COVID-19: Health Care Providers

Health care professionals are those responsible for treating and working with patients and families affected by COVID-19. This page houses information and resources for health care professionals responding to COVID-19. Recommendations will change as we move through Wisconsin’s roadmap to reopen using public health principles of testing, tracing, and tracking the new coronavirus to decrease COVID-19 cases and death.

Monitoring Resources

 

The Office of Civil Rights at the Department of Health and Human Services released a Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19) to ensure compliance with the American with Disabilities Act.

Physical health and safety guidance

 Reporting and surveillance guidance

The state epidemiologist declared COVID-19 a Category I reportable disease per a memo issued on Feb. 4, 2020. Health care providers and laboratories must report confirmed or suspected cases to the Department of Health Services (DHS) within 24 hours of detection.

  • To relieve the reporting burden, DHS waived the requirement (April 6 Memo) for notifying local health departments by telephone of suspected and confirmed cases as long as cases are reported to WEDSS.
  • Patients being tested using a molecular amplification test (e.g. PCR, NAAT) must be reported to public health as having a suspect case of COVID-19 while laboratory results are pending.
  • Positive and negative laboratory results from a molecular amplification test (e.g. PCR, NAAT) must be reported.
  • Only positive laboratory test results from a serologic test (antibody test) must be reported. Negative results do not need to be reported.
  • Patients being tested using a serologic test (antibody test) do not need to be reported until positive test results are received.
  • COVID-19 related hospitalizations and deaths are reportable in Wisconsin.

Reporting via WEDSS is strongly encouraged. In lieu of WEDSS reporting, the Wisconsin Patient Information Form can also be used to report to the patient’s local public health agency via fax.


COVID-19 surveillance case definition

NOTE: the COVID-19 Surveillance Case Definition is a set of uniform criteria used to define COVID-19 disease for public health surveillance, which enables public health officials to classify and count cases consistently across reporting jurisdictions. This surveillance case definition is not intended to be used by healthcare providers for making a clinical diagnosis, determining who should be tested for COVID-19, or determining how to meet an individual patient’s health needs.

Clinical description: People with confirmed COVID-19 infections (also known as SARS-CoV-2, nCoV) can have a wide range of symptoms, from mild to severe. Mild illness may include sore throat, headache, myalgia, fatigue and upper respiratory symptoms. Symptoms of more severe illness may include fever, cough and shortness of breath. Some people also have gastrointestinal symptoms including nausea, vomiting, or diarrhea. Infrequently people with COVID-19 may experience complications, such as pneumonia and acute respiratory distress syndrome (ARDS). Asymptomatic infections have also been reported.

Clinical criteria for surveillance
At least two of the following symptoms:

  • fever (measured or subjective), or chills or rigors
  • myalgia (muscle aches)
  • headache
  • sore throat
  • new olfactory or taste disorder(s) (e.g., loss of sense of smell or taste)

OR
At least one of the following symptoms:

  • cough
  • shortness of breath
  • difficulty breathing

OR
Severe respiratory illness with at least one of the following:

  • clinical or radiographic evidence of pneumonia, or
  • Acute respiratory distress syndrome (ARDS).

AND
No alternative more likely diagnosis.


Laboratory evidence for surveillance

Confirmatory laboratory evidence:

  • Detection of SARS-CoV-2 RNA in a clinical specimen using a molecular amplification detection test (e.g. PCR, NAAT).

Presumptive laboratory evidence:

  • Detection of specific IgM, IgG or total antibody in serum, plasma, or whole blood indicative of a new or recent infection.*
    (*Serologic methods for diagnosis are currently being defined).
  • Detection of specific antigen in a clinical specimen.

Epidemiologic evidence for surveillance
Any one of the following exposures in the 14 days before onset of symptoms:

  • Close contact with a confirmed OR probable case of COVID-19 disease.
  • Member of a cluster of illnesses as defined by public health (risk cohort) where at least one confirmed case has been diagnosed (e.g. an outbreak-associated case).
  • Travel to or resides in an area with sustained, ongoing community transmission of SARS-CoV-2.

Surveillance case definitions for COVID-19

Confirmed case:
Confirmatory laboratory evidence, irrespective of clinical signs or symptoms.

Probable case:
An illness meeting the clinical criteria AND epidemiologic evidence without confirmatory laboratory evidence.

OR
Presumptive laboratory evidence AND either:

  • Clinical criteria OR
  • Epidemiologic evidence

OR
A death certificate that lists COVID-19 disease or SARS-CoV-2 as a cause of death or a significant condition contributing to death.

Suspect case:
An illness with clinically compatible symptoms of COVID-19 infection, for whom laboratory confirmation is pending, and who does not otherwise meet a probable case definition.

OR
Presumptive laboratory evidence without:

  • Clinical criteria OR
  • Epidemiologic evidence

OR
An illness meeting the clinical criteria reported to public health that does not meet a confirmed or probable case definition, and does not have a negative laboratory result for COVID-19.

 Testing

Health care providers are encouraged to obtain COVID-19 testing for all symptomatic patients, even patients with mild symptoms.

Widespread testing will serve an important public health purpose in the next phase of Wisconsin’s COVID-19 response. Testing, coupled with timely and thorough contact tracing, isolation and quarantine, will require close partnerships between clinicians and local public health agencies.

At this time, overall laboratory capacity in Wisconsin can support testing for patients in outpatient settings who have symptoms suggestive of COVID-19. In addition to the common presentations of fever, headache, cough, and shortness of breath, COVID-19 can also present as a mild, afebrile illness with symptoms including sore throat, myalgia, and alterations in the sense of taste or smell. We encourage all clinicians to test patients in the clinic and outpatient setting to reduce demand on hospitals and emergency departments.

