COVID-19: Staging environment

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Determining when to schedule in-person vs remote visits - WIP

Last reviewed: June 16, 2020
Last updated: June 16, 2020
Per the Ministry of Health (May 26, 2020), non-essential and elective in-person services carried out by health care providers may be gradually restarted, where appropriate.  

The determination of which services should be provided remotely and which should be provided in-person should be made by healthcare providers guided by best clinical evidence and according to the following four principles (MOH, May 26, 2020):

Proportionality

  • Consider available capacity to provide those services, both real and anticipated.

Minimizing harm to patients

  • Strive to limit harm to patients wherever possible.
  • Activities that have higher implications for morbidity/mortality if delayed too long should be prioritized over those with fewer implications for morbidity/mortality if delayed too long.
  • Consider the differential benefits and burdens to patients and patient populations, as well as available alternatives to relieve pain and suffering.

Equity

  • All persons with the same clinical needs should be treated in the same way unless relevant differences exist (e.g. different levels of clinical urgency).
  • Special attention should be paid to actions that might further disadvantage the already disadvantaged or vulnerable.

Reciprocity

  • Certain patients and patient populations will be particularly burdened as a result of our health system’s limited capacity to restart services.
  • The health system has an obligation to ensure that those who continue to be burdened have their health monitored, receive appropriate care, and be re-evaluated for emergent activities should they require them.
Clinical scenarios

That can be safely assessed and treated remotely (Virtual Care Playbook, CMA, 2020):

  • Mental health issues.
  • Skin problems (have patient submit photos in advance as resolution is much better than a high-quality video camera).
  • Urinary, sinus and minor skin infections (pharyngitis too if you can arrange throat swabs).
  • Sexual health care, including screening and treatment for sexually transmitted infections, and hormonal/oral contraception.
  • Travel medicine.
  • Conditions monitored with home devices and/or lab tests (e.g., hypertension, lipid management, thyroid conditions and some diabetes care; in-person consultations will still be needed for some exam elements).
  • Lab, imaging and specialist reports.
  • Other assessments that do not require palpation or auscultation.

That may warrant an in-person visit (OCFP, March 26, 2020):

Putting it into practice

All healthcare settings are encouraged to switch to virtual visits whenever possible. This decision should be based on an assessment of patient frailty in combination with self-management capability, in terms of both health and technological literacy, as well as technology access.

  • Does the patient have a phone or internet at home?
  • If the patient has access to internet, are they comfortable downloading and using apps, following links, watching videos, downloading attachments, taking and sending photos and videos?
Virtual self-management capacity

Learn from another practice

Flu shots and flurries: how Red Lake FHT organized a parking lot clinic during COVID-19

Tip: Use who you can. If nurses and other medical staff are burned out, use community health partners like social workers, dieticians, etc. to step in to support roles.

  • Team A: 1 vaccinator, 1 administrator
  • Team B: 1 vaccinator, 1 administrator
  • Team C: 1-2 staff to manage traffic and parking

Tip: Ask patients to arrive 15 minutes early.

  • Schedule in 45-minute blocks:
    • 15 min: Vaccinations
    • 15 min: Observation
    • 15 min: Team warm-up inside, redrawing, administrative tasks, etc.
  • Stagger teams by 15 minutes. (Example, Team A’s first block is 9 am, Team B’s first block is 9:15).
  • Patient flow: start with 8-10 patients per 15 minutes and increase as staff comfort/ability allows.

Red lake sample schedule

Prep tips

  • Outreach via Facebook 24-48 hours before clinic.
  • Set aside a dedicated cell phone # for vaccination patients, so they don’t tie up clinic phone lines.
  • Print billing sheets in the morning. Use highlighters to identify:
    • Patients over 65 who can receive high dose if available
    • Young children who might need a 5/8ths needle
  • Prepare trays in advance.
  • Weigh down or secure garbage bags and empty sharps containers so they don’t blow away.
  • Have rescue meds close at hand and ensure all staff know where to access them.
  • Leave 1 parking space empty between cars so teams can maneuver carts between and around.

