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. 

UW - Madison Research Participation Opportunity for Protecting Healthcare Workers from COVID-19. The research is titled, "Role of naso-oropharyngeal antiseptic decolonization to reduce covid-19 viral shedding and disease transmission." For more information on how to enroll, visit the Shield Research Study.

 

Monitoring Resources

 
 

PPE

 

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 Americans with Disabilities Act.

Physical health and safety guidance

 Considerations for allocation of scarce resources

The Wisconsin Department of Health Services, in collaboration with the State Disaster Medical Advisory Committee, and with input from Wisconsin clinicians, bioethicists, advocacy groups and residents through a public comment process, proposes a number of considerations for hospitals developing or revising allocation guidelines for mechanical ventilators and other scarce resources during a public health emergency.

  1. Allocation guidelines should be transparent. It is understandable that people would be frustrated and angry if a loved one does not receive treatment that may have sustained his or her life. Emotions will be heightened if there is a perception that decisions are being made randomly, in secret, or with guidelines that are not publicly disclosed and potentially discriminatory. Transparency is a key ethical principle that should be upheld when developing and implementing protocols for the allocation of scarce resources. Guidelines adopted by hospitals should be made available upon to request by the public, and hospitals should consider posting their guidelines online for public viewing.
  2. Allocation guidelines should include input from the community. Guidelines developed without the involvement of the community may be biased or may be seen as biased, leading to unfair treatment of individuals or groups of individuals. As such, it is important that guidelines be developed in a way that incorporates feedback from the public, especially traditionally marginalized and vulnerable communities.  
  3. Allocation guidelines should be based on medical considerations only. The following considerations should not play a role in allocation decisions: ability to pay, race, ethnicity, sex, gender, gender identity, self-identification as LGBTQ+, disability status, incarceration status, and immigration and citizenship status. Allocation strategies should be developed around the goal of saving the greatest number of lives, and adhere to the fundamental principle that human lives are equally deserving of being saved. Guidelines are intended to be based on the best medical determination of a patient’s likelihood to survive for a determined period, such as one year, without incorporating assessments of quality of life, which can be subjective and potentially discriminatory to people with disabilities. 
  4. Allocation guidelines should be mindful of greater co-morbidity burden for patients harmed by health disparities. Allocation strategies should be developed around the goal of saving the greatest number of lives, and adhere to the fundamental principle that human lives are equally deserving of being saved. Focusing on the number of lives saved may be preferable to focusing on the quantity of life-years saved, because the latter may disadvantage socio-economically vulnerable communities who tend to have a greater burden of medical co-morbidities. Socio-economically vulnerable patients will be impacted in ways that compound health disparities because of a higher prevalence of underlying medical conditions, lack of access to health care, greater exposure to the coronavirus, and other factors. 
  5. Allocation guidelines should apply to non-COVID-19 and COVID-19 patients equally. While the COVID-19 epidemic may be the motivating force behind development of new guidelines, hospital guidelines should be applied to all patients during a time of shortage. This ensures fair access to treatments that could benefit patients regardless of disease.
  6. Allocation guidelines should acknowledge that decisions to withhold life-sustaining treatment and decisions withdraw life-sustaining treatment may be necessary in a crisis situation, and should incorporate an ethical framework relevant to both scenarios. The decision as to whether a patient’s respiratory status should be supported with a ventilator should be based on objective medical criteria, not on whether the patient has already been started on a ventilator. Failing to remove a patient from a ventilator who is less likely to benefit than another patient is not consistent with the ethical principles of triage in the context of scarcity.   
  7. Allocation guidelines should clarify that a patient’s home ventilator should not be considered community property. As such, home ventilators should not be subject to reallocation even in the context of scarcity. However, should a patient with a home ventilator require a hospital ventilator for worsening respiratory status, they should be subject to the same guidelines as all other patients.
  8. Allocation guidelines should ideally be executed by a Clinical Triage Team that reports to a Clinical Triage Team Oversight Committee. Neither individual providers nor treating medical teams should determine whether or not their patient should receive a ventilator, even when guidelines are delineated. Rather, a Triage Team (or at the minimum Triage Officer), familiar with 1) ethical frameworks of resource allocation in times of crisis and scarcity, 2) availability of resources at their given institution, and 3) the guidelines of their given institution, should make such decisions. The Triage Team would ideally consist of medical intensivists, nursing leadership and hospital administration. Triage teams may also benefit from including ethics committee representatives.