Number of COVID-19 test results (positive or negative) and the percent positive, by day (last 14 days)

To facilitate rapid public health response and initiation of contact investigations, all patients with suspected COVID-19 infections must be reported to public health. This means patients with a pending molecular test should be reported to public health while laboratory results are pending. These tests are intended to diagnosis acute infections. Patients who have a pending test to detect antibodies do NOT need to be reported to public health while results are pending. However, positive antibody test results must be reported. In addition, COVID-19 related hospitalizations and deaths are reportable in Wisconsin. Reporting via WEDSS is strongly encouraged. In lieu of WEDSS reporting, the Wisconsin Patient Information form can be used to report to the patient’s local public health agency while results are pending.

Providers should educate patients who are being tested for an acute COVID-19 infection about how to properly isolate themselves and are encouraged to share DHS’s What should I do if I was tested for COVID-19 and am awaiting results? Providers should also educate patients who can't be tested to self-isolate at home, separated from household contacts, and share DHS’s What should I do if I am diagnosed with COVID-19?

All patients who are suspected of having COVID-19 should be reminded that their household and intimate contacts should self-quarantine for 14 days. Providers should report patients who they have diagnosed with COVID-19, but who are not being tested, to public health. These reports are important to the public health response and will help us to better understand the burden of disease.


Visit the DHS COVID-19: Wisconsin Summary Data for daily updates on the number of new cases and the number of tests performed. This webpage also provides daily updates on the statewide testing capacity.

 

Access to testing

While current capacity within the state exceeds the daily number of tests ordered, in some areas of the state access to testing is still limited. The WSLH COVID-19 webpage includes a list of Wisconsin reference laboratories that accept outside specimens for testing. These may be an option in addition to national reference labs.

To address shortages of specimen collection kits (swabs, transport media, etc.), DHS has emergency supplies available at no charge to qualifying Wisconsin clinicians, local and tribal health centers, clinical laboratories, and others collecting specimens in response to COVID-19. The supplies and laboratory services are available for testing symptomatic and asymptomatic individuals. Decisions to test asymptomatic persons should be informed by public health or clinical priorities for a facility or region. For more information about what is available and to make a request, visit the DHS COVID-19 Testing Supplies Request webpage.

Providers can also refer to CDC's Priorities for COVID-19 Testing (Nucleic Acid or Antigen) webpage for additional guidance on prioritization.

CDC priorities for COVID-19 testing using a nucleic acid or antigen test

High priority:

  • Hospitalized patients.
  • Healthcare facility workers, workers in congregate living settings, and first responders with symptoms.
  • Residents in long-term care facilities or other congregate living settings, including correctional and detention facilities and shelters, with symptoms.

Priority:

  • Persons with symptoms of a possible infection with COVID-19, including: fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat.
  • Persons without symptoms who are prioritized by health departments or clinicians, including but not limited to:  public health monitoring, sentinel surveillance, presence of underlying medical condition or disability, residency in a congregate housing setting such as a homeless shelter or long term care facility, or screening of other asymptomatic individuals according to state and local plans.
Testing at a public health laboratory

Wisconsin’s two public health labs testing for COVID-19, the Wisconsin State Laboratory of Hygiene (WSLH) and Milwaukee Health Department Laboratory (MHDL), have worked with DHS to develop a priority list for public health lab testing for COVID-19. This list is NOT intended for use by clinicians or clinical or commercial labs for determining testing priority in the community or in their facility.

To conserve resources for testing in public health labs, WSLH and MHDL are only testing samples for the following patients:

  • Hospitalized patients with COVID-19 symptoms.
  • Patients with COVID-19 symptoms for whom rapid diagnosis is needed to inform infection control practices (for example, labor and delivery, dialysis, aerosol-generating procedures).
  • Residents of a long-term care facility with COVID-19 symptoms.
  • Residents in a jail, prison, or other congregate setting with COVID-19 symptoms.
  • Health care workers or first responders (for example, fire, EMS, police) with COVID-19 symptoms.
  • Essential staff in high-consequence congregate settings (for example, prisons or jails) with COVID-19 symptoms.
  • Utility workers (water, sewer, gas, electric, power generation, distribution and production of raw materials; oil and biofuel refining) with COVID-19 symptoms.
  • Post-mortem testing for a person with COVID-19 symptoms prior to death OR who died of unknown causes AND where results would influence infection control interventions at a facility or information for a public health response.

Providers may send specimens to WSLH or MHDL only if they meet Wisconsin public health laboratory testing priorities listed above. If equivalent or more rapid turnaround is available through an in-house or commercial lab, providers are encouraged to use these other laboratory options.

Wisconsin’s patient information form MUST accompany the lab requisition form for specimens submitted to WSLH or MHDL.

Testing for patients who do not meet one of the Wisconsin public health laboratory priorities listed above, but for whom testing is requested by a provider, should have their specimen submitted to in-house, commercial, or reference labs for testing.

Responses to common questions about testing

Are serology (antibody test) results for SARS-CoV-2 also reportable?

Yes, providers should report patients with POSITIVE serology results to WEDSS once the positive laboratory results are received.

Where should I send specimens?

Many commercial and clinical labs are now performing COVID-19 testing. If your health system is performing large numbers of tests (such as drive-through testing sites, testing of ill health care workers), these specimens should be sent to commercial or in-house labs. Health plans have been asked to waive cost-sharing for COVID-19 laboratory and radiology testing. See the WSLH website for a list of Wisconsin reference labs accepting outside specimens.

How will we get patient results?

As with other testing, clinicians can expect results to be communicated directly from the lab. Please do not contact DHS or your local health department for test results.

How will my patient get their results?

As with other testing, clinicians should share test results with patients directly. Please do NOT tell patients to contact their local health department or DHS for test results, or updates on the status of their testing.

What are other testing considerations?

