CHECKLIST AND RISK STRATIFICATION FOR OPENING OF INTERVENTIONAL PAIN MANAGEMENT PRACTICES

We hope this letter finds you well! Hopefully, you and your family stayed healthy during the lockdown and are now ready to get back to work. Before you do, there are some things you need to think about. This message will serve to give you some food for thought, so that when you get to work, you do it safely for your patients, staff and yourself. Thank you to Ricardo Buenaventura, MD for compiling these following steps to help the ASIPP members reopen their practices in a safe and efficient manner. 

Please check with your state's department of health and medical board regulations to make sure your office is in compliance with your local regulations.

There are several steps to take as you open your office to a full schedule, and range of procedures, during the coronavirus pandemic of 2020. Checklist

 1. Check with your state 

 First, check with your state for when you can resume normal medical office visits and medical/surgical procedures. In some states, medical offices were never shut down. Elective procedures were banned, and emergent cases could only proceed at the physician's discretion in almost all states. Elective procedures can now resume in phase I, with variable dates during May and June 2020, if the patient can be discharged the same day. 

 2. Prepare your office and staff for new safety measures

 Prepare your office for the new paradigm of social distancing and required use of PPE. Every staff member should be screened on a daily basis for signs of illness and their temperature should be checked and logged. In some states, a ban on mass gatherings of more than 10 people remains in place. Restructure the office to minimize clustering of staff at break areas and patients in the waiting room or check out areas. All business offices can open, but all employees in the offices need to wear masks in most states. There are no clear guidelines that mandate visitors or patients in a doctor's office or hospitals have to wear masks, but it would be prudent to encourage your patients to do so. Only patients should be allowed in your office; drivers and/or family members should not be allowed in the office. Of course, if the patient needs assistance from a family member or the patient is a minor, then one person may accompany them. Patients should be screened for signs of illness, asked about their travel history to any area where COVID-19 is highly prevalent (not just to China or other foreign hotspots), questioned about any loss of smell, and have their temperature checked. Ideally, screening is done outside the building or at the entrance, and any staff member doing the screening would be wearing a mask. Patients may use their own personal mask in your office but if they don't have one, you should provide one. During surgery, they have to wear surgical or N95 masks, in some states.

The office should be prepared for social distancing. The chairs in the waiting room should be spaced 6 feet apart and all excess chairs should be removed from the waiting room. All surfaces in the office that would be expected to come in contact with people should be wiped down at the start of the day, the middle of the day, and the end of the day. Any chair or table used by a patient should be wiped down after each use. The restrooms should be monitored, cleaned and wiped down after each use. Hand sanitizer is required in high traffic areas.

 Any work that can be done from home should be encouraged. This might include back office work such as accounting, bookkeeping, insurance authorizations and billing. Staff work hours could be staggered such that work that doesn't require the patient's presence can be done after clinic hours by staff coming in later in the day. Work stations in the office may need to be reconfigured to allow proper spacing between work staff. Telemedicine has gained much more acceptance and is now being used by most offices. This should be continued as offices open to a more regular schedule, as it will help to reduce patient traffic in offices.

 Make sure you have an adequate supply of PPE for all medical and clerical staff in the office and for patients. Expect greater utilization of PPE than before due to increased use by staff and patients. You will need to maintain an adequate stock to remain open and be in compliance with Ohio Department of Health (ODH) recommendations. Each office will have to decide on the type of masks their staff will wear and whether face shields are needed.

 3. Organize scheduling and maximize telemedicine

 Telemedicine was encouraged by the US Government as a way to continue caring for the US population during this pandemic without exposing the patients or healthcare workers to the coronavirus. Just because the country is slowly opening up does not mean the virus is no longer a risk. Telemedicine involves communication with a patient who is not physically in the same room with the provider. The providers and patients who have used it have found it to be a nice way of delivering healthcare in the comfort of their own homes. Patients at home or work can take 15 minutes to do a follow up on the phone with the provider, rather than drive across town for a visit. We should continue to offer telemedicine for these reasons.

Right now, because of a waiver, the reimbursements for telemedicine visits that utilize audio or audiovisual communication can receive the same reimbursement. It is uncertain if this will continue after the waiver period ends, whenever this public health emergency is over. Until then, we should incorporate telemedicine to the fullest in our offices to take advantage of its benefits in terms of social distancing, safety and convenience to the patients and healthcare providers.