    The Oversight Committee confirms appropriate application of guidelines, assesses trends, and suggests guideline changes based on experience as the epidemic evolves. The Oversight Committee should also be attuned to adverse impacts of social determinants of health. Evaluation of the impact of care provided under conditions of extreme scarcity needs to carefully consider the impact of triage decisions on such vulnerable patients. The Oversight Committee should evaluate trends related to the allocation strategy to ensure that these decisions are not systematically biased against specific groups. Finally, the Oversight Committee should consider avoiding an appeals process, as it is susceptible to undue sway by individuals and families of influence. Moreover, in the context of a crisis, with the need for expediency, an appellate process would be difficult to administer in a timely and transparent manner. Development of any appeals process, or the decision to avoiding appeals, should be made in consultation with relevant stakeholders in a publicly engaged process. 

References

Hospitals developing or revising allocation guidelines may benefit from reviewing documents developed on this topic by national organizations and other state health departments, which are referenced below.

  1. Institute of Medicine Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington DC: National Academies Press (US); 2009.
  2. Centers for Disease Control and Prevention; Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency, 2011. Atlanta, GA; 2011.
  3. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020;323(18):1773–1774. doi:10.1001/jama.2020.5046
  4. University of Pittsburgh Model Hospital Policy for Allocation of Scarce Critical Care Resources During a Public Health Emergency
  5. New York State Health Department Ventilator Allocation Guidelines, 2015
  6. Minnesota Pandemic Ethics Project

 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.

  • Providers and organizations using SARS-CoV-2 antigen tests should be aware of all reporting requirements for COVID-19. All positive antigen results should be reported to local public health departments. Negative antigen test results are not required to be reported to the state but still need to be reported to HHS. (HAN #17)
  • Information on communicable disease reporting

COVID-19 surveillance case definition

Note: The COVID-19 Surveillance Case Definition is a set of uniform criteria used to define COVID-19 disease or infection 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 asymptomatic infection to severe illness. Among symptomatic individuals with COVID-19 disease, mild to moderate illness occurs in approximately 80% of cases, severe infection requiring supplemental oxygen occurs in approximately 15% of cases, and critical infection requiring mechanical ventilation occurs in approximately 5% of cases. The frequency of asymptomatic presentations among all individuals with SARS-CoV-2 infection is still unknown and may vary by age. Mild to moderate illness may include fever, sore throat, headache, myalgia, fatigue, and upper respiratory symptoms. Symptoms of more severe illness may include fever, cough, difficulty breathing, 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). The incubation period of COVID-19 disease ranges from 2–14 days after infection, with an average time from infection to clinical illness of 4–5 days. 


Clinical Criteria for Surveillance

At least two of the following symptoms: 

  • Fever (measured or subjective), or chills, or rigors (shaking chills) 
  • Myalgia (muscle aches)
  • Headache 
  • Sore throat 
  • Nausea or vomiting
  • Diarrhea
  • Fatigue
  • Congestion or runny nose

OR

At least one of the following symptoms: 

  • Cough 
  • Shortness of breath 
  • Difficulty breathing
  • New olfactory disorder (loss of smell)
  • New taste disorder (loss of taste)

OR

Severe respiratory illness with at least one of the following:

  • Clinical or radiographic evidence of pneumonia
  • 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 or autopsy specimen using a molecular amplification detection test (e.g. PCR, NAAT).

Presumptive laboratory evidence: Detection of SARS-CoV-2 by antigen test in a respiratory specimen.

Supportive laboratory evidence:

  • Detection of specific IgM, IgG, IgA or total antibody in serum, plasma, or whole blood
  • Detection of specific antigen by immunocytochemistry in an autopsy 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).

*For non-healthcare workers in a community setting, a person is considered to be in close contact of a COVID-19 case if any of following interactions occurred while the case was infectious: (1) was within 6 feet for more than 15 minutes total in a day, (2) had physical contact, (3) had direct contact with the respiratory secretions of the infected individual (from coughing, sneezing, contact with dirty tissue, shared drinking glass, food, towels or other personal items), (4) lives with or stayed overnight for at least one night in a household without complete separation from the infected individual.

For healthcare workers, refer to CDC’s Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 to determine whether an interaction should be considered close contact.


Vital records criteria for surveillance

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


Surveillance case definitions for COVID-19

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

Probable case: 
Meets clinical criteria AND epidemiologic evidence with no confirmatory lab testing performed (i.e., no COVID-19 PCR or NAAT performed).

OR

Presumptive laboratory evidence

OR

Meets vital records criteria

Suspect case:
Meets clinical criteria, for whom laboratory confirmation is pending, and who does not otherwise meet a probable case definition.

OR

Supportive laboratory evidence with no prior history of being a confirmed or probable case.

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 confirmatory lab result for COVID-19.


Surveillance criteria to distinguish a new case of COVID-19

A repeat positive test for SARS-CoV-2 RNA using a molecular amplification detection test (i.e., PCR, NAAT) within 3 months of the initial report should not be counted as a new case for surveillance purposes.