Encounter Logistics

  • Administrator:
    • have list ready, confirm names of patients
    • Screen for COVID-19 symptoms
    • Quick consent
    • Confirm observation period and instruct patients to honk if they have a problem
    • Document injection side with R/L on billing sheet
    • Assist with cotton ball/tape for injection side
  • Vaccinator:
    • Vaccinate car driver first, so their observation period is already underway

Sample prioritization of primary care services

Putting it into practice
Determining when to schedule in-person vs remote visits
Sample prioritization of primary care services

Transitions from one phase to the next should depend on stages of provincial re-opening, office readiness, and community COVID-19 prevalence.

When businesses and schools reopen

  • Acute or subacute symptoms
  • Potentially unstable chronic disease, such as post-myocardial infarction, post-stroke, congestive heart failure (CHF), uncontrolled diabetes, cancer
  • Severe or unstable mental health diagnoses
  • Pre-existing developmental concerns among infants / children
  • Pregnancy and newborn care
  • Mental Health visits, if concerned destabilization will result without in-person visit
  • Other matters presenting risk, for example addiction, at-risk sexual practices
  • IUD insertion/removal, endometrial biopsy
  • Skin biopsies (for suspected melanoma)
  • Injections (anti-psychotics, Depo-Provera, Prolia, methotrexate, etc)
  • Adult vaccines (Prevnar/Pneumovax)
  • Joint injections for chronic/acute pain
  • Allergy shots (if office space allows)
  • Suture removal
  • Palliative care visits (office or home)
  • MAID requests
  • Driver’s Medicals/3rd party medicals for essential service workers

When pandemic epidemiology is stable

  • Chronic symptoms
  • Well infant / child visits
  • Contraception
  • Chronic diseases previously well controlled, requiring interval follow-up (diabetes, hypertension, renal insufficiency, stable CHF, mental health diagnoses)
  • Adult immunizations (routine Shingrix, Tdap, etc)
  • Driver’s Medicals/3rd party medicals for non-essential services
  • Pap smears for follow-up of prior abnormal
  • Mental Health (routine visits)
  • ENT, cardiac, GU non-urgent issues requiring exam
  • Deaf or vulnerable patients unable to have virtual visits (if non-urgent concern)
  • Skin exams if photo/video insufficient
  • Skin biopsies (for non-melanoma lesions)
  • Liquid nitrogen treatments (warts, AKs)

When pandemic epidemiology is stable, physical distancing requirements are lifted, most activities have returned to normal

  • Blood pressure checks for those without chronic disease
  • Sexually transmitted infection screening in average risk individuals
  • Cancer screening: cervix and colon, then breast
    • For cervical cancer screening in individuals without a history of abnormal lesions there is no rush to do a Pap test even if it has been a bit more than 3 years. Some countries do Pap tests every five years, with no difference in cervical cancer mortality (Milbank Quarterly, 2012).
    • For breast screening, considering low effect size of screening and CTFPHC recommendation for 2-3 year screening, this could wait until 3 years (CTFPHC, 2018).
  • Meet and greets for new patients
  • Routine PAP
  • Periodic/Preventative Care Reviews
  • B12 injections
  • Diabetic checks
  • Hypertension review
  • Stable CHF/COPD visits
  • Contraception review
  • STI screening
  • Smoking cessation

When capacity exists

  • Patient-initiated health promotion

Functional overview

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We use the “text with icon” field to quickly orient the user with the type of information/content to expect in the inline copy by using common and easy to understand visual cues/icons.

Used when providing guidance/best practice/recommendations re delivering care/permission to do something. 

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Used when providing external links to recommendations/further information. 

For example:

Used when conveying REALLY important information that applies to the whole population, high risks, red flags, gov’t requirements, etc.  The point of use is to make the user STOP and read.  So we tended to use it sparingly otherwise the impact of the icon will be diluted.

