COVID-19 and Patient Safety in the Medical and Dental Office

In May 2023, the federal Public Health Emergency declaration for SARS-CoV-2 officially ended. Nonetheless, as we move forward into the sixth year with COVID-19, repercussions from the virus persist across the spectrum of healthcare. Medical and dental practices must continue to remain mindful of new variants, infection rates, vaccines, protocols, and resources within their community.

According to the CDC’s “COVID Data Tracker,” SARS-CoV-2 “is constantly changing and accumulating mutations in its genetic code over time. New variants of SARS-CoV-2 are expected to continue to emerge. Some variants will emerge and disappear, while others will emerge and continue to spread and may replace previous variants.” The rate of hospital admissions rises and falls in different regions as new variants manifest. The potential always exists for community transmission to surge and for hospital beds to be in short supply once again. For more variant information, follow the CDC’s updated recommendations in “Infection Control Guidance: SARS-CoV-2.”

Practices must also be aware that all three respiratory viruses—SARS-CoV-2, RSV, and the flu—may be seen within their office settings. Understanding the differences between the three viruses will help ensure a precise differential diagnosis. See our article “Flu, RSV, or COVID-19? Convergence of Three Viruses Creates Risk of Diagnostic Errors” for additional strategies.

As communities around the country face ongoing COVID-19 infections, what are the latest considerations for keeping patients and staff safe within medical and dental office settings? Consider the strategies presented in this guide.

Mask Requirements

The CDC lifted its recommendation for mandatory universal masking in all healthcare settings in September 2022. Except in rare circumstances, medical and dental practices followed suit. With the recent rise of highly mutated COVID-19 variants, some facilities reinstated mandatory masking based on local transmission rates. (Check the CDC’s “COVID Data Tracker” for the status of variant ratios in the United States.) With the potential for newer variants to lead to a significant wave of COVID-19 over the next year, medical and dental practices should remain attentive to infection rates within their local jurisdiction.

If masking is required in your community or clinical setting, practice staff who make in-office patient appointments will need to communicate patient expectations to follow established infection-control protocols prior to the patient’s arrival in the office. It is also important to post signage on the entrance door and on the website.

For patients who are sick, immunocompromised, and in close proximity to one another, wearing masks continues to be clinically prudent. Have masks available for these patients.

Managing the Unvaccinated

According to the CDC’s “COVID Data Tracker,” vaccination rates across the U.S. have slowed over the past year as restrictions were lifted. (See the CDC’s weekly “COVID-19, flu, and RSV vaccination dashboards.”)

Many practices continue to ask, “How do we handle our unvaccinated patients?” While some read “unvaccinated” as shorthand for “antivaccine” or “against the COVID-19 vaccine,” in fact, the unvaccinated population includes adults and children with certain medical conditions, as well as infants not yet eligible for a COVID-19 vaccine. Admittedly, however, most practitioner questions about unvaccinated patients pertain to those who are eligible for a COVID-19 vaccine but have declined it for various reasons. Many parents with young children and adolescents, for example, fail to seek the vaccine due to its novelty.

Assess why a patient is not vaccinated and document the reason in the patient record. Patients who are members of certain religious communities may decline a vaccine on those grounds. Others may decline the vaccine due to concerns about its efficacy, common side effects, and potential adverse events.

Should there be a surge in community transmission rates, and depending on the medical or dental specialty and patient type, practices might consider maintaining the office policies and practices for infection control that were in effect before vaccinations became available. These include the use of telehealth, curbside visits, pre-examination questions and screening, masking by patients and staff, physical distancing, and disinfecting patient care areas frequently. Another option is designating one exam room only for the treatment of unvaccinated patients by fully vaccinated clinicians wearing personal protective equipment (PPE), while maintaining rigorous screening for patients entering the facility.

Alternatively, unvaccinated patients might be seen only during certain hours, such as at the beginning or end of the day. It is not recommended that practices follow a blanket policy of refusing to see unvaccinated patients. Always evaluate patients individually for risk, acuity, and treatment options.

Vaccine Considerations

The following recommendations will assist in vaccine administration and management:

• Updated Vaccines: The FDA approved the 2024–2025 mRNA COVID-19 vaccine on August 22, 2024, and the Novavax COVID-19 vaccine, adjuvanted (2024–2025) on August 30, 2024. For vaccine-specific information, including dosing, see the CDC’s “COVID-19 Vaccine Safety” and “Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States.”
• Informed Decision Making: Medical and dental practices should implement plans to educate patients and guide them to an informed decision about the vaccines available within their community. Vaccine fact sheets for recipients and caregivers are available through the FDA website. The CDC also provides easy-to-understand information for patients on its website: “Benefits of Getting Vaccinated” and “Myths & Facts About COVID-19 Vaccines.”
• Vaccine Administration: If your practice administers COVID-19 vaccines, establish policies and procedures for storage and inventory, patient screening and scheduling, patient education, documentation, patient follow-up, and managing medication errors and emergencies. The CDC provides guidance on vaccine administration, vaccine storage and handling, and COVID-19 vaccination training programs and reference materials for healthcare professionals, as does the World Health Organization (WHO) through its online training.
• Reimbursement: See the Health Resources and Services Administration’s “COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured.”