To date, there has been minimal evidence of reinfection among persons with a prior confirmed COVID-19 infection and growing evidence that repeat positive RNA tests do not correlate with active infection when viral culture is performed. Similarly the experience with other coronaviruses is that reinfection is rare within the first year. Note: The time period of 3 months may be extended further if more data become available to show risk of reinfection remains low beyond 3 months of the initial report.

 Testing

Updated information on the COVID-19 testing process

The Department of Health Services and Wisconsin Emergency Management hosted a webinar on May 27, 2020 to present updated information for health care professionals on the COVID-19 testing process.

Resources

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.

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. Visit our Labs and Testing page to find 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:

  • Public Health Investigations as directed by state or local public health
  • Hospitalized patient with COVID-19 symptoms
  • Patient with COVID-19 symptoms for whom rapid diagnosis is needed to inform infection control practices (for example, labor and delivery, dialysis, aerosol-generating procedures)
  • Resident of a long-term care facility with COVID-19 symptoms
  • Resident in a jail, prison, or other congregate setting with COVID-19 symptoms
  • Health care worker or first Responder (e.g. fire, EMS, police) with COVID-19 symptoms
  • Essential staff in high consequence congregate settings (e.g. prisons or jails) with COVID-19 symptoms
  • Utility workers (water, sewer, gas, electric, power, distribution of raw materials, oil and biofuel refining) with COVID-19 symptoms
  • Underserved populations with poor access to testing (e.g., underinsured, patients at Federally Qualified Health Centers, homeless patients, migrant workers, etc.) with COVID-19 symptoms
  • Post-mortem testing for a person with COVID-19 symptoms prior to death who died of unknown causes AND where results would influence infection control interventions at a facility or inform 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.

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.


Symptom-based strategy for determining when health care workers can return to work

Health care workers with mild to moderate illness who are not severely immunocompromised:

  • At least 10 days have passed since symptoms first appeared, and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (for example, cough, shortness of breath) have improved.

Note: Health care workers who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive viral diagnostic test. 

Health care workers with severe to critical illness or who are severely immunocompromised:

  • At least 20 days have passed since last symptoms first appeared
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (for example, cough, shortness of breath) have improved.

Note: Health care workers who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 20 days have passed since the date of their first positive diagnostic test.

As described by the CDC, an estimated 95% of severely or critically ill patients, including some who are severely immunocompromised, no longer had replication-competent virus 15 days after onset of symptoms; no patient had replication-competent virus more than 20 days after onset of symptoms. Because of their often extensive and close contact with vulnerable individuals in health care settings, the more conservative period of 20 days was applied in this guidance. However, because the majority of severely or critically ill patients no longer appear to be infectious 10 to 15 days after onset of symptoms, facilities operating under critical staffing shortages might choose to allow health care workers to return to work after 10 to 15 days, instead of 20 days.


Test-based strategy for determining when health care workers can return to work

In some instances, a test-based strategy could be considered to allow health care workers to return to work earlier than if the symptom-based strategy were used. However, as described by the CDC, many individuals will have prolonged viral shedding, limiting the utility of this approach. A test-based strategy could also be considered for some health care workers (for example, those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the health care workers being infectious for more than 20 days.

Criteria for the test-based strategy

Health care workers who are symptomatic:

Health care workers who are not symptomatic:

If a symptomatic health care worker 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 health care worker be free of fever and other acute symptoms of their illness for at least 24 hours. 

If testing was not performed, and the health care worker had fever and a mild 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 health care worker be free of fever and 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 the type of exposure and PPE. In general, HCWs with prolonged contact to a COVID-19 positive individual without the use of certain PPE should be excluded from work for 14 days, during which they should monitor for fever or symptoms consistent with COVID-19. If any HCW reports symptoms during this 14 day period, they should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing (see above for guidance on return to work).

When staffing shortages are occurring, healthcare facilities and employers (in collaboration with human resources and occupational health services) may need to implement crisis capacity strategies to continue to provide patient care. See CDC's Strategies to Mitigate Healthcare Personnel Staffing Shortages for additional guidelines.

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.

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.

 Non-COVID-19 immunization services

Ensuring that immunization services, including influenza vaccine services this fall, are maintained or reinitiated is essential for protecting people and communities from vaccine-preventable diseases and outbreaks, and for reducing the burden of illness during the upcoming influenza season.

The CDC has issued Interim Guidance for Immunization Services During the COVID-19 Pandemic to help immunization providers in a variety of clinical settings plan for safe vaccine administration during the COVID-19 pandemic. This guidance will be updated as the COVID-19 pandemic evolves.

