Optometry Practice Reactivation Preparedness Guide

Shelter-in-place declarations and stay-at-home orders have limited practices to only essential care, such as urgent and emergent care. Based on updated reports, social distancing and the cessation of normal and routine activities is believed to be slowing the spread of the greatest public health emergency that our country, and the world, has seen in our lifetime.

This pandemic, by all accounts, is a temporary event. As such, the President's Administration issued  The Guidelines for Opening Up America Again. Following these guidelines, on April 19th, the U.S. Centers for Medicare & Medicaid Services (CMS) released  Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare:  Phase I.

The CMS opens the recommendations with the following statement: 

The United States is experiencing an unprecedented public health emergency from the COVID-19 pandemic. Healthcare facilities in some areas are stretched to their limits of capacity, and surge areas have been needed to augment care for patients with COVID-19. To expand capacity to care for these patients and to conserve adequate staff and supplies, especially personal protective equipment (PPE), on March 18 CMS recommended limiting non-essential care and expanding surge capacity into ambulatory surgical centers and other areas. However, CMS recognizes that at this time many areas have a low, or relatively low and stable incidence of COVID-19, and that it is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 healthcare. In addition, as states and localities begin to stabilize, it is important to restart care that is currently being postponed, such as certain procedural care (surgeries and procedures), chronic disease care, and, ultimately, preventive care. Patients continue to have ongoing healthcare needs that are currently being deferred. Therefore, if states or regions have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, then they may proceed to Phase I.  

The CMS concludes the recommendations with the following statement: 

All facilities should continually evaluate whether their region remains a low risk of incidence and should be prepared to cease non-essential procedures if there is a surge. By following the above recommendations, flexibility can allow for safely extending in-person non-emergent care in select communities and facilities. States are already beginning to initiate Phase I openings and you will be re-activating your practices in the near future. As doctors of optometry prepare to resume delivery of complete, comprehensive eye health and vision care under a new phase of the nation's continuing COVID-19 pandemic response, the AOA recommends that clinical judgment and practice operations should be informed by the  CMS re-opening guidance of April 19, and the  Opening Up America Again plan, as well as all state, state board and local health directives.  

The AOA has confirmed the Centers for Disease Control and Prevention (CDC) has removed the agency's March 17 nationwide recommendation to postpone routine eye care and it is no longer in effect, and that  CMS's specific guidance on re-opening facilities to provide non-emergent and non-Covid-19 health care is in force. Under this framework, state-by-state decisions will guide when and how doctors and practices can resume delivery of complete, comprehensive care. The CDC has followed this guidance with a proposed " Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic."

On an ongoing basis, including by remaining in close contact with their state association, doctors should stay informed as their state's governor and other state and local authorities update the status of public health and safety measures in effect, specifically as they relate to the operations of optometry practices and the delivery of care by doctors of optometry, other physicians and health care providers.  

Suggested steps to prepare optometry practices, staff and patients for a safe return 

As physical distancing is eased, a rapid increase in the number of patients seeking routine eye and vision health care is anticipated. Below are suggested steps for a safe return to delivering the full range of essential eye health and vision care that Americans need.

Anticipate when you will return to a normal (or new normal) schedule.

• Watch for  communications and updated information from the AOA for national trends and changes.
  • The  #AskAOA Practice Reactivation Webinars provide up-to-date information and details for doctors and staff.  
  • The  #AskAOA May 12 webinar includes the latest updates regarding practice reopenings.
• Closely monitor CMS, CDC, and all state and local guidance related to routine vs. urgent and emergent care, and when changes can be expected.
• Monitor updates and communicate frequently with your state optometric association regarding state government and board of optometry guidance.
• Utilize the time now to evaluate and assess your practice and identify opportunities to enhance the practice moving forward. This includes, but is not limited to, all clinical and non-clinical services; office purchasing and staff roles and responsibilities critical to office recovery; and optimization (e.g., scheduling all available open slots and increased/staggered available office hours).
• Connect with county and city health board/officers regarding guidance and alert them of your plans for reopening.
• Communicate with local medical offices, surgery centers and hospitals to inform them that you are planning to open for emergent and non-emergent care, consultation and referrals.

Develop an action plan for your staff before you open your doors for both routine and emergency care.

• Consult guidance from the following sites regarding infection prevention measures and begin a plan to implement appropriate protocols within your office.  
  • CMS recommendations
  • CDC recommendations 
  • CDC Clinic Preparedness Guidance
  • U.S. Department of Labor's Occupational Safety and Health Administration (OSHA)
• Determine priorities for preparing office space and clinical areas based on suggested guidelines for cleaning and sanitizing the medical office and dispensary, and how long this process may take.
  