Ongoing Screening and Management

The following recommendations will assist in ongoing screening and management of suspected COVID-19 patients in your practice:

• Legislation and Guidance: Reference the CDC, your state licensing board, professional societies, and federal, state, and local authorities for public health guidance and new legislation. Monitor for outbreaks of COVID-19 cases within your community. Stay on top of current trends to protect your patients and your practice.
• Infection Control Protocols for the Office Setting: Per the CDC, the updated “Infection Control Guidance: SARS-CoV-2” provides specific instructions for healthcare facilities and healthcare settings (medical and dental).
• Screening Criteria: Follow the CDC’s screening process for those entering your office setting: “CDC Facilities COVID-19 Screening” (paper form). Assess visitors to your facility for symptoms and contact exposure and direct them to remain outside if COVID-19 infection is suspected.
• Differentiating Between the Flu, RSV, and COVID-19: The flu, RSV, and COVID-19 are all respiratory illnesses that can present with similar symptoms. For further guidance, see our article “Flu, RSV, or COVID-19? Convergence of Three Viruses Creates Risk of Diagnostic Errors.” Check the CDC’s “Respiratory Illnesses Data Channel” to view community trends for these three viruses.
• Accepting Patients: It is strongly recommended that practices not turn away patients who are not fully vaccinated or simply because a patient calls with acute respiratory symptoms. Triage all patients over the phone or via telemedicine and manage them according to CDC recommendations. Refusing assessment/care may lead to concerns of patient abandonment.
• Telehealth Triage: For communities with high transmission rates, the CDC recommends alternatives to face-to-face triage and visits, particularly for high-risk patients, if screening can take place over the phone, via telemedicine, through patient portals or online self-assessment tools, or through a designated external triage station. Licensed staff should be trained in triage protocol to determine which patients can be managed safely at home versus those who need to be seen at the office or at a designated community facility. The Doctors Company offers resources on telehealth. For a list of telehealth COVID-19 rules by state, see the Federation of State Medical Boards (FSMB) document, “U.S. States and Territories Modifying Requirements for Telehealth in Response to COVID-19.”
• Designated Triage Location: To limit exposure in your facility should transmission levels become very high, check with your local public health authorities for locations designated to triage suspected patients. Community emergency preparedness plans would be activated so that parties are coordinating efforts to deliver effective public health intervention.
• Patient Testing: Medical and dental practitioners should determine which patients require testing based on presenting symptoms, history, contact exposure, community transmission of disease, and for early identification in special settings (such as nursing home admission or elective surgery). See the CDC’s “Testing for COVID-19.” Reporting COVID cases is no longer mandatory in most locations except under certain circumstances, such as work-related transmission under the Occupational Safety and Health Administration (OSHA). Check with your local health department and the CDC website for current requirements.
• Elective Services: If cases of COVID-19 trend significantly upward within your community, check with regional health authorities on the provision of nonessential and elective healthcare visits and group-related activities. States and counties vary depending on the number of cases, availability of PPE, and availability of hospital beds. Some states may reinstate restrictions on the provision of nonurgent, elective surgeries and procedures. (See the FSMB’s “COVID-related Legislation.”) In some states, violations may result in fines or complaints to the medical or dental board. Check with state and local regulatory agencies for any related mandates.
• Office Messaging: If local transmission rates become high, screen patients prior to visits using screening questionnaires via texts and/or emails. For those exhibiting symptoms of COVID-19, consider scheduling a telehealth visit. Post entry-door signage requiring patients and visitors who are exhibiting COVID-19 symptoms or who have had recent contact exposure to immediately notify facility personnel by telephone for instructions on accessing care. (See the CDC’s “Symptoms of COVID-19.”) Include information on the practice website regarding office policies for appointments, telephone assessment/telemedicine, and visitors. Also, post COVID-19 resources for patients with a reminder to maintain physical distance, wear a face mask if exhibiting symptoms of cough, and follow local orders to lessen community spread.
• Physical Distancing: The CDC continues to recommend physical distancing to lessen the transmission of respiratory viruses. Encourage patients and staff to sit at least six feet or more apart and reconfigure seating as needed.
• Limit Exposure: Limit staff exposure to suspected COVID-19 patients by keeping the exam room door closed. Ideally, the designated exam room should be at the back of the office, away from other staff and patients. Only vaccinated employees should interact with these patients to avoid workplace transmission.
• Surface Disinfection: Disinfect surfaces once the patient exits the room. Ensure that participating staff members continue to wear PPE. For information about cleaning agents, see the Environmental Protection Agency’s “About List N: Disinfectants for Coronavirus (COVID-19).”
• Dental Office Considerations: The CDC’s latest recommendations apply to all healthcare settings, including dentistry. Continue to screen patients for coronavirus symptoms and postpone nonurgent dental care if the patient has tested positive at home or is symptomatic for COVID-19. Urgent febrile patients may be seen if the fever is suspected to be due to a dental condition, but the dentist should make this determination. Continue to follow the most current PPE guidelines as defined by the CDC and OSHA. Periodically review state health department COVID-19 guidance and county infection rates. Devices such as ultrasonic scalers, high-speed dental handpieces, and air/water syringes produce aerosols during use, creating additional exposure risk for clinicians. The CDC recommends additional precautions, such as four-handed dentistry, high-evacuation suction, and the use of dental dams during these procedures to reduce the risk of droplets. Participating staff should wear NIOSH-approved N95 masks or higher-level respirators in areas with high rates of coronavirus transmission. Review the CDC’s “Best Practices in Dental Infection Prevention and Control.”
• Patient Education: Refer to CDC resources for providing suspected COVID-19 patients and their close contacts with up-to-date information about the virus. Provide information about how to follow infection-control practices at home, such as in-home isolation and quarantine, hand hygiene, cough etiquette, waste disposal, and the use of masks. Remind patients and their families to access information about the virus through reputable sources such as the CDC, not through social media.
• Provider/Staff Exposure: Encourage vaccination among your staff and screening for symptoms/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed, monitored, and documented in administrative files. See the CDC’s “Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2,” which also outlines return to work criteria for healthcare personnel who were exposed to individuals with confirmed SARS-CoV-2 infection. Per OSHA, COVID-19 can be a recordable workplace illness if an employee is infected because of performing work-related duties.
• Staff Training: Assess the need for additional staff training to review screening and triage protocols, patient management, use of PPE, patient communications, and any revision in policies and procedures that have been made to adapt to the evolution of the virus. Document all training provided to staff and maintain records in administrative files.
• Team Briefs: Conduct daily staff briefs/huddles and end-of-day debriefs. These provide all staff with opportunities to discuss issues anticipated during the day and identify concerns, pre- and post-clinic, including COVID-19 updates. (See the Agency for Healthcare Research and Quality’s TeamSTEPPS® tools.)