If patients will be brought to the office, then scheduled appointments will have to be spaced further apart so that social distancing can be accommodated in the office at least during Phase I and II. When they are checked out this should be done in a way that also minimizes patient crowding. The patient should also be allowed to leave the office quickly and then the follow up visit can be scheduled later over the telephone or by email. During pre-appointment reminder calls, patients should be pre-screened, notified of new in-office measures and encouraged to wear personal masks to their office visit. 

 You may also want to consider the risks of performing interventional pain procedures based on the patient's age, medical history, physical condition and residence status (i.e. nursing home, assisted living). The attached American Society of Interventional Pain Physicians (ASIPP) toolkit contains recommendations on risk stratification. http://www.asipp.org/asipp-updates/changes-to-risk-stratification-documents

 4. Testing

Rules are highly variable for each state. Please look at the Department of Health posting.

If a patient is asymptomatic and has not had a reason to be tested for coronavirus before, what do you do? If the patient is coming in for a routine visit, then routine screening, including a temperature check, should suffice.

 For IPM procedures in awake patients where the airway, face and neck are not involved, testing may not be necessary if they are asymptomatic and pass all standard coronavirus screenings, including temperature checks. Risk Stratification

 If a person has a history of a positive coronavirus test, elective procedures should be delayed until the patient is considered no longer infectious and has recovered. The CDC uses both test-based and non-test based strategies. 

  • Test-based strategy
    1. No fever without use of fever-reducing medicines.
    2. Improvement of respiratory symptoms.
    3. Negative results from two SARS-CoV-2 tests >= 24 hours apart.
  • Non-test-based strategy
    • A fever for 72 hours without use of fever-reducing medicines.
    • At least 7 days since the symptoms first appeared.

5. Risk Disclosure

Finally, as you open your offices, you should consider the use of a risk disclosure to explain the risks to your patients in this uncertain time. The risk disclosure should discuss the risks of leaving the safety of their own home to seek medical care and receiving medical treatments that might alter their response to the coronavirus should they get it (i.e., their infection may be more severe). An example risk disclosure can be found in the link below to the ASIPP toolkit for restarting your practice after the recent COVID-19 shutdown. http://www.asipp.org/asipp-updates/changes-to-risk-stratification-documents

American Society of Interventional Pain Physicians and Society of Interventional Pain Management Surgery Centers is committed to advocating for our patients and physicians, and we hope to continue to stay in touch with you throughout the year, specifically in May.

Specifically on May 28, Medicare will hold a meeting to create a NCD (National Coverage Designation) for Facet Blocks. It is important that the Medicare CAC members from your states attend, and more important that your state IPP provides public comment afterwards. Any questions on this issue, please contact Amol Soin, President-Elect, who will be in charge of this effort.

Dr. Amol Soin, President-Elect of ASIPP, is reaching out to each state society president to help facilitate more regional/state engagement this year. We want to enhance outreach to all members of the ASIPP society this year and look forward to more outreach in the coming months.

If you have any questions, please feel free to contact us.

Laxmaiah Manchikanti, MD
Chairman of the Board and Chief Executive Officer, ASIPP, SIPMS
Co-Director, Pain Management Centers of America
Medical Director, Pain Management Centers of Paducah and Marion,
Ambulatory Surgery Center and Pain Care Surgery Center
Clinical Professor, Anesthesiology and Perioperative Medicine
University of Louisville, Kentucky
Professor of Anesthesiology-Research
Department of Anesthesiology, School of Medicine
LSU Health Sciences Center
2831 Lone Oak Road
Paducah, KY 42003
270-554-8373 ext. 4101
[email protected]

Amol Soin, MD
President-Elect, ASIPP
President, SIPMS
Ohio Pain Clinic
8934 Kingsridge Drive, Suite 101
Centerville, OH 45458
937-760-7246
[email protected]

Reopening the Office Checklist and Links

  • Check with your state and local officials about reopening during the coronavirus pandemic. Checklist
  • Prepare your office before reopening

3. Incorporate social distancing in your office scheduling and incorporate telemedicine.

 4. Testing