• • CMS recommends that healthcare providers and staff wear surgical face masks at all times.

  • Eye protection for the optometrist is recommended.

  • In regions with high prevalence of COVID-19, an N95 mask for the optometrist can be considered when available. The CDC’s recommendations on N95 extended use and/or reuse should be followed.

  • You or your staff may want to consider wearing disposable gloves or gowns. When returning home, remove shoes and clothing before entering the house and shower immediately. Consider scrubs and a laundry service at work.

  • Consider installing front desk breath shield and slit-lamp barriers.

  • Consider marking the floor to denote appropriate social distancing space from front desk.

  • Reconsider your previous workflows-eliminate or reduce tasks that don’t contribute to improved patient care.

  • CMS recommends all staff should be routinely screened for symptoms of COVID -19. Encourage workers to stay home if sick.

  • You should ask staff each day if they have symptoms.

  • You should take you and your staff’s temperature and oxygen saturation each day.

  • When adequate testing capability is established, patients and staff should be screened by laboratory testing.

There are two COVID related workplace posters that ODs need in their office:

Families First Coronavirus Response Act (FFCRA) notice and a new notice, Workplace Poster – Supplemental Paid Sick Leave for Non-Food Sector Employees.

• • Any non-clinical items should be stored, including display models, flyers, brochures, displays, etc.

  • Remove shared items (pens, clipboards, etc.).

  • Limit transfer of cards/paper orders/Rx from staff to patients.

• • Only patients may enter office for appointment.

  • Spouses, friends, and family members should wait outside. They can assist patient to the front door and hand off to technician.

  • Exceptions might be pediatric patients and others requiring a caretaker.

  • Anyone entering the building should be pre-screened in the same way as patients.

  • Implement curbside dispensing when possible

• • Consider accepting supply deliveries outside and sanitize once in practice.

  • Let sales reps know before you open that you prefer to interact remotely.

• • Staff training on and proper use of PPE.

  • Develop a written protocol for staff.

  • Perform a walk-through of the newly developed protocol in the days prior to opening and develop talking points for FAQs.

  • All staff should wear masks.

  • Promote frequent & thorough hand washing. Instruct staff to wash hands after every patient.

  • CMS recommends maximum use of all telehealth modalities. Explain to staff what conditions can be treated via telehealth and the procedure to schedule telehealth appointments.

  • Make sure you put up the new required in-office poster.

  • Allow as many staff members as possible to work from home.

  • Discourage workers from using other workers’ phones, desks, offices, or other work tools & equipment, whenever possible.

  • Consider mental health of your staff (& YOU!) while re-establishing new care delivery flow (offer counseling programs).

• • Assign one person to be responsible for sanitizing office.

  • Train on procedure to sanitize office after each patient – walk through process to demonstrate exactly what is needed.

  • Establish frame sanitization technique. One example might be to have one technician pull the desired frame from the display in an effort to limit the number of people touching the frame display. After patient tries on frame, put used frames in collection tray. Clean each frame before putting back on shelf.

  • The Environmental Protection Agency has a list of approved COVID-19 cleaners.

  • Some suggestions for frame sanitization include spraying peroxide diluted with water (50/50) then wiping the frame or cleaning with soap and water for a minimum of 20 seconds.

  • Others have recommended a hypochlorous acid solution that contains at least 0.015% of the active ingredient, which is listed as HOCL or hypochlorous acid. The EPA has determined that HOCL is as effective as bleach at killing enveloped viruses, including SARS-CoV-2, and unlike bleach, HOCL is non-toxic and non-corrosive, so it is safer to use on delicate surfaces such as glasses and skin.

• • Explain new safety policies over phone appointment confirmation calls.

  • Ask if patient has any symptoms of fever.

  • Request patient documentation be completed online, etc., if possible, prior to appointment.

• • Check-in can be done over the phone. Have tech complete history over phone while patient in vehicle, if not submitted before appointment.

  • Lock front door & request patients call or text the office from vehicle upon arrival, so entrance to & movement thru facility can be coordinated by staff.

  • Consider co-pay prepayment/billing &/or payment systems that don’t require staff to touch cash/credit card.

  • Take patient temperature before entering the waiting room. If a patient has a fever (100°F or higher, per CDC), they should be referred to their primary care physician (PCP) and not permitted in the office.

  • Also, consider using a pulse oximeter to screen patients.

  • Patients wait to be called-in for appointment once previous patient is gone and sanitation is complete.

• • Patients who come to an appointment should be asked prior to entering the waiting room:

  • Have you tested positive for COVID-19 or been exposed to someone who has in the past 2 to 14 days?

  • Have you had a fever in the past 3 days?