  • Number of health care providers present during the procedure should be limited to those essential for patient care and procedure support. Visitors should not be present for specimen collection. Specimen collection should be performed in a normal examination room with the door closed.
  • A single nasopharyngeal (NP) swab is sufficient for testing. Specimen collection should be done by trained individuals.
  • The ordering provider is responsible for receiving COVID-19 test results from the laboratory and communicating the result to the patient.

 Caring for health care workers exposed or diagnosed with COVID-19

The following information reflects the most current recommendations for monitoring, excluding and return to work criteria for health care workers and was adapted from DHS HAN #1DHS HAN #2CDC Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19), and CDC’s Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19.

Who is considered a health care worker or health care personnel?

The following definition of health care workers (HCWs) is broader than the common use of the phrase. The following should not be used as an exhaustive list but instead is intended to provide examples of the broad range of activities and job responsibilities that should be included in the definition of healthcare worker for the purposes of responding to COVID-19. The definition should also not be restricted to employees of a facility or agency, but should also be applied to volunteers.

*HCWs include, but are not limited to: emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, dentists, laboratorians, students and trainees, aides, caregiver, others who provide care or services, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). This definition would also include workers who provide these services or serve these roles in a home or group health setting.

*Adapted from the CDC definition of a HCW.


Routine monitoring of healthcare workers

All health care organizations should develop and implement procedures for evaluating HCWs for symptoms of respiratory illness before every shift.

The purpose of monitoring is to identify illness early and encourage self-isolation at home to reduce the potential of transmission to co-workers and patients. Monitoring should include temperature checks and query for symptoms of COVID-19 like illness, which may include any of the following:

  • measured temperature >100.0F* (37.8C) or subjective fever
  • cough
  • shortness of breath or difficulty breathing
  • sore throat
  • myalgia
  • chills
  • repeated shaking with chills
  • headache
  • new loss of taste or smell

*CDC recommends fever cutoffs that are different in its guidance for the health care workers. This is done to recognize illness early.

COVID-19 may present as a spectrum of illness ranging from mild to severe symptoms. Employers should develop protocols to triage and address these situations.

Monitoring may be performed by designated staff at the facility or by HCWs, themselves, with allowances for documentation of the symptoms screen to supervisors (e.g. via text, email or other methods). HCWs should be evaluated before every shift. Those who develop symptoms while at work should be instructed to don a face mask, notify their supervisor, and leave work for the day. HCWs reporting symptoms consistent with COVID-19 like illness should be tested.


Testing, isolation and quarantine for healthcare workers

Health care workers who are ill

HCWs should not report to work when ill. This includes illnesses with only mild symptoms that would not normally cause them to miss work. Employers should reinforce this message and should explore available resources for back-up coverage. Employers should evaluate existing sick leave policies to ensure they do not pose unnecessary burdens on essential staff who must miss work due to illness. Any HCW reporting COVID-19 like symptoms, regardless of severity, should be prioritized for testing.

HCWs with suspected or confirmed** COVID-19 should be excluded from work and should follow the same self-isolation and self-monitoring guidelines as others diagnosed with COVID-19 to avoid transmission COVID-19 to household or community members and to identify any new or worsening symptoms that may require medical attention.

**Suspected COVID-19 refers to any individual with an illness consistent with COVID-19, with or without a known exposure. Confirmed COVID-19 refers to any individual with or without symptoms, who has a positive result of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from a clinical specimen.


Return to work criteria for health care workers with suspected or confirmed COVID-19

  • Symptomatic HCWs with suspected or confirmed COVID-19 should be excluded from work until:

Symptom-based strategy

  • At least 10 days have passed since symptoms first appeared, AND
  • At least 3 days have passed since recovery. Recovery is defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath)

OR

Test-based strategy

  • Resolution of fever without the use of fever-reducing medications, AND
  • Improvement in respiratory symptoms (e.g., cough, shortness of breath), AND
  • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). See CDC’s Interim Guidance for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus. NOTE: There have been reports of prolonged detection of RNA via PCR without direct correlation to viral culture (i.e., detecting viral RNA via PCR does not necessarily mean that infectious virus is present).
  • Asymptomatic HCWs with lab-confirmed COVID-19 should be excluded from work until:

Time-based strategy

  • 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms. NOTE: since symptoms cannot be used to gauge where these individuals are in the course of their infection, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test. 

OR

Test-based strategy

  • Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). See CDC’s Interim Guidance for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus. NOTE: since symptoms are not present, it is not possible to gauge where these individuals are in the course of their infection. There have been reports of prolonged detection of RNA via PCR without direct correlation to viral culture (i.e., detecting viral RNA via PCR does not necessarily mean that infectious virus is present).
  • If a symptomatic HCW tests negative for COVID-19, they may return to work after the illness has resolved following their employer’s return to work policy. DHS recommends minimally the HCW be afebrile and free of other acute symptoms of their illness for at least 24 hours.
  • If testing was not performed, and the HCW had a mild, afebrile illness with an alternate explanatory diagnosis AND no known exposure, they may return to work following their employer’s return to work policy and after the illness has resolved. We recommend minimally the HCW be afebrile and free of other acute symptoms of their illness for at least 24 hours.

Return to work practices and work restrictions

After returning to work, all HCWs previously excluded from work due to suspected or confirmed COVID-19 should:

Wear a facemask for source control at all times while in the health care facility until all symptoms are completely resolved or at baseline. A facemask instead of a cloth face covering should be used by these HCWs for source control during this time period while in the facility. After this time period, these HCW should revert to their facility policy regarding universal source control during the pandemic.

  • A facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated, including when caring for patients with suspected or confirmed COVID-19.
  • Of note, N95 or other respirators with an exhaust valve might not provide source control.

Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.


