Ensuring continuity of care by small family practices and clinics in the primary care setting during COVID 19 pandemic 2020 - A position paper by the Academy of Family Physicians of India

Abstract

The world is passing through a global pandemic of COVID 19. The number of positive cases has crossed over twenty thousand as of April 2020. Like everyone else, it is indeed a very challenging situation for family physicians and primary care providers as most of the guidelines presently have focused on screening, quarantine, isolation, and hospital-based management. Limited information or clarity is available on running small private clinics during pandemic times. The key concern is professional obligation versus risks of community transmission. Family physicians see routine flu-like illnesses throughout the year with seasonal variation within their practices. This document is intended to develop consensus and standard practices for the family physicians and other primary care providers during the pandemic, ensuring optimal continuity of care. This document was reviewed by the national executive of the Academy of Family Physicians of India and approved for dissemination among members. However, due to the dynamic status of the pandemic, all practitioners are advised to closely follow the instructions, guidelines, and advisories of national, state and local health authorities as well.

'I urge you to as much as possible, avoid going to the hospital for routine check-ups. When necessary, you could get the required guidance over the phone from your known local doctor, family doctor, or some relative who is a doctor. In case you have a non-essential, elective surgery scheduled, I would urge you to postpone it by a month'

- Honorable Prime Minister of Indian, Shri Narenda Modi

(Address to the nation on March 19th, 2020)

COVID 19: Background

The first case COVID 19 was reported in India on 30^th January 2020 in the Kerala state of India. Screening of international travelers and quarantine was already in place since the novel coronavirus started to appear as a grave public health challenge in China. COVID 19 was declared a global pandemic on 11^th March 2020 by the World Health Organization. The government of India and various state governments have swang into swift action on various fronts to address the pandemic crisis. The prime minister of India called for Janta Curfew - self-imposed voluntary lockdown by the public on 22^nd March 2020. This was followed up by lockdown in 75 districts across India, the one that was impacted by COVID 19 positive cases. Further from 25^th March, a nationwide lockdown has been imposed for 21 days.

COVID 19 pandemic: Functioning of family practices and primary care clinics

India is in the middle of one of the worst public health crises of the century given the epidemiological pattern and impact of COVID 19 pandemic. From 25^th March 2020, the whole country is under a national wide lockdown like many other parts of the world. In the absence of any plausible guidelines for small private clinics during pandemic times, it is necessary to develop practice standards because of the risks of community transmission. As per the initial advisory issued by the various government agencies, OPD - outpatient services are to be limited or suspended and only emergency services at hospitals are to be continued. All elective surgeries are to be postponed for a month's time. Small hospitals and clinics are supposed to provide emergency care only with diligent maintenance of proper hygiene, sanitation, and personal protection equipment (PPE). Presently all positive COVID patients and their contacts are being taken care of by the public health system at designated COVID hospitals. There is no direct role of family physicians apart from the triage of potentially infected persons and arranging for appropriate referral. However, as a professional obligation, they are expected to maintain continuity of care to their patients suffering from other non-covid acute as well as chronic community-based illnesses.

PPE use and prevention of contamination

There have been instances reported, where health care workers have been found to be carrying and spreading infection inadvertently. Two doctors running Mohalla Clinics were found positive. [1] Two general practitioners have also tested positive in Mumbai. [2]. The first two doctors to die in India due to COVID 19 are family physicians.[3] During pandemics, our principle should be first doing no harm and establishing the continuity of care. Seasonal flu and suspected COVID 19 patients or contacts, if seen face to face, should be examined with utmost care with full PPE protection by all clinical and nonclinical staff. The whole clinic premise should be sanitized as per standards. All potential patients, contacts should be referred to the designated COVID state health system institutions through proper triage channels. All clinics and practitioners should take initiative and should establish communication links with local COVID 19 helplines and local health authorities in case there is a need. All persons should be guided through seamless access to the most appropriate healthcare facility during the period of crisis.

Primary care routine consultations during the pandemic

Considering the pandemic situation, it is wise to limit all nonurgent face to face routine consultations at clinics. All patients must be seen with a prior appointment and formal telephone triage. A separate area within the clinic for fever screening should be designated. All clinical and nonclinical staff must use a face mask during the entire work duration. All patients entering the clinic premise should also use a face mask and be given hand sanitizer. The number of accompanying patients should be limited to maximum one and the only patients should be allowed to enter the examination chamber provided there is no contraindication. Clinics may be opened for a reduced duration of each day for the convenience of the community. This may be modified further depending upon the instructions from the local health authorities. All practicing doctors in the community are expected to comply with the instructions of the local health authorities. In the districts, states, communities where no cases have been reported, and are not under lockdown, clinics may continue to provide services with upgraded levels of sanitation, hygiene, and personal protection. Those who are in government services should continue to work as per established protocols.

Shift to digital: Optimise continuity of care

Leveraging on the technological advancements, family physicians should optimize continuity of care to the community, through available digital communication platforms. During this period of crisis, primary care providers should extend triage services and health care advice to anyone who seeks help through email, telephone and video conferencing. Though this may not be the most ideal, we understand that a large majority of the common health problems in primary care can be addressed in this way. Therefore family physicians can address most non-flu like illnesses and general health problems that are not being currently seen at routine hospital OPDs. This is most of the optimal and most useful care family doctors can provide during the period of COVID 19 pandemic. Further, in a meeting of all medical associations with the Prime Minister of India, the issue of the legal standing of telemedicine was raised. Academy of Family Physicians of India was also represented at this meeting. Almost immediately the Medical Council of India issued guidelines on a telemedicine consultation. Telemedicine consultation should be organized within the framework of this guideline. [4]

Keep updated with scientific knowledge

Family physicians should also keep ourselves updated with scientific knowledge as it is evolving. Keeping a close eye on the directions of your local health authorities regarding the pandemic is expected from all family doctors. Family physicians should function as an efficient resource person for the community and health authorities and coordinate for appropriate health education, screening, home management, and referral to health facilities as and when required. Home care for any patient should be in lines of the protocol promulgated by local health authorities, All India Institute of Medical Sciences (AIIMS), Indian Council for Medical Research (ICMR), Ministry of Health and Family Welfare (MOHFW) and the respective state government health authorities and revised from time to time.

National Helpline and Social Media activities by Family Physicians

Academy of Family Physicians of India (AFPI) is running a national chat helpline www.wefightcorona.in for the general public. This is a free service and anyone can visit the site and get authentic information and advice from family physicians. The academy is thankful to all volunteers who have registered themselves for the national helpline. Currently, more than sixty family physicians have signed up and providing online help. As professionals, we are expected to disseminate only positive, authentic and practically useful resources for our patients and communities. Members of the academy are expected to refrain from any unnecessary forwarding and sharing of unauthentic material. Family doctors should refrain from posting and sharing any controversial material on social media.

Protect yourself as reserve healthcare workforce

It is a well-known fact that those healthcare professionals who are working in the direct care of provision to COVID 19 patients are at higher risk of infection and many of them may require quarantine in due course if the pandemic situation worsens further. Self-care, care of our families and immediate community is our responsibility. To our members who are in private practice, we advise them to be ready to volunteer and report to any call of duty should any emergency be called by health agencies, and should the situation escalate further.

We stand together in solidarity

We applaud all healthcare workers for their heroic work. This is also time to show solidarity with all stakeholders including governments and local health authorities. Please be safe and volunteer to keep our communities safer. We stand in solidarity with our patients, communities, government, and nation. We stand in solidarity with our professional colleagues all world over. We stand by all human beings all across the globe in the moment of crisis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.