Highlights include:

  • Considerations for routine administration of all recommended vaccinations for children, adolescents, and adults, including pregnant people.
  • General practices for the safe delivery of vaccination services, including considerations for alternative vaccination sites.
  • Strategies for catch-up vaccinations.

 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
BCD 2020-28
Guidance Related to Viral Whole Genome Sequencing of SARS-CoV-2 for the Public Health Response October 1, 2020
BCD 2020-27
Prevention and Control of Acute Respiratory Illness Outbreaks in Long-Term Care Facilities September 23, 2020
BCD-2020-26
Prevention and Control of Acute Respiratory Illness Outbreaks in Long-Term Care Facilities September 17, 2020
September 23, 2020
BCD 2020-25
Crisis Standards of Practice for COVID-19 Contact Tracing and Symptom Monitoring September 15, 2020
2020-11 Action
Request for Applications: Behavioral Health Treatment for Long-Term Care Facility Staff Impacted by COVID-19 June 22, 2020
August 1, 2020
BCD 2020-19
Guidance on the role of COVID-19 testing in decisions around transfers from acute care hospitals to post-acute and long-term care facilities June 9, 2020
BCD 2020-20
Guidance on the transfer of hospitalized patients infected with COVID-19 to post-acute and long-term care facilities June 9, 2020
BCD 2020-21
Guidance on the disposition of medically stable post-acute and long-term care residents with confirmed or clinically suspected COVID-19 infection June 9, 2020
20-003
Wisconsin Hospices CMS 1135 Waiver Provisions and Governor Evers Emergency Order # 21 June 8, 2020
20-004
Wisconsin Nursing Homes – CMS 1135 Waiver Provisions and Governor Evers Executive Order # 21 June 8, 2020
20-007
Wisconsin Home Health Agencies – CMS 1135 Waiver Provisions and Governor Evers Emergency Order # 21 June 8, 2020
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
June 2, 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
20-005
Guidance for Ambulatory Surgical Centers Temporarily Enrolling as a Hospital During the COVID-19 Public Health Emergency April 16, 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. Dental offices should balance the need to provide necessary services while minimizing risk to patients and dental health care personnel (DHCP). CDC has developed a framework for delivery of care during the COVID-19 pandemic. Public health guidance will shift as the COVID-19 outbreak evolves. Therefore, all dental professionals should regularly check for and be aware of updates to guidance for dental settings as well as the general infection prevention and control recommendations for COVID-19.

During the COVID-19 pandemic, the risk associated with dentistry involves the use of rotary dental and surgical instruments, such as handpieces, ultrasonic scalers, and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris. There is currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice. Therefore, additional infection prevention and control practices are recommended in addition to standard precautions. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infections. To protect the health and safety of Wisconsin dental professionals, dental offices should follow interim guidance from CDC, OSHA, and the American Dental Association (ADA). This document serves as a summary of the most current recommendations.

The Organization for Safety, Asepsis and Prevention (OSAP) and DentaQuest Partnership for Oral Health Advancement (DQP) have released Best Practices for Infection Control in Dental Practices During the COVID-19 Pandemic, a checklist to assist DHCP with implementing interim guidance provided by CDC, ADA, ADHA, and OSHA. Designed as a fillable PDF, the checklist is printable and mobile-friendly. Updates to the document will be made as interim guidance changes.

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 notify occupational health services or their infection control coordinator to arrange for further evaluation, or 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.
  • Dental practices are encouraged to implement sick leave policies for DHCP that are flexible, nonpunitive, and consistent with public health guidance. DHCP should be reminded to stay home when they are ill and should receive no penalties when needing to stay home when ill or under quarantine. They can return to work following the DHS guidance regarding return to work criteria.
  • DHCP should be trained in all new policies and procedures, with a special focus on the use and removal of PPE.
  • DHCP should also be trained to adhere to physical distancing at all times, and should be reminded that the potential for exposure is not limited to direct patient care interactions but can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers or visitors in break rooms or other common areas. Practices should provide designated areas for DHCP to take breaks, eat, and drink where all individuals can remain at least 6 feet apart from each other.
  • 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.

Employers should select appropriate PPE and provide it to DHCP in accordance with OSHA’s PPE standards (29 CFR 1910 Subpart I). DHCP must receive training on and demonstrate an understanding of when to use PPE; what PPE is necessary; how to properly don, use, and doff PPE in a manner to prevent self-contamination; how to properly dispose of or disinfect and maintain PPE; and the limitations of PPE.

Dental offices must ensure that any reusable PPE is properly cleaned, decontaminated, and maintained after and between uses.

Dental offices should have written policies and procedures describing a recommended sequence for safely donning and doffing PPE.