Administrative Recordkeeping

Document administrative records of community transmission rates, current protocols, and updated policies followed by your office. Content may include records of PPE supplies/shortages, cleaning protocols followed, communications with patients, case incidence, and available medical and dental resources within your community. Documentation that you have taken steps to follow recommended infection-control protocols may be your best defense if litigation related to COVID-19 should occur in the future.

Managing Legal Risks

According to the WHO, the influx of variants in the U.S. will continue to present unique challenges. Government authorities in some states may mandate additional restrictions of public activities, while other states will likely maintain unrestricted business operations. Medical and dental offices will continue to face challenges as they provide “catch-up” care for patients who postponed care because of fears and they implement ongoing CDC recommendations for practice operations, vaccinations, and managing sick employees.

Liability becomes a concern for healthcare practitioners if treatment of patients without COVID-19 is delayed due to hospital and emergency room conditions. Invariably, the question becomes, “Did the hospital comply with community standards regarding access and delivery of services?” Following an adverse event—when plaintiff’s counsel would attempt to prove that the facility failed to follow what other similarly situated medical centers did in the same or similar situations—much would depend on whether the hospital complied with CDC guidelines and executive orders then in effect.

The bottom line: Even with the availability of the vaccine and lower transmission rates, medical and dental practices must not become complacent or be less vigilant. Because the virus continues to be a moving target, all healthcare practitioners and facilities must remain well-informed and current on public health guidance for screening protocols and patient management, as well as regulatory requirements affecting their practices. Continued careful screening of respiratory illness with a bias for suspicion that a patient might have COVID-19 will serve healthcare practitioners well. We emphasize that the key to future litigation defense is keeping office policies and procedures current while following recommended guidelines and documenting adherence (in both administrative files and medical and dental records).

The dynamics surrounding the virus will continue to evolve, particularly with the spread of variants and as the population’s vaccination status fluctuates. What does not change is that healthcare practitioners and care teams must remain watchful and adapt their practices accordingly. Remain exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as they become available from the CDC.

Additional Guidance

If you need help or have additional questions, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.