Exclusion of health care workers with a known close contact to a COVID-19 case

The CDC published Interim Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 providing a framework for assessing the risk of COVID-19 based on different types of exposures in healthcare settings. Recommendations for excluding staff from work depend on whether the exposure is considered high, medium, or low-risk. In general, HCWs with medium and high-risk exposure should be excluded from work for 14 days, during which they should monitor for symptoms and/or fever in coordination with their local health department. If any HCW reports symptoms during this 14 day period, they should be prioritized for COVID-19 testing (see above for guidance of return to work).

For health Care facilities that would suffer significant staffing shortages compromising their ability to adequately care for patients, HCWs with medium-risk exposures may continue to see patients if they:

  • Wear appropriate personal protective equipment (PPE), AND
  • Complete a daily check of symptoms, prior to the start of their shift, in coordination with their employee health department. 

Decisions to allow exposed HCWs to continue to work while asymptomatic should be made after a systematic review of the facility’s staffing and other resources. Facilities are encouraged to continue to exclude exposed staff when possible. Communication and coordination with the facility’s local health department is important.

DHS does not recommend requiring a negative COVID-19 test prior to returning to work for asymptomatic HCWs.

Exposure Risk Level

Recommended exclusion

Recommended exclusion during staffing shortage

High

14 days

14 days if feasible

Medium

14 days

None, but must wear PPE during patient care activities

Low

None

None

References

 Vaccine

Multiple candidate COVID-19 vaccines are currently under development (see a regularly updated list of in-development therapeutic and vaccine candidates) and an Advisory Committee on Immunization Practices (ACIP) COVID-19 vaccine work group is about to be initiated to help inform ACIP’s recommendations on potential use of COVID-19 vaccines in the U.S.

 Isolation and quarantine guidance

Guidance for local health department enforcement of quarantine

When possible, DHS recommends voluntary quarantine or isolation. If there is reason to believe that an individual may not voluntarily abide by quarantine or isolation recommendations, the LHD should evaluate the individual’s circumstances that make nonadherence likely, and provide linkages to available resources that can support quarantine at home.

These may include:

  • Food delivery
  • Social support
  • Telehealth/information resources
  • Mental health resources

If individuals demonstrate they are unwilling to voluntarily isolate, the LHD may have to issue a quarantine/isolation order. The quarantine/isolation order should be issued in writing. If the person fails to comply, the LHD may petition a court to order compliance. The LHD must prove by clear and convincing evidence that the directive is the least restrictive measure that will protect the public’s health.

The LHD may employ quarantine guards if intent to violate a quarantine order is shown. Typically, the LHD employs local law enforcement. The quarantine guards have police powers to use all necessary means to enforce the quarantine. The costs of the quarantine guards are the responsibility of the county or municipality. During a state of emergency, if the person is quarantined outside their home, those costs may be reimbursable by the state. If necessary, the LHD can remove a person to a separate place for quarantine/isolation if removal would not endanger the person’s health.

Anyone who enters a quarantine/isolation premises without authorization is subject to a fine not to exceed $10,000 or nine months in jail, or both. Anyone who willfully violates laws relating to public health may be subject to 30 days in jail or fined not more than $500, or both. DHS has a toolkit of legal forms to assist LHDs with quarantine/isolation enforcement issues.

 Memos issued by DHS

Below is a listing of all memos issued by DHS containing guidance for COVID-19.

Official Number Description Issue Date Attachments Obsolete Date
20-009
Licensure/Certification Application for Temporary Assisted Living Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency State May 29, 2020
BCD 2020-18
Guidance to Coroners and Medical Examiners on Postmortem COVID-19 Testing at the Wisconsin State Laboratory of Hygiene and the Milwaukee Health Department Laboratory May 29, 2020
2020-09 Action
Applications for Awards to Address Behavioral Health Needs Arising from the COVID-19 Pandemic May 19, 2020
20-008
State Licensure Application for Temporary Nursing Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency May 1, 2020
20-006
Use of Remote Support Providers in Regulated Adult Family Homes April 24, 2020
20-007
Wisconsin Home Health Agencies – CMS 1135 Waiver Provisions and Governor Evers Emergency Order # 21 April 24, 2020
20-004
Wisconsin Nursing Homes – CMS 1135 Waiver Provisions and Governor Evers Executive Order # 21 April 16, 2020
20-005
Guidance for Ambulatory Surgical Centers Temporarily Enrolling as a Hospital During the COVID-19 Public Health Emergency April 16, 2020
20-003
Wisconsin Hospices CMS 1135 Waiver Provisions and Governor Evers Emergency Order # 21 April 8, 2020
20-002
CMS 1135 Waiver Provisions – Wisconsin Hospitals April 6, 2020
BCD 2020-17
Changes to COVID-19 Reporting Requirements for Wisconsin Hospitals and Health Departments April 6, 2020
20-001
State Licensure Application for Temporary Expansion Locations during Public Health Emergency related to COVID-19 April 3, 2020
2020-04
Minimum Contact Standards for Support and Service Coordination: New Requirements Necessitated by the Novel Coronavirus (COVID-19) Pandemic April 2, 2020
BCD 2020-14
Information for Dental Health Care Professionals (DHCP): What You Need to Know about Coronavirus Disease (COVID-19) March 20, 2020
BCD 2020-15
Important Information for Recipients of Personal Protective Equipment (PPE) from the Strategic National Stockpile (SNS) March 20, 2020
BCD 2020-16
Important Guidance for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) (REVISED) in Long-Term Care Facilities and Assisted Living Facilities March 20, 2020
BCD 2020-12
Updated guidance for local health departments and government partners about home isolation and quarantine for COVID-19 March 19, 2020
BCD 2020-13
What to do if someone breaks quarantine: Guidance for Local Health Departments (LHDs) March 19, 2020
BCD 2020-10
Ryan White Part B and Life Care Services Emergency Financial Assistance Policy in Response to COVID-19 March 18, 2020
BCD 2020-11
Adult/Juvenile Correctional Facilities, Local Jails, and Secure Treatment Centers in Wisconsin Guidance for Coronavirus Disease 2019 (COVID-19) March 18, 2020
BCD 2020-09
Urgent Update – Prioritization of COVID-19 Testing for Hospitalized Patients March 17, 2020
BCD 2020-07
Important Recommendations for Prevention of COVID-19 in Long-Term Care Facilities and Assisted Living Facilities March 13, 2020
March 20, 2020
BCD 2020-08
Public Health Guidance for Discontinuation of Home Isolation and Voluntary Home Quarantine for Individuals Infected with or Exposed to COVID-19 March 13, 2020
BCD 2020-04
Coronavirus Disease 2019 (COVID-19) Update: Recommendations on Domestic and International Travel March 12, 2020
BCD 2020-05
New Mass Gathering Guidance for Novel Coronavirus (COVID-19) March 12, 2020
March 19, 2020
BCD 2020-06
Updated Guidance on Infection Control during Specimen Collection for COVID-19 in Outpatient Settings March 12, 2020
EMS 20-02
Interim Guidance for Emergency Medical Services (EMS) Systems, Practitioners and Public Safety Answering Points (PSAPs) Regarding COVID-19 March 12, 2020
BCD 2020-03
Updates to COVID-19 Testing Procedures March 9, 2020
March 19, 2020
BCD 2020-02
New Requirements for Reporting Cases and Patients Under Investigation for COVID-19 February 4, 2020
EMS 20-01
Interim Guidance for Emergency Medical Service (EMS) Providers in Wisconsin Regarding COVID-19 Associated with the Outbreak in Wuhan, China January 31, 2020