  • Only dental offices and/or practices with appropriate and sufficient PPE for all DHCP should provide dental care. Conduct an inventory of all available PPE supplies needed for all in-office procedures; assume that supply sources may be unpredictable and inconsistent for the near future. Use the burn rate calculator to plan and optimize the use of PPE. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.
  • Extended use of face masks and respirators should only be undertaken after implementing all necessary administrative and engineering controls. See more information below on PPE optimization.
  • DHCP may encounter symptomatic or pre-symptomatic patients with SARS-CoV-2 infection, and should follow these recommendations for PPE:
    • Implement universal eye protection and wear eye protection to ensure the eyes are protected from exposure to respiratory secretions during patient care encounters, including those where splashes and sprays are not anticipated. Goggles should also be worn in the office setting, as well as while providing direct patient care. Note that protective eyewear (e.g., safety glasses, trauma glasses) with gaps between the glasses and the face likely do not protect eyes from all splashes and sprays.
    • The type of mouth and nose protection is determined by the type of procedure performed:
      • Wear a surgical mask to protect the nose and mouth during patient care encounters, including those where splashes and sprays are not anticipated.
      • During aerosol-generating procedures, use an N95 respirator or a respirator that offers an equivalent or higher level protection, such as other disposable filtering face-piece respirators, powered air-purifying respirators, or elastomeric respirators.
      • Respirators must be used in the context of a complete respiratory protection program in accordance with OSHA standards.
      • Respirators with exhalation valves are not recommended.
      • Respirators that comply with international standards may be considered during times of known shortages. CDC has guidance entitled Factors to Consider When Planning to Purchase Respirators from Another Country, which includes a webinar, and Assessments of International Respirators.
    • Face shields are recommended for aerosol and non-aerosol procedures.
    • Cloth face coverings should only be used for nonpatient and administrative staff.
  • To address asymptomatic and pre-symptomatic transmission, implement source control (require face masks 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 face mask at all times while they are in the dental setting. In areas with moderate to substantial community transmission, DHCP should also wear eye protection in addition to their face mask during encounters with patients not suspected of SARS-CoV-2 infection to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions, including those where splashes and sprays are not anticipated. In such communities, DHCP should also use an N95 respirator or a respirator that offers an equivalent or higher level of protection during aerosol-generating procedures.

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. To determine clearance to abandon quarantine, refer to guidance from the CDC.
  • If the patient reports symptoms of COVID-19, avoid nonemergent dental care and, if possible, delay dental care until the patient has ended isolation or quarantine.
  • 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.
  • People with COVID-19 who have ended home isolation can receive dental care following standard precautions.

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 by ensuring patients are seated at least 6 feet apart from each other.
  • Schedule appointments far enough apart to minimize possible contact with other patients in the waiting room.
  • Have patients wait in their vehicle or outside the dental facility until contacted by mobile phone or otherwise 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 face mask upon entering. Individuals providing transportation should be asked to wait in the vehicle or drop off the patient. Practices should encourage use of alternative mechanisms for patient and visitor interactions, such as video-call applications on cell phones or tablets.

On-Site Patient Screening

  • Actively screen everyone for fever and COVID-19 symptoms and exposure to others with SARS-CoV-2 infection immediately upon entering the office/practice and document the absence of symptoms consistent with COVID-19. This should include asking them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection. 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, they can be seen in dental settings with appropriate protocols and PPE.
  • Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures (require face masks or cloth face coverings) are recommended for everyone in the dental clinic, even if they do not have signs and symptoms of COVID-19.
  • If a patient does exhibit signs and symptoms of COVID-19 or has experienced an exposure for which quarantine would be recommended, DHCP should follow CDC’s recommended infection prevention and control practices when providing dental health care for a patient with suspected or confirmed SARS-CoV-2 infection.
    • Non-emergent treatment should be deferred and if they are not already wearing a cloth face covering, the patient should be given a face mask to cover their nose and mouth. They should be sent home immediately and instructed to call their health care provider. If the patient is manifesting emergency warning signs for COVID-19 (e.g., having trouble breathing), they should be referred to a medical facility or 911 should be called and informed that the patient may have COVID-19.
    • If emergency dental care is medically necessary for a patient who has, or is suspected of having, COVID-19, DHCP should follow CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.
      • When possible, DHCP should schedule such patients at the end of the day and without any other patients at the same time.
      • Provide treatment in an individual patient room with a closed door and use a NIOSH-approved N95 or equivalent or higher-level respirator (or face mask if a respirator is not available), gown, gloves, and eye protection.
      • Aerosol-generating procedures should be avoided if possible. If such procedures must be performed, they should take place in an airborne infection isolation room. DHCP in the room should wear an N95 or equivalent or higher-level respirator and eye protection, gloves, and a gown. The number of DHCP present during the procedure should be limited to only those essential for patient care and procedural support, and visitors should not be present.
      • Patient transport should be limited to medically essential purposes and patients should wear a cloth face covering or mask during transport, or cover their mouth and nose with tissues if a cloth face covering is unavailable or cannot be tolerated.
      • DHCP should delay entering the operatory to clean and disinfect until after sufficient time has elapsed for enough air changes to remove potentially infectious particles. CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities provides a table to calculate the time required for airborne-contaminant removal by efficiency.

