Contextualizing “Essential Healthcare Providers” and “Essential Healthcare Services” during the COVID-19 Deluge

Physical distancing/Social Solidarity/Social Innovation

 

March 30, 2020

Dear Colleagues,

There has been tremendous confusion and misplacement of priorities surrounding the terms “essential healthcare” and “essential healthcare providers” during this time of COVID-19. Particularly, these surround whether licensed acupuncturists can and/or should be continuing to deliver care. Please read this note carefully in consideration of this:

1.     The determination of which professions are or are not “essential healthcare providers” is determined at the state level. In general, it would likely be valuable to be determined as such for many reasons. This is a separate issue, however, from whether to keep your doors open during the COVID-19 crisis.

2.     The issue at hand now is not at all about whether licensed acupuncturists are valued as a group, or if they are officially “essential healthcare providers”. Medical doctors are closing doors. Surgeries are being delayed. Dental procedures are being postponed. These providers are clearly “essential healthcare providers”, but they are not providing essential services in this context. This is not about “worth”, it is about patient safety. Whether a patient should be seen depends not on whether you are an “essential healthcare provider”, but rather on the nature of the condition to be treated as an “essential health care service”.

3.     An essential healthcare service should be considered from three points of view during the COVID-19 crisis:

a.     If the patient were not to receive the service, would that patient end up in the ER, hospital, or otherwise become endangered (e.g. increase opioid use or seeking) by not receiving care in the immediate time frame?

b.     Does the provider offering the care have the needed personal protective equipment (PPE) to minimize the risk of spread between provider and patient? If not, the service should not be provided at this time. For clear guidelines on PPE, please see https://www.cdc.gov/hai/prevent/ppe.html. The basics of PPE include:

i.     Masks
ii.     Eye protection
iii.     Gloves
iv.     Gowns

Please see Appendix A for more detail on precautionary measures.

c.     Should the provider offering the service have adequate PPE, would it be a better use of that equipment to donate it to front-line providers who are at known, imminent risk of exposure? If the PPE is to be used in the ambulatory clinic, it should be to save PPE that would otherwise be needed for the patient in the hospital setting. (I.e., the patient would go to the hospital and the same volume or more PPE would be needed in that setting.) Every use of PPE depletes the global supply.

4.     Regardless of whether a patient has an emergent condition which could lead to further harm or a trip to the hospital, patients should not be treated in the ambulatory setting if they have any signs of illness or fever, or other cold and flu-like symptoms. Patients should be prescreened prior to coming to the office, and if they have concerning signs should be seen in the ER or hospital rather in the ambulatory clinic setting. While silent carriers can be asymptomatic and can still convey disease, the ability to manage a silent carrier in the clinic is far easier than a patient who is sneezing and coughing, with rhinorrhea. It should be noted, EVERY patient and EVERY provider should be considered an infectious silent carrier, and universal precautions should always be observed.

5.     This level of “shut down” is particularly critical during this immediate timeframe to blunt the wave of patients all becoming ill simultaneously. It should not be understood as likely to stop coronavirus in its entirety. Medical institutions are overwhelmed already, and PPE and resources (e.g. ventilators) are running low. If fewer people get sick all at once, there will be better and safer-to-deliver care available, leading to much less morbidity and mortality. How big the tsunami of patients will be depends on our actions now. Picture the destruction a tsunami of water can bring, and you can understand the destruction a tsunami of coronavirus infections can yield.

Final thoughts: Every state is putting out different recommendations to providers as to who may treat and who may not. Some states have explicitly forbidden any practice, while others allow provider discretion. We recognize there is still an epidemic of pain, and an opioid crisis occurring, despite coronavirus. Considering the limited availability of PPE and ability to assure a safe treatment environment in almost every case, the ASA strongly recommends that acupuncturists close doors for in-person treatments during this crisis.” The economic burden this creates is profound, however this is also a critical moment in history. Please stay alert for economic relief options, and do all you can to provide telehealth services and teach patients to do as much self- care as humanly possible. We will get through this!

For more information on safeguards for practice, see https://www.asacu.org/2020/03/asa-covid-19-resource- page/ and https://www.asacu.org/2020/03/recommendations-for-licensed-acupuncturists/

In Health and Solidarity,

Your ASA Board of Directors

 


 

Appendix A

Checklist for seeing patients during the COVID-19 crisis:

  1. Non-essential visits from patients should very clearly be postponed, and group visits should be discontinued at present. The primary means of transmission of the coronaviruses is through close personal contact, especially among groups and in spaces that cannot be adequately cleaned and monitored. The more people that pass through your offices, the greater the chances that one will have coronavirus.
  2. ALL patients should be prescreened by phone, before they come to their appointments, for any signs of illness, and for travel or exposure risks as outlined by public health authorities. No patient should arrive at your clinic ill. If a patient is ill on prescreening, they should remain home or be sent to the hospital if illness is severe. Patients arriving at the office with acute illness should be sent home and not treated by the acupuncturist.
  3. All patients and providers should be considered “silent carriers”, and universal precautions should be employed.
  4. If the acupuncturist has any signs of illness, all patient visits should be cancelled. Patients seen in the last 14 days should be notified that they may have been exposed.
  5. In every possible case, counsel patients by phone or via an on-line platform regarding health maintenance, sick care, and use of herbal medicine, if you use herbs.
  6. Patients should be taken directly from the entryway to their treatment rooms. Avoid having patients congregate in the waiting areas. Patients can wait in their cars if they arrive early.
  7. Proper Personal Protective Equipment must be used with every patient. This includes masks (mouth/nose and eyes), gloves, and gowns.
  8. Disposable treatment table coverings should be used and discarded after each patient. This should include disposable pillowcase coverings with protective plastic.
  9. Stagger booking so that patients do not overlap, and wipe down any surfaces that may have been contacted during the visit with appropriate cleaning products, including bathroom facilities. High volume clinics need to decrease their volume if they cannot assure patient separation.
  10. Remove non-essential items that could be vectors for virus transmission from the waiting room, treatment rooms, and other common areas. Decreasing the number of points of contact for contaminants will decrease the risk of transmission and make cleaning procedures more effective. Detailed guidance on workplace preparedness can also be found from OSHA: https://www.osha.gov/Publications/OSHA3990.pdf
  11. Practitioners should change clothing upon arrival to the office, and remove work clothing prior to leaving the office. Shower upon returning home.


IN ALL CIRCUMSTANCES, OBSERVE THE BASICS!

● Avoid close contact and observe physical distancing.

● Avoid touching your eyes, nose, and mouth with unwashed hands.

● Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains 60%-90% alcohol if soap and water are not available. COVID-19 can transmit through both respiratory droplets and via stool, so careful handwashing is critical.

● Cover coughs and sneezes with a tissue, then throw it in the trash can. Cough or sneeze into your elbow and not your hand if you do not have a tissue available. If you contaminate your hand and then touch other objects, you will spread the virus.

Please note, this list is developing and subject to change. Other possible precautions may be advisable.