 Dental health care professionals guidance

Dental Health Care Interim Recommendations – Return to Work

Dental Office/Practice Preparation

The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) recognize that the practice of dentistry presents unique challenges when working in our current COVID-19 environment. Both organizations also acknowledge that individuals have and will continue to have a need for dental services during this time. The following recommendations build on existing guidance from CDC, OSHA, and the American Dental Association (ADA) to keep dental health care personnel (DHCP) and patients safe while meeting urgent needs.

In thinking about moving beyond emergent and urgent procedures – returning to work – it is imperative to proceed with caution and informed judgment, considering the context of the environment where you work and the community where you live. It is essential to avoid advancing to routine procedures too quickly and ensuring that all the necessary Personal Protective Equipment (PPE), environmental controls, and workplace precautions recommended by the CDC, OSHA, ADA, and other national organizations are in place.

Each dental office/practice should create a COVID-19 policy and procedures re-opening plan and provide training to all DHCP prior to seeing patients. Offices/practices should check with their malpractice carrier to determine if a revised informed consent form is needed. For more detailed recommendations on returning to work, refer to the ADA Return to Work Interim Guidance Toolkit. Dental offices/practices should also review the general guidelines for businesses issued by the Wisconsin Economic Development Corporation.

DHCP/Staff

  • All DHCP should self-monitor by remaining alert to symptoms of COVID-19, including cough, shortness of breath, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. This list is not all inclusive.
  • DHCP experiencing the above symptoms should not report to work. They should consider contacting their medical provider.
  • DHCP should have their temperature checked with a touchless thermometer before beginning every shift using current CDC protocols. DHCP with a temperature over 100.0*F or who develop COVID-19 symptoms at work should return home. If you identify multiple DHCP who are ill and have worked closely together, contact your local health department for guidance.
  • DHCP should be trained in all new policies and procedures, with a special focus on the use and removal of PPE.
  • If a worker becomes sick with COVID-19, employers should contact their local health department to discuss the appropriate management of potentially exposed employees, in addition to cleaning and disinfecting.

PPE

DHCP SHOULD FOLLOW CDC AND OSHA UPDATED GUIDELINES REGARDING STANDARD AND TRANSMISSION-BASED PRECAUTIONS AND PERSONAL PROTECTIVE EQUIPMENT AT ALL TIMES.

  • Only dental offices/practices with appropriate and sufficient PPE for all DHCP should consider slowly resuming urgent procedures that are necessary to prevent the development of dental emergencies.
  • The CDC and OSHA recommend the following as essential for keeping DHCP safe while addressing the needs of dental patients.
    • N95 respirators, required for aerosol-generating procedures; if not available, use surgical mask and full-face shield. Respirators must be used in the context of a complete respiratory protection program in accordance with OSHA standards.
    • Surgical masks (Level 3 if available)
    • Face shields (recommended for aerosol and non-aerosol procedures at this time)
    • Goggles
    • Gloves
    • Gowns
    • Cloth face coverings, only for non-patient and administrative staff
  • Conduct an inventory of all available PPE supplies needed for all in-office procedures; assume that supply sources maybe unpredictable and inconsistent for the near future.
  • To address asymptomatic and pre-symptomatic transmission, implement source control (require facemasks or cloth face coverings) for everyone entering the dental setting (patients, and required companions), regardless of whether they have COVID-19 symptoms.
  •  DHCP should wear a facemask at all times while they are in the dental setting.
  • Refer to the CDC and the ADA websites for proper donning and doffing techniques of PPE. The American Dental Hygiene Association (ADHA) Interim Guidance also contains useful information on donning and doffing protocols.

