SECTION 1: Prevention Policy

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1. Patients older than age 70 or those with known cardiovascular disease will not be seen for routine office visits until the epidemic has sufficiently subsided or they become infected and are fully recovered.

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2. Patients older than age 70 or those with Diabetes, COPD or cardiovascular disease will not be given immunosuppressive therapy if the risk of Covid-19 death is greater than the risk of not treating their other disease.  After they check in, such patients will be asked to wait in their cars instead of the waiting room

3. All patients will be notified to not come into the office if they have had a fever or dry cough or any other flu symptoms within the past 24 hours, or if they have been near someone with proven Covid-19 infection or traveled outside the country within 30 days, but to call to reschedule their appointments. (See below:  “Criteria for Exclusion from Cancer Center…”)

4. Visitors are not to accompany patients into the office unless a special exception is made for special needs.  No guests, only patients, will be allowed in the chemotherapy area.

5. All persons coming to the office must put on a mask when leaving home and must wear it the entire time they are at the office and afterwards until they arrive home.

6. When patients first arrive, they must wait outside until they have been cleared by medical personnel. They must have their temperature checked, and they must leave if they have a fever >100.0 degrees, a cough, or other flu symptoms, or if they have had any of these within 24 hours.  They must complete a questionnaire to identify their risk factors for having the virus and for dying if they catch the virus.  Those at high risk of having the virus will not be allowed in the office but will be sent home, for the protection of other patients.  Those at high risk of dying if infected will be sent to wait in their cars, and their cell phone number or car description will be recorded so they can be called in at the right time.

7. . All personnel have been tested at baseline for Covid-19 infection and are negative. Any personnel who later develop fever, cough or other flu symptoms must be immediately retested and stay home for 14 days.  If they have a known high risk exposure to the virus, they must stay home 28 days or for 14 days after a positive test.  (See below:  “Exposures to COVID-19 Patients by Medical Personnel” and “Criteria for Exclusion from Cancer Center..”)

8. All personnel must wear masks at all times when near other employees and to wear M95 masks and eye protection when near patients.  They are to avoid shaking hands with anyone but to use alternative greeting methods.  All personnel must make every effort to stay more than 6 feet away from other persons. They must follow the same precautions outside work as they do at work, including wearing a mask to protect others, to avoid developing Covid-19 infection and then bringing it into the office.

9. All surfaces that could be contaminated by cough or other respiratory secretions or by patient or employee touch are to be disinfected with bleach, alcohol or other EPA-approved disinfectant daily.  This includes all keypads, phone keyboards, computer keyboards, computer mouses, countertops, and waiting room chairs.  Exam room counters, chairs, tables, and anything else a patient might touch, and chemotherapy recliners, bed, IV poles and chemo carts, should be disinfected after every patient.  Finally, surfaces frequently touched such as all door handles, toilet and faucet handles, should be disinfected multiple times throughout the day.  The patient schedule must be shortened to permit personnel time to complete all essential disinfecting procedures.

10. Magazines are to be made unavailable in exam rooms, waiting room and treatment areas, and the public drinking fountain is to be closed.

11. All personnel must obsessively wash their hands for 20 seconds with soap and water, or with alcohol hand rub, after every patient contact or after touching any object or surface that might have become contaminated with virus.  All personnel must always refrain from ever touching their face, eyes, nose or mouth with their hands. (Rarely, in special circumstances this may be done if thorough hand washing is performed beforehand and afterward.)