  • Have you had a cough or shortness of breath in the past 3 days?

  • Have you had chest pain in the past 3 days?

  • Have you or a family member recently traveled to high impact areas such as New York, Detroit, etc.?

  • Have you experience a change in taste or smell?

• • CMS recommends patients should wear a face covering - ask all patients to present with a face covering or mask.

  • If they do not have one, a mask should be provided by the office.

  • The doctor can reschedule or refuse to see a patient if they refuse to wear a mask.

  • You may want to ask patients to use hand sanitizer.

  • Inform patients that you will speak as little as possible during the slit-lamp examination, and request that the patient also refrain from talking.

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

  • No paper to patient if possible (eRx, email receipt).

• • Establish a prioritization policy for providing care and scheduling.

  • CA Dept of Public Health states the priority scheduling should consider: 1) patients with acute illnesses that cannot be handled through telehealth, 2) patients with chronic illness that have not been seen due to Stay-at-Home rules and need in person visit, 3) preventive services including vaccinations, 4) previously cancelled or postponed patients, and 5) other patients needing in person visit to monitor status or assess illness, etc.

  • CMS recommends maintaining low patient volumes. Ramp-up slowly.

  • Consider reducing the number of patient appointment to one per hour per doctor.

  • You might want to perform optical dispensing or adjustments by appointment only.

  • Keep patients six feet apart at a minimum.

  • No more than one patient in any work area (waiting room, dispensary, etc.) at a time.

  • Establish a longer timeframe in between patient appointments.

  • Consider extending office hours to make up lost time.

  • Offices should consider whether special hours of operation could be in place for patients who are higher at-risk.

  • Understand it may take time for your patient volume to reach its pre-COVID-19 levels.

• • Wash hands and put on new gloves prior to each examination.

  • Always wear other PPE.

  • Take patient directly to examination room.

  • Disinfect occluder after each use.

  • Hold stereopsis and color test book for patient (don’t let patient touch it).

  • Avoid conversation when close to patient (during slit lamp examination or fundoscopy).

  • Use single-use protective coverings, if possible.

  • Non-contact tonometry may micro-aerosolize the virus.

  • Disinfect tonometer prism according to manufacturer’s guidelines.

  • Use binocular indirect or fundus photography to maximize distance during fundus examination.

  • Clean/disinfect equipment before and after each use,including chair and anything touched during examination.

  • Minimize specialty tests to critical needs (visual fields, optical coherence tomography, corneal topography, etc.).

  • Use touchless paper towel dispensers.

• • Because viral shedding can be prolonged (up to 37 days in one study), repeat testing (RT-PCR performed on a nasopharyngeal swab) is recommended for patients prior to treatment if less than 6 weeks from COVID-19 diagnosis, except in emergent circumstances. If SARS-CoV-2 testing is positive, delayed or not available, the patient should wear a surgical mask. The treating optometrist should wear an N95 mask, rather than a surgical mask, in addition to gown, gloves and eye protection.

§ In most cases, you do not need to shut down your facility. If it has been less than 7 days since the sick employee has been in the facility, close off any areas used for prolonged periods of time by the sick person:

§ Wait 24

hours before cleaning and disinfecting to minimize potential for other

employees being exposed to respiratory droplets. If waiting 24 hours is not

feasible, wait as long as possible.

§ During this

waiting period, open outside doors and windows to increase air circulation in

these areas.

§ If it has

been 7 days or more since the sick employee used the facility, additional

cleaning and disinfection is not necessary. Continue routinely cleaning and

disinfecting all high-touch surfaces in the facility.

§ You will

need to ask the employee which coworkers they have been in “close contact” with

within the prior two weeks & cross-check time sheets. (The CDC defines

“close contact” as a person that has been within six feet of the infected

employee for more than 15 minutes without wearing PPE.)

§ You have an

obligation to notify staff when you learn of an employee diagnosis, required

isolation or death due to the coronavirus. You should alert those who have been

in close contact with the employee within one business day. You should tell everyone

who was possibly exposed at work to the positive employee, without revealing

that employee’s identity.

§ The notice

must include: 1) Notice that the employee may have been exposed to COVID-19; 2)

Notice of COVID-19 related benefits to which the employee may be entitled that

may include those provided by the federal Families First Coronavirus

Response Act, California’s Supplemental Paid Sick Leave law, California’s mandatory paid sick leave, workers’ compensation, company

sick leave or benefits available under local law; 3) Notice that the employee

is protected from retaliation and discrimination; 4) The company’s disinfection

and safety plan per CDC guidelines; 5) Where known, notice should include

dates, locations and titles similar to those set forth in Cal/OSHA logs of

work-related injuries and illnesses, even if the employer is not required to

maintain such logs. 6) Include the advice given on the CDC

site for their situation and, of course, direct them to their own doctors.