For example:

  • Any persons experiencing one of the following should be told to self-isolate and tested as soon as possible:
    • Fever (temperature of 37.8°C or greater)
    • New/worsening cough
    • Shortness of breath (dyspnea)
    • Sore throat
    • Difficulty swallowing
    • New olfactory or taste disorder(s)
    • Nausea/vomiting, diarrhea, abdominal pain
    • Runny nose, or nasal congestion (in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc.)
  • There is only low-quality evidence available on COVID-19, as it is an emerging virus. Many studies being released have not been peer-reviewed. Among those that have been peer-reviewed, many are small, retrospective observational studies and thus have serious limitations and risks of bias. While the findings of emerging COVID-19 studies can be useful in helping to broaden our understanding about how the virus might operate, the results of COVID-19 studies should not be considered validated.
  • As reports of children experiencing a multi-system inflammatory syndrome multiply, the Canadian Paediatric Surveillance Program issued a Public Health Alert (CPSP, May 12, 2020) encouraging those providing paediatric care to familiarize themselves with the presentations of this emerging syndrome. It has now been included in the case definition and is reportable to public health.

Generally used when conveying information that applies to the part of the population, things that are “strongly recommended” but maybe not yet mandated, cautions, etc. Similar criteria as the (!) icon, but with a content that isn’t quite as MUST READ. The point of use is to make the user PAUSE and read.  Used more frequently.

For example:

  • OCFP and CFPC suggest strongly considering PPE use for all patient encounters that involve less than 6 feet of separation due to the possibility of asymptomatic and pre-symptomatic transmission. For more information on PPE, see Infection prevention and control: PPE, HCW infection control, cleaning.
  • While rare, clinicians should be aware of this potential syndrome and maintain a high index of suspicion to identify cases. Some patients have deteriorated quickly and have required intensive care unit admission for vasopressors and mechanical ventilation.
  • Caution should be taken when using NSAIDs in the context of acute respiratory infections (ARI) and patients with the following conditions.

Commonly used and understood icon that conveys “geolocate”. Used when linking out to regional/local resources.  

For example:

Used for when we provide talking tips.

For example:

  • Responding to questions about unproven therapies for COVID-19: “Though research is underway, there are currently no medications recommended for preventing or treating COVID-19 because there is not enough evidence to make any conclusions yet” (CMAJ, 2020).
  • “This is your home and we will make every effort to make you comfortable in your new room with all of your belongings.”
  • “In-room dining is important for you and other residents so that we can protect everyone, including yourself.”
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

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  • Mostly commonly used “table”. “cleanest” in look and feel.  Allows for a maximum of 3 columns, infinite rows.
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  • Inner border can be grey or blue.
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

FAQ/info block

Answer 1

Answer 2

Answer 3

Another “click to reveal” block. commonly used for FAQs, chronic diseasae mgmt, special pops, etc. For example:

Please note the content contained within the answer is NOT searchable using the search function.

Stack of papers. Multiple Choice
Option 1
can have multiple rows within section

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can have multiple rows within section

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can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Option 2
can have multiple rows within section

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can have multiple rows within section

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Takes up a lot of page “real estate”. We tend to NOT use unless there are multiple Y/N questions/use of block consistently. For example, see: COVID-19: Social Care Guidance. Please note the content contained within the answer is NOT searchable using the search function.

Card block

We use this block when displaying similar information that has consistent headings/categories. It was originally developed to contain rx info. Allows us to use horizontal real estate and not overload the vertical/infinite scroll issue. Also gives provides opportunity to add additional information with each card that pops out for more details. Mobile friendly. Searchable in search function. For example:

Pop-out block

Designed for talking tips, etc. Generally used to contain information that is not necessarily immediately relevant for all users. But, for those that are interested, they can click to “opt-in” to view the content. Content is NOT searchable using the search function. For example:

Image block

Used for images of diagrams, static flow charts, evidence tables that go beyond three columns, etc. Please note, if we can we try NOT to use images for evidence tables are they do not render well in mobile. Where possible, consider how the content can be summarized differently/more succiently before going down the image route. For example:

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