Patient Pre-Screening

  • Dental offices/practices should make every effort to interview and pre-screen patients by telephone, text monitoring systems, or video conference before the visit. Consider teledentistry to reduce exposure to DHCP.
  • Determine the patient’s COVID-19 status. As the pandemic progresses, many individuals will recover from the COVID-19 infection. It is important to determine when a patient who was diagnosed with the disease is ready to discontinue home isolation. CDC suggests two approaches to determine clearance to abandon quarantine:
    • Time-since-illness-onset and time-since-recovery strategy (non-test-based:  Persons with COVID-19 who had symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:
      • At least 3 days (72 hours) have passed since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath; and,
      • At least 10 days have passed since symptoms first appeared.
  • Test-based strategy: Persons with COVID-19 who had symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:
    • Resolution of fever without the use of fever-reducing medications,
    • Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
    • Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥ 24 hours apart** (total of two negative specimens).
  • Individuals with laboratory-confirmed COVID-19 who have not had any symptoms may discontinue home isolation when at least 10 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness.

Registration and Reception 

  • Have hand-sanitizer available at the entry upon arrival.
  • Tissues and waste baskets should be readily accessible. Ensure bathrooms are stocked with soap and paper towels.
  • If forms need to be completed, furnish pens for patients to keep or ask patients to use their own. Clean clipboards after each patient use.
  • Remove magazines, reading materials, toys, remote controls, and non-essential furniture that could be touched by patients and which cannot be easily disinfected. Arrange reception area chairs to optimize social distancing.
  • Schedule appointments far enough apart to minimize possible contact with other patients in the waiting room.
  • Have patients wait in their vehicle until called in by office staff, as appropriate.
  • Strongly discourage patients from bringing companions to their appointments, except for instances where the patient requires assistance (e.g., pediatric patients, patients with special needs, elderly patients). If companions are required, they should also be screened upon arrival and given a procedural mask upon entering. Individuals providing transportation should be asked to wait in the vehicle or asked to drop the patient off.

On-Site Patient Screening

  • Actively screen everyone for fever and COVID-19 symptoms (e.g., fever, cough, difficulty breathing), immediately upon entering the office/practice. If a patient does not have a fever and is otherwise without even mild symptoms, they can be seen assuming appropriate protocols and PPE are in place.
  • If a patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other signs or symptoms of COVID-19 infection (e.g., fever, cough, difficulty breathing), they can be seen in dental settings with appropriate protocols and PPE.
  • If a patient does exhibit signs and symptoms of COVID-19, the patient should be asked to reschedule and instructed to contact their medical provider or referred for testing, as appropriate. The reason for the rescheduling should be noted.

Providing Clinical Care

  • There have been some recommendations of having patients rinse with a pre-procedural mouth-rinse, such as 1% Hydrogen Peroxide, 0.2% - 1% povidone, or 0.5 – 1% cetylpyridinium chloride for 30 to 60 seconds. To date, there are no clinical studies to either support or contraindicate its virucidal effect against COVID-19.
  • DHCP should strive to limit intraoral radiation as much as possible as it can stimulate saliva secretions and coughing. The use of extra-oral dental radiographs such as panoramic, extra-oral bitewings and/or cone beam are recommended alternatives to reduce coughing, etc.
  • DHCP should reduce aerosol production as much as possible and prioritize the use of hand instrumentation.
  • DHCP should use rubber dams or isolating systems (e.g., DryShield, isolite, etc.) along with high volume suction when performing all aerosol-producing procedures.
  • Once the rubber dam is in place the following technique may provide additional reduction in aerosol contaminants - swab the tooth or teeth with either 62% or higher ethanol or 0.1% sodium hypochlorite solution for 1 minute before initiating treatment.
  • Anti-retraction function of some high speed handpieces may provide additional protection against cross-contamination.
  • DHCP should prefer the use of high-volume evacuators at all times as backflow can occur when using a saliva ejector.
  • DHCP should minimize the use of a 3-in-1 syringe (combined air/water syringe functions) whenever possible as it may create droplets due to forcible ejection of water/air.
  • If dental hygiene procedures are performed, avoid the use of ultrasonic scalers and air-polishing procedures until further notice. Clinical judgment, patients and staff safety, and the public welfare must be considered at all times.
  • DHCP should consider contacting all patients who received dental care in the dental office/practice 48 - 72 hours after care was given to determine if the patient is exhibiting any signs or symptoms of COVID-19. If yes, the patient should be referred for testing or encouraged to contact their medical provider. DHCP should follow CDC guidance for health care professionals with potential exposure.
  • The patient should be reminded to contact the dental office/practice if COVID-19 symptoms appear within the next 14 days.

The state of Wisconsin has also contracted with the Battelle Company to provide decontamination services for certain PPE supplies. The site located in Madison will be a vaporized hydrogen oxide machine for N95 masks and regional sites with UV decontamination procedures for other specific PPE. Please refer to: www.battelle.org/decon for further details.

Additional resources and guidance are available from the FDA, ADA, EPA, WI DHS, OSHA, and the ADHA. Please refer to the links provided below.

Additional Resources:

 Caring for pregnant women

  • The CDC outlines interim considerations for infection prevention and control of 2019 Coronavirus Disease 2019 (COVID-19) in inpatient obstetric healthcare settings.
  • The American College of Obstetricians and Gynecologist (ACOG) has practice guidelines for health care providers who see pregnant women.
  • The Maternal Child Health (MCH) Navigator has resources and information on COVID-19 as it relates to the MCH Leadership Competencies including ethics, critical thinking, communication, family-professional partnerships, cultural competency, working with communities and systems, and others.  