Providing Clinical Care

  • Ensure that DHCP are educated, trained, and have practiced the appropriate use of PPE prior to care for a patient. This includes correct use of PPE and prevention of contamination of clothing, skin, and the environment during the process of removing PPE.
  • Limit care to one patient at a time, whenever possible.
  • Ensure you have the appropriate PPE and supplies to support your patients. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.
  • There is no published evidence regarding the clinical effectiveness of preprocedural mouth rinses to reduce SARS-CoV-2 viral loads or to prevent transmission. Preprocedure mouth rinses with an antimicrobial product (chlorhexidine gluconate, essential oils, povidone iodine or cetylpyridinium chloride) may reduce levels of oral microorganisms in aerosol and spatter generated during dental procedures.
  • DHCP should strive to limit intra-oral 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 minimally invasive/atraumatic restorative techniques (hand instruments only). Commonly used dental equipment known to create aerosols and airborne contamination include ultrasonic scaler, high-speed dental hand piece, air/water syringe, air polishing, and air abrasion.
  • If aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction, and rubber dams or isolating systems to minimize droplet spatter and aerosols.
  • Anti-retraction function of some high-speed hand pieces may provide additional protection against cross-contamination.
  • 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.
  • Avoid aerosol-generating procedures whenever possible, including use of high-speed hand pieces, air/water syringes, and ultrasonic scalers. Clinical judgment, patient and staff safety, and the public welfare must be considered at all times.

Exposure Management

  • Patients should be reminded to contact the dental office and/or practice if COVID-19 signs or symptoms appear or if they are diagnosed with COVID-19 within the next two days.
    • The patient should be referred for testing or encouraged to contact their medical provider, if not already done.
    • DHCP should follow CDC guidance for health care professionals with potential exposure. Consideration is given for the duration of exposure, the type of PPE that was used, and if aerosol-generating procedures were performed.
  • If DHCP have been exposed outside of the dental health care setting, they should follow the relevant guidance for community-related exposure or international travel.
  • For DHCP with COVID-19,  DHS provides guidance for returning to work.

Engineering Controls

CDC provides recommendation for proper maintenance of ventilation systems and patient placement:

  • Consult with HVAC professional to understand clinical air flow patterns, determine air changes per hour, increasing filtration efficiency, and increasing the percentage of outdoor air supplies through the HVAC system.
  • Limit use of demand-controlled ventilation.
  • Consider use of portable high-efficiency particulate air filtration unit while the patient is undergoing, and immediately following, an aerosol-generating procedure.
  • For dental facilities with open floor plans, to prevent the spread of pathogens there should be:
    • At least 6 feet between patient chairs.
    • Physical barriers between patient chairs.
    • Operatories should be oriented parallel to the direction of airflow.
  • Where feasible, place the patient's head near the return air vents, away from pedestrian corridors, and toward the rear wall when using vestibule-type office layouts.

Environmental Infection Control

  • DHCP should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient.
  • Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in dental settings, including patient care areas where aerosol-generating procedures are performed.
  • Only use EPA-registered disinfectants identified in List N that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.
  • The efficacy of alternative disinfection methods, such as ultrasonic waves, high intensity UV radiation, and LED blue light, against SARS-CoV-2 virus is not known.

PPE Supply Optimization Strategies

  • Major distributors in the U.S. have reported shortages of PPE, especially surgical masks and respirators. The anticipated timeline for return to routine levels of PPE is not yet known. CDC has developed a series of strategies or options to optimize supplies of PPE in health care settings when there is limited supply, and a burn rate calculator that provides information for health care facilities to plan and optimize the use of PPE for response to the COVID-19 pandemic. Optimization strategies are provided for gloves, gowns, face masks, eye protection, and respirators.
  • These policies are only intended to remain in effect during times of shortages during the COVID-19 pandemic. DHCP should review this guidance carefully, as it is based on a set of tiered recommendations. Strategies should be implemented sequentially.
  • Decisions to move to contingency and crisis capacity strategies are based on the following assumptions:
    • Facilities understand their current PPE inventory and supply chain.
    • Facilities understand their PPE utilization rate.
    • Facilities are in communication with local health care coalitions, local public health department, and county emergency preparedness management regarding identification of additional supplies.
    • Facilities have already implemented engineering and administrative control measures.
    • Facilities have provided DHCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE that is used to perform job responsibilities.
  • Extended use of face masks and respirators should only be undertaken when the facility is at contingency or crisis capacity and has reasonably implemented all applicable administrative and engineering controls. Such controls include selectively canceling elective and non-urgent procedures and appointments for which PPE is typically used by DHCP. Extended use of PPE is not intended to encourage dental facilities to practice at a normal patient volume during a PPE shortage, but only to be implemented in the short term when other controls have been exhausted. Once the supply of PPE has increased, facilities should return to conventional strategies.

