease

Airborne Transmission Route of COVID-19: Why 2 Meters/6 Feet of Inter-Personal Distance Could Not Be Enough

Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19

Information Overload: A Method to Share Updates among Frontline Staff during the COVID-19 Pandemic. Otolaryngol Neck Surg