 Home visiting programs

COVID-19 Protecting yourself during a home visit P-02664The following information is for home visiting providers, including Nurse Family Partnership, Parents as Teachers, Early Head Start, Healthy Families America, and Prenatal Care Coordination

The Safer at Home order identifies the following:

  • Wisconsinites can continue to work for or obtain human service operations.
  • All essential businesses and operations are encouraged to remain open.
  • Essential businesses and operations, will, when possible, use technology to avoid meeting in person.
  • To the greatest extent possible, essential businesses and operations will comply with physical distancing requirements, including:
    • Maintaining physical distancing of at least six feet between people
    • Washing hands with soap and water for at least 20 seconds as frequently as possible, or using hand sanitizer
    • Covering coughs or sneezes (into the sleeve or elbow, not hands)
    • Regularly cleaning high-touch surfaces
    • Avoiding shaking hands
    • Following all other public health recommendations issued by DHS and the Centers for Disease Control and Prevention (CDC)

Operationalizing Safer at Home for home visiting programs

  • Home visitors and prenatal care coordinators provide social services for economically disadvantaged individuals and families. These services can be considered Human Service Operations.
  • Home visiting and Prenatal Care Coordination (PNCC) services are encouraged to continue because families may have greater needs during the pandemic.
  • During the COVID-19 crisis, home visiting and PNCC services can be maintained through virtual visits.
    • Utilize telehealth services (which may be provided through audio or video communication technology, including videoconferencing software) to determine treatment options. Per Health and Human Services Office for Civil Rights guidance, providers can use audio or video communication technology to provide telehealth to patients during the COVID-19 public health emergency.  Health care providers will not be subject to penalties for violations of the HIPAA Privacy, Security, and Breach Notification Rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency.
    • Guidance on the COVID-19 response is provided by the models utilized by the Family Foundations Home Visiting agencies in Wisconsin:
      • Nurse Family Partnership
      • Parents as Teachers
      • Early Head Start
      • Healthy Families America
    • Model-specific recommendations will be continually updated as any new information is received from the CDC and the federal government.

For prenatal care coordination providers, the Medicaid program has issued a number of Forward Health Updates related to telehealth services during the public health emergency for COVID-19. You can find summaries of recently published materials and resources here.

Note: ForwardHealth will allow real-time technology, including phone communication, for currently covered services that can be delivered with functional equivalency to the face-to-face services. This applies to all components of PNCC including assessment, care planning, case management, health education and nutrition counseling, and postpartum services.

Checklist: Questions to ask if a home-based visit is requested

Home visiting providers should consult with their supervisor and agency policies if they identify a need for a home-based visit. Prior to a home visit, the care coordinator should have video or verbal contact with the program participant to assess and evaluate the current home environment. Please consider the following:

  • Does the provider or anyone in the home have a fever and/or respiratory symptoms or exposure to someone who is symptomatic or tested positive for COVID-19 within the past 14 days?
  • Could the family’s needs be addressed in other ways (for example, medical care, community resources)?
  • Is it possible to follow physical distancing requirements for the home visit?
  • Is personal protective equipment appropriate and available?
    • Due to PPE shortages, home visiting providers should identify ways to preserve PPE supplies, when available, and should develop protocols for managing families with limited or no PPE.
    • In accordance with DHS guidance, home visiting providers should implement use of universal cloth face coverings  by all workers (source control) when they enter a family’s home. Families should also wear cloth face coverings when interacting with someone from outside their residence.
  • Are there protocols for cleaning tools and equipment (for example, scales, stethoscope, and developmental screening tools) used during the visit?

CDC recommends that home health care personnel refer to Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for Coronavirus Disease 2019 (COVID-19) in a Healthcare Setting. Home care providers should contact their local health department for questions and frequently review the CDC website dedicated to COVID-19 for health care professionals.

Note: Due to the fluid nature of the COVID-19 crisis, guidance may change and be updated.

 Infection preventionists

 Information about Wisconsin's Medicaid Section 1135 Waiver

On April 16, 2020, the Wisconsin Department of Health Services sent a letter to the Centers for Medicare & Medicaid Services to request approval for flexibilities listed under Section 1135 of the Social Security Act (42 U.S.C. § 1320b-5) as related to the COVID-19 disease.

 Newborn hearing screening

The work of newborn hearing screening in Wisconsin continues during the COVID-19 outbreak. Thank you for all you have done to continue screening every baby for congenital blood, heart, and hearing conditions.  As described below, the Centers for Disease Control and Prevention (CDC) considers newborn screening an essential service, as does the Wisconsin Department of Health Services (DHS) and the obligations, laws, and Wisconsin DHS policies regarding newborn screening and all related follow-up remain unchanged during this time, including those of newborn hearing screening.

Because the CDC considers the late identification of congenital hearing loss “a developmental emergency,” newborn hearing screening and appropriate follow-up is considered an essential service and should be completed to the safest extent possible.

National, state, local, and your hospital, clinic, and/or practice safety guidelines should be followed to protect all involved. It is critical that:

  • Reporting requirements continue as usual (less than 7 days after testing).
  • Newborn hearing screening should be accomplished before hospital discharge or within 30 days of birth if the infant was not born in a hospital.
  • If the birth hospital was re-screening babies at the hospital prior to COVID-19, we ask that you continue to do so following recommended COVID-19 precautions:
  • If the family is unable to return for timely follow-up, i.e., before 14 days of age for rescreening or before three months of age for diagnostic audiologic evaluation, the hospital should perform regular outreach with the family to facilitate follow-up as soon as possible. This outreach should be documented within Wisconsin Early Hearing Detection and Intervention (EHDI) - Tracking Referral and Coordination (WE-TRAC) case notes as a “COVID-19 Note.”
  • It is the responsibility of the hospital AND outpatient referral audiology clinic to track infants who have been unable to complete the early hearing detection and intervention process and ensure follow-up occurs. In order to assure follow-up, family outreach and care coordination will require a team approach.  

To reduce the need for multiple visits during the COVID-19 outbreak and to ensure timely identification of infants who are deaf or hard of hearing during this time, hospitals are asked to consider the following:

  • Work with local audiologists to complete diagnostic audiologic testing prior to hospital discharge for infants who do not pass the hearing screening (especially for high-risk infants)
    And/or
  • Upon newborn hearing screening failure at outpatient rescreening, complete the diagnostic testing at that same visit.