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 Battelle's website for further details.

The Department of Health Services has developed an interim guidance document on respirator use. This document is intended for those who are currently using UVC or vaporous hydrogen peroxide (VHP) for decontamination, or time for inactivation of filtering face piece respirators (FFRs). 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-02664

During the COVID-19 public health emergency, home visiting programs continue to play a vital role in addressing the needs of pregnant women, young children, and families, whether in-person or virtually. Families may have greater needs at this time, making it essential to continue services to: 

  • Connect families to needed health, mental health, child care, and other services.
  • Identify strategies for managing family stress and social isolation.
  • Keep families informed about current public health recommendations related to COVID-19.
  • Promote family emergency planning strategies.

A variety of programs support families with home visiting services, including the Maternal, Infant, and Early Childhood Home Visiting funded programs, Prenatal Care Coordination, Birth to 3 Program, Children’s Long Term Supports Waiver, and others.

Have a Plan

Having policies and procedures in place will ensure programs support guidance of what is required for all staff to adhere to during COVID-19 response. Develop plans and policies to provide a balance of in-person and virtual home visiting in an era of COVID-19. Agency-specific circumstances, program requirements, funding limitations, and local conditions will inform the plan. The plan also needs to acknowledge and focus on family choice since these services are voluntary. The following activities will support the planning process:

  • Assure home visiting services are addressed in the local continuity of operations plan or emergency preparedness plan. The purpose of the plan is to:
    • Respond to disasters and public health emergencies. 
    • Continue priority activities in emergencies. 
    • Restore programs and services after emergencies.
    • Provide for leadership succession and organization in any situation.
    • Redirect services and programs.
    • Assign staff to response activities and priority services.
  • Stay up to date with CDC guidelines, state and local recommendations, and media messaging.
  • Reach out to local/tribal health departments and other agencies and partner programs that send staff into homes to identify and align with their practices. 
  • Monitor ForwardHealth updates for Medicaid-covered services.
  • Continue to talk with funders, models, and agencies about their requirements and recommendations and how they impact the provision of services.
  • Get input from parent leaders related to family choice. Work with partners to think about how to share that input with funders, agencies, and models.
  • Work with local programs and home visitors on the ground to get their input about concerns or questions. Work with partners to share that input with funders, agencies, and models.
  • Assure the home visiting workforce and families have access to cloth face coverings. Note: Surgical masks should be reserved for health care workers, and face shields should only supplement respiratory protection, not replace it.
  • Assure families have access to technology for telehealth visits.

Telehealth

  • 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.
  • The current model recommendation for Maternal, Infant, and Early Childhood Home Visiting programs in Wisconsin is to support the continuation of services via telecommunication/telehealth, such as telephone or video communication.
    • Models include 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.  
  • Medicaid allows real-time technology, including phone communication, for currently covered services that can be delivered with functional equivalency to face-to-face services. This applies to all components of prenatal care coordination (PNCC) including assessment, care planning, case management, health education and nutrition counseling, and postpartum services. Telehealth resources are available on the ForwardHealth website.

Home Visits

Decisions about in-person services will be guided by the level of local and regional COVID-19 transmission and resources to respond to cases and outbreaks. Since local and regional COVID response will vary, there is a need for both continuity of operations and emergency preparedness plans, as well as policies and procedures for the home visiting agency. These plans should be shared with the local/tribal health department. For example, there should be a clear plan with steps of when to move from exclusively telehealth services to combination telehealth and in-person services. 

It will be important to consider if the needs of the families require a home visit or if the needs could be met in other ways such as a virtual contact or referral to other health care or community resources. Also, staff will need to consider their own risk of transmitting or contracting the infection and identify family members in the home who are at greater risk of transmitting infection or having complications if infected with COVID-19. Service providers and families need to jointly decide if the benefits of an in-person home visit outweigh the risks.

The Health Resources and Services Administration (HRSA) has additional information to support decision-making. This information on home visitor mitigation of risk has been developed by HRSA, in consultation with the Centers for Disease Control and Prevention (CDC).