  • Plan a process to sterilize all equipment and materials, including frames, with the best recommended disinfectant.
    
    • For surfaces, the best disinfectant is diluted bleach solution. To create a bleach solution:
      
      • Purchase spray bottle and fill with diluted bleach solution.
      • Prepare a bleach solution by mixing: 5 tablespoons (1/3 cup) bleach per gallon of water; or 4 teaspoons bleach per quart of water.
  • It is also critical to review and adhere to any manufacturer recommendations for best approaches for sterilizing equipment in your office. Specific best practices were discussed in detail in the #AskAOA webinars. Some general best practices for commonly used technology are included below:
    
    • OCT, autorefractor, other equipment: (check with manufacturer)
      • Most recommend careful cleaning with 70% alcohol but beware possible damage.
    • Tonometer tips
      • 1:10 diluted bleach (4 teaspoons bleach per 32-ounce H2O).
      • Hydrogen peroxide (50/50).
      • With either, soak for no longer than five minutes max to limit damage.
      • 70% alcohol does work against SARS-CoV-2 but may not be effective against adenovirus.
• As glasses and frames can potentially become contaminated by SARS-CoV-2, it is important to follow best practices for cleaning and disinfecting them after each use. Doctors and staff should  follow manufacturer recommendations for individual frames. In addition, The Vision Council has assembled some guidance regarding optimal cleaners.
  • Anti-bacterial wipes can be a good option to clean eyeglasses and sunglasses. However, only the manufacturer of the frame can ensure this option based on its chemical composition and their frame material.
  • Soap and warm water.
  • A mild mixture of hydrogen peroxide and water may be used for sanitization, though doctors and staff should consult manufacturers for the mixing ratio instructions.
• Ensure HVAC filters are high-quality, pathogen-attractive, fresh and exchanged regularly. Make air exchange rate higher if possible.

Map out how you will triage and prioritize those patients who require urgent or emergent care, those with original appointments and those who need to be rescheduled.

• For example, in some states it is important to consider that health care providers are choosing to open at 50% capacity soon after the "shelter in place" orders are lifted and you may need to incorporate this into your plans.
• Use telehealth and virtual care whenever possible to continue to provide service and reduce the risk of COVID-19 transmission.

Take stock of existing supplies and work to anticipate adequate needs moving forward to maintain recommended levels of cleanliness and sanitization.

Ensure clinical and non-clinical staff have appropriate personal protective equipment (PPE) including facemasks, gloves and eye protection; have access to germicidal wipes; and have an ample supply of hand sanitizer, soap and water.

• Ensure that all staff wear washable cloth or disposable masks; gloves should be required when working directly with patients and changed with each patient.
• Staff should receive job-specific training on PPE and demonstrate competency with selection and proper use of PPE (e.g., putting on and removing without self-contamination).
• Refer to AOAExcel for important information regarding PPE access.
• Contact state association for locally accessible resources.

Develop screening protocols for staff and patients. 

• Optometric practices should screen patients, visitors and staff members for symptoms of COVID-19 prior to and/or upon their arrival at the facility, including utilizing non-contact infrared temperature readers (NOTE: Temperature alone does not assess or exclude disease). The CDC defines a fever as a temperature at or above 100.4°F. 
  • Ask if they have tested positive for COVID-19.
  • Ask if they are coughing.
  • Ask if they have shortness of breath.
  • Ask if they have red eye or eyes (conjunctivitis can be a presenting sign of COVID-19).
  • If patients or staff report or appear ill, recommend that they consult and/or seek medical care from their primary care physician (PCP) the same day.
  • Patients or staff should consult their PCP first unless they are experiencing emergency warning signs. If they develop any emergency warning signs for COVID-19 they should seek medical attention immediately:
    • Trouble breathing.
    • Persistent pain or pressure in the chest.
    • New confusion or inability to arouse.
    • Bluish lips or face.
• Any staff member showing signs of being sick should not be permitted to work.
• CDC's Symptoms of Coronavirus.
• Patients and visitors exhibiting signs of being sick should be rescheduled, unless an emergency dictates otherwise, and referred to their PCP.

Outline workload plans for staff so as to prepare for cleaning and sanitizing, while safely keeping up with patient flow as best as possible.

Identify strategies for your office that manage patient flow and ensure appropriate physical distancing, including, but not limited to: 

• Re-evaluate office flow and waiting area capacity.
• Request patients call or text the office upon arrival so entrance to and movement through the facility can be coordinated by staff.
• Instruct patients that companions should remain outside of the facility and not accompany the patient into the facility unless they are a parent/guardian of the patient or if they are a true caregiver and need to assist the patient.
• Establish a longer timeframe in-between patient appointments.
• All patients and companions in the building must wear cloth or disposable masks at all times.
• Determine if door is to be locked to limit entrants, or propped open to reduce handle being touched and exchange fresh air, or another alternative.