Contact the Wisconsin Sound Beginnings Program for additional support. Hospitals and audiology clinics can reach out to Program Director Elizabeth Seeliger.  Out-of-hospital providers can reach out to Noel Fernandez.

 Provider resources

 Preparedness resources

The following were originally developed for influenza, but may be useful in developing a plan for COVID-19 as many of the strategies are the same.

  • Pandemic Preparedness Resources: CDC webpage containing guidance and tools developed for pandemic influenza planning and preparedness. These can serve as appropriate resources for health departments in the event the current COVID-19 becomes widespread in the community.
  • Public Health Discussion Guide: CDC document to help guide a local health department's discussion in developing and maintaining an outbreak response plan.
  • Get Your School Ready for Pandemic Flu: CDC booklet providing information for schools to help develop strategies to slow the spread of respiratory illness.
  • Planning Resources for Schools: CDC webpage that includes information on planning for a possible COVID-19 outbreak and for creating an outbreak response plan.
  • Hospital Discussion Guide: CDC document to help guide a hospital's discussion in developing and maintaining an outbreak response plan.
  • Emergency Management Discussion Guide: CDC document to help guide a community emergency management planning agency's discussion in developing and maintaining an outbreak response plan.
  • Planning Resources for Business: CDC webpage that includes information on planning for a possible COVID-19 outbreak and for creating an outbreak response plan.

 Reproductive health family planning resources

COVID-19 telehealth and in-clinic guidelines and best practices

Reproductive health and family planning remains an essential service. During this unprecedented time it is important to note the following best practices.

Information on telehealth

  • DHS telehealth recommendations: “On March 18, DHS notified Medicaid providers of two changes that should increase the use of telehealth. First, Medicaid members can now participate in telehealth visits from any location, including their homes. Second, Medicaid members can now have visits with their doctors over the telephone, not just using face-to-face technology. These changes are permanent and will be available to people who access Medicaid services even after the current emergency ends.”
  • NFPRHA: Initiating Telehealth in Response to COVID-19.

See the DHS e-health page for information on virtual visits and telehealth.

See the DHS privacy page for HIPAA compliance.

Additional guidance

Billing and coding

Consent

  • Identify the patient using two identifiers: Full Name, Date of Birth.
  • Obtain verbally consent for care, Notice of Privacy Practices (HIPAA), and right to refuse care as applicable from the patient if unable to obtain electronic or written.
  • Inform patient of potential privacy risks when using third-party e-visit platforms.
  • Document verbal consent for the Telehealth Service. Example: “Do I have your consent to conduct today’s visit by phone/video conference?” Document Yes/No.

Documentation
The documentation requirements for televisits are the same as for a face-to-face visit. Additional recommended practices include:

  • The telehealth mode of communication (telephone, video [name of the product used], audio, etc.)
  • Location of patient
  • Location of provider
  • Names and roles of the clinic staff participating in the telehealth services

Curbside and drive-through services
The following services can be curbside or drive-through appointments: Birth control refills, dispensing condoms, dispensing emergency contraceptives, and STI treatment.

  • Use “Curbside Pick-Up” to dispense to patients without them having to enter the health center following a telehealth visit. Designate a space in the parking lot marked “Reserved for Curbside Pickup.” Arrange for any payment in advance by phone or electronically if applicable. Instruct patient to call on arrival. Deliver medication curbside using all standard precautions, patient identification, and dispensation workflows. Document all details in the medical record including “curbside pickup.”
  • Submit a prescription to the patient’s local pharmacy. For patients who are able to go to a pharmacy, consider sending a prescription for them to pick up. Encourage patients to call their pharmacy in advance to ensure prescription is ready for pickup to minimize waiting time and to use drive-through pharmacy or curbside pickup pharmacy services where possible.

Email us if you have more questions.

Provider resources

Contraception during COVID-19

Telehealth guidelines and resources

Billing and coding

Resource hubs

Patient education resources

Mental health guidance

Coping tips for those serving on the frontlines

Throughout Wisconsin, frontline workers provide essential health and safety services that keep our communities functioning during the COVID-19 pandemic. Braving increased risks to help others is part of their jobs, but it can come with a cost. Routine stress, added to the rational concern many frontline workers have for their own health and the well-being of their loved ones, can leave these professionals—and their families—vulnerable to the negative effects of secondary trauma and other mental and behavioral health challenges, like suicidal thoughts and harmful substance use.

Try these five strategies
  • Build a solid foundation: Invest in your health with adequate sleep, good nutrition, regular physical activity, and active relaxation.
  • Connect with colleagues: Celebrate successes and mourn sorrows with your co-workers as a group.
  • Take breaks: Time away from work, whenever possible, can help you see beyond the immediate crisis.
  • Stay connected: Communicate with friends and family as often as you can, even if you are practicing self-isolation.
  • Talk it out: Consider talking about your experiences and emotions with a trusted peer or mental or behavioral health professional. It’s okay to reach out for support, and talking can help.
Resources to help you manage stress and adapt to change

For frontline workers

Balancing your duty to the clients and patients in your care with your own mental, physical, and emotional health needs isn’t easy. Learn how to manage and reduce stress of providing care during the COVID-19 pandemic and prevent secondary trauma from negatively impacting your personal and professional life by exploring the resources below:

For families of frontline workers

Frontline workers aren’t the only ones who experience stress while providing essential health and safety services during large-scale emergencies like the COVID-19 pandemic. That stress is shared by the loved ones around them. Learn how to recognize toxic stress and build a support system that helps everyone in your circle offer and ask for support by exploring the resources below:

 

More information
Last Revised: June 1, 2020

 RESPONSE RESOURCES FOR WISCONSINITES — www.dhs.wisconsin.gov/covid-19/help.htm