Best practice policies and procedures include the following:

  • Home visiting programs assess staff and clients for symptoms of COVID-19 infection prior to entering a home.
  • Home visiting staff and clients follow safety precautions related to physical distancing, hand washing and the use of cloth face coverings.
  • If any person within the home is found to be ill, they are referred for testing and medical care and the visit is conducted via telehealth options.
  • Staff at high risk of severe COVID-19 complications (those who are older or have underlying health conditions) avoid conducting in-person home visits with sick clients.
  • If a home visitor develops signs and symptoms of illness while on the job or after providing a home visit, they notify their supervisor and follow current CDC and local and state health department guidance. 
  • All non-dedicated, non-disposable medical equipment used for patient care (such as scales, stethoscope, developmental screening tools) should be cleaned and disinfected according to manufacturer’s instructions and facility policies.

Provider Considerations for a Home Visit

Prior to an in-person visit, the home visitor should have video or verbal contact with the program participant to assess and evaluate the current home environment. Ask program participants if they are willing to share the following information and inform family of the necessity of providing this information prior to a visit:

  • Does anyone in the home have symptoms of a COVID-19 infection?
  • Has anyone in the home had contact, within the last 14 days, with someone who tested positive for COVID-19, is under investigation for COVID-19, or is ill with respiratory symptoms?
  • Are there people in the household with weakened immune systems, over the age of 60, or with chronic health problems who are at higher risk of COVID-19 complications?

Family Considerations for a Home Visit

  • Families need to know their home visitor does not have a fever or other symptoms of COVID-19 and is prepared to follow safety precautions recommended by the CDC and the employing agency.
  • Families can seek advice from their primary care provider if there are safety concerns about home visits for clients and children with special health care needs. Home visitors can support referral to medical services and consultation for families without a primary care provider.

Preparing for a Home Visit

Home visitors need to inform families about safety measures for in-person visits. For more information, see the handout COVID-19: Protecting yourself during a home visit. The home visitor should make the final decision as to their ability to maintain safety and wellbeing of all participants; for themselves and families during a home visit. Key questions include the following:

  • Is it possible to maintain a distance of at least 6 feet between the home visitor and family members during a visit? 
  • Could the home visit can take place outside?
  • How can contact with frequently-touched surfaces in the home be minimized?
  • Is there access to soap and water for at least 20 seconds of handwashing before entering the home and after exiting?
  • If soap and water are not available, is there access to hand sanitizer that contains at least 60% alcohol? 
  • What reminders are needed to avoid touching eyes, nose, and mouth?

Personal Protective Equipment (PPE)

  • For more information on PPE, please see the DHS COVID-19 PPE webpage.
  • 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. See the fact sheet for Home and Community Based Service Providers and the fact sheet for Recipients of Home and Community Based Services.
  • In accordance with DHS guidance, home visiting providers should implement use of universal cloth face coverings by all workers when they enter a family’s home. Families should also wear cloth face coverings when interacting with someone from outside their residence.
  • Identify barriers to the use of cloth face coverings. Individuals may not be able to wear a face covering safely due to traumatic personal experiences or medical concerns. Individuals may also fear racial profiling or discrimination based on wearing—or not wearing—a face covering. Access to clean or appropriate face coverings may also be a barrier.
  • Home visitors can help families understand recommendations for face coverings for children.
    • The CDC recommends that everyone 2 years and older wear a cloth face covering that covers their nose and mouth when they are out in the community when social distancing measures are difficult to maintain. 
    • The CDC and the American Academy of Pediatrics caution that face coverings should not be put on babies or children younger than 2 years of age because of the risk of suffocation. 
    • Face masks should not be used for anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the face covering without assistance (CDC).
    • Use of a cloth face covering is not appropriate if it presents a choking or strangulation hazard for a child or if children touch their face more frequently when wearing a face covering (AAP).
    • Children over the age of 2 should wear cloth face coverings in places where they may not be able to avoid staying 6 feet away from others such as appointments with medical providers and home visitors. 
    • Children do not need to wear a cloth face covering when at home or riding in car or vehicle with their family (assuming they have not been exposed to anyone with COVID-19). 

Training and Resources

 Infection preventionists

 Information about Wisconsin's Medicaid Section 1135 Waivers and K Appendices

In response to the COVID-19 pandemic, the Wisconsin Department of Health Services has requested flexibilities from the Centers for Medicare and Medicaid Services. These requests with summary cover sheets are available for review.

 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

Preparing and responding to the Coronavirus (COVID-19) pandemic.

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.

Logo for Resilient Wisconsin: Connected. Stronger. Thriving.

Finding healthy ways to cope with challenges is more important than ever. Resilient Wisconsin offers strategies for practicing self-care, maintaining social connections, and reducing stress and anxiety. 

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: October 21, 2020