The notice must be sent in the manner usually used to communicate with

employees and may be by mail, email, text or in-person. Records of these

notices must be kept for three years.

§ Tell them

the following: Someone in our workplace has tested positive for Covid-19, and

they have identified you as a close contact according to the CDC definition. We

are here to support you. If you are at work, please prepare to leave as quickly

as you can. Once you get home — or if you are already working from there — find

a place to self-isolate, monitor yourself for any symptoms, and talk to your

doctors. How can I support you in doing all this?”

§ Follow-up

with a check-in with employee.

§ The law also

imposes a separate obligation to notify local public health departments of any

COVID-19 outbreak at a worksite within 48 hours of notification of an outbreak as determined by the State Department

of Public Health. An “outbreak” currently is three or more laboratory-confirmed

cases of COVID-19, not within the same household and not among close contacts,

within a two-week period.

§ Not all

reporting requirements are the same. The definitions of “outbreak” and

notification requirements under this new law differ from reporting obligations to workers’ compensation insurance

carriers. It is important for employers to understand their obligations under

all COVID-19 rules.

§ The CDC also

provides the following recommendations for most businesses that have suspected or confirmed

COVID-19 cases:

§ It is

recommended to close off areas used by the ill persons and wait as long as

practical before beginning cleaning and disinfection to minimize potential for

exposure to respiratory droplets. Open outside doors and windows to increase

air circulation in the area. If possible, wait up to 24 hours before beginning

cleaning and disinfection.

§ Cleaning

staff should clean and disinfect all areas (e.g., offices, bathrooms, and

common areas) used by the ill persons, focusing especially on frequently

touched surfaces.

§ To clean and

disinfect: If surfaces are dirty, they should be cleaned using a detergent or

soap and water prior to disinfection (Note: “cleaning” will remove some germs,

but “disinfection” is also necessary).

§ For

disinfection, diluted household bleach solutions, alcohol solutions with at

least 70% alcohol, and most common EPA-registered household disinfectants

should be effective.

§ Diluted

household bleach solutions can be used if appropriate for the surface. Follow

manufacturer’s instructions for application and proper ventilation. Check to

ensure the product is not past its expiration date. Never mix household bleach

with ammonia or any other cleanser. Unexpired household bleach will be effective

against coronaviruses when properly diluted.

§ Cleaning

staff should wear disposable gloves and gowns for all tasks in the cleaning

process, including handling trash.

§ Gloves and

gowns should be compatible with the disinfectant products being used.

§ Additional

PPE might be required based on the cleaning/disinfectant products being used

and whether there is a risk of splash. Follow the manufacturer’s instructions

regarding other protective measures recommended on the product labeling.

§ Gloves and

gowns should be removed carefully to avoid contamination of the wearer and the

surrounding area. Be sure to clean hands after removing gloves.

§ Employers

should develop policies for worker protection and provide training to all

cleaning staff on site prior to providing cleaning tasks. Training should

include when to use PPE, what PPE is necessary, how to properly don (put on),

use, and doff (take off ) PPE, and how to properly dispose of PPE.

§ If you

require gloves or masks or other PPE, prepare a simple half-page Job Safety

Analysis (JSA): list the hazards and the PPE (gloves, masks, etc., as needed),

and the person who drafts the JSA should sign and date it.

§ The CDC

provides that the employees who worked closely to the infected worker should be

instructed to proceed based on the CDC Public Health Recommendations for

Community-Related Exposure. This includes staying home until 14 days after last

exposure, maintaining social distance from others, and self-monitoring for

symptoms (i.e., fever, cough, or shortness of breath).

§ How long

should the employees who worked near the employee stay at home? Those employees

should first consult and follow the advice of their healthcare providers or

public health department regarding the length of time to stay at home. The CDC

recommends that those who have had close contact for a prolonged period of time

with an infected person should remain at home for 14 days after last exposure.

If they develop symptoms, they should remain home for at least seven days from

the initial onset of the symptoms, three days without a fever (achieved without

medication), and improvement in respiratory symptoms (e.g., cough, shortness of

breath).

§ We also

recommend you call your local public health official to see if they have

stricter guidance. That information may also be online, for example Los

Angeles County has its own rules about when employees should return to

work.

New guidance from the CDC as of

7/27/2020: Because PCR tests can remain positive long after an individual is no

longer infectious, proof of a negative test should not be required prior to

returning to the workplace after documented COVID infection. Rather, symptom-

or protocol-based criteria should be used in determining when an employee is

safe to return to the workplace.