Utilize this time out of office for staff education and re-education and training. 

• AOA's EyeLearn Professional Development Hub has resources for paraoptometric professionals; considering staffing models potentially changing, cross-training may also be beneficial. 

Develop a new system for sterilization of the office, based on all available guidelines. Patient safety protocols are critical to patient-centric care moving forward. 

• Opening cleaning protocol.
• Closing cleaning protocol.
• Equipment and exam room cleaning protocol in-between patients. 

Continue messaging to your patients. 

• Reach out to them during this difficult time to see how they are doing through all relevant communications channels (e.g., website, social media, email, direct mail, advertising, etc.).
• Update your website, social media channels and phone voicemail to communicate that your office is open for eye health and vision care, and use the opportunity to reinforce the importance for the care you deliver and how you are taking steps to protect patient and staff health and safety.
• Remind your patients, when relevant, you are open for essential routine and urgent care, emergencies, telehealth consultations, questions and concerns.
  • Ensure that all communications reinforce your practice safety protocols.
• Based on expectations for a return to routine care, begin booking routine appointments for an anticipated day one re-activation and beyond (be sure to make patients aware there remains a chance the limited schedule order may not be lifted).
• When appropriate for patients, consider utilizing telehealth to prioritize in-patient care for those who have urgent needs.
• Contact and check up on your complex patients:
  • Diabetic retinopathy.
  • Glaucoma.
  • Age-related macular degeneration.
  • Complex contact lens patients (e.g., scleral).
  • Myopia management patients.
  • Refractive surgery referrals.
  • Patients who are referred to the practice for specialist care.
• Identify patients whose care has been postponed:
  • Individuals referred for non-urgent surgery and/or routine care.
  • Alert those who may need to reschedule or restart their authorization and scheduling process. 

Prepare for your staff needs as they assimilate into the new working environment. 

• Demonstrate consideration for the mental health of the staff and team while re-establishing the new care delivery flow.
• Strategies to reduce stress and potential burn out may include:
  • Ensure a positive work environment.
  • Eliminate or reduce tasks that are not contributing to improved patient care.
  • Facilitate access to support programs, if possible.
  • Encourage balance.
  • Communicate, communicate, communicate.
  • Consider brief morning meetings before patients arrive.
    • Discuss successes, challenges and changes in office protocols.

Contact other medical practices in the area to see when they will be re-opening or if they have new protocols in place. 

• Sub-specialty ophthalmology for referrals.
• Local emergency departments for referrals. 

Post signage in the office of the new steps and protocols to ensure maximum safety. 

Utilize AOA resources. 

• AOA COVID-19 Hub
• AOAExcel
• Patient resources
• AOA's EyeLearn Professional Development Hub

Celebrate re-opening the practice!    

This remains an evolving situation and AOA encourages doctors of optometry to continue to consult the CMS and federal, state and local governments and officials for guidance. Doctors can visit  AOA's coronavirus resource for the latest information.

Access to PPE for optometry practices

The urgent nationwide shortage of supplies of PPE for frontline, essential care providers, including doctors of optometry, is placing America's health care workforce and the public at further risk. The AOA is among the leading national health care organizations actively urging the president, Congress and equipment suppliers to immediately focus on and fix this dire situation.

During the nationwide shortage.

Due to the efforts of states, localities and public health organizations, and through federal prioritization and targeting efforts, PPE supplies are being directed to outbreak hotspots and potential future hotspots. Doctors are advised to explore current availability of quality PPE through state and local agencies as well as other immediate term sources. 

Next steps for securing PPE for optometry practices.

Looking beyond the current nationwide shortage, AOA doctors are advised that AOAExcel's exclusive group purchasing organization (GPO) partner, Intalere, is positioned to gain assured, long-term access to steady supplies of hospital-grade, quality-controlled PPE at competitive pricing. This is an AOA member benefit.  

• For doctors/practices already enrolled in AOAExcel's GPO program:  You may directly contact Intalere's Operational Continuity & Emergency Management team at 877.711.5600 for the latest information on PPE availability and access. (Intalere member number is required. If not known, it can be accessed by contacting the AOAExcel team.
• For doctors/practices not yet enrolled in AOAExcel's GPO program:  Provide basic registration information. The enrollment process will be completed within four business days. To get started or for other assistance, contact the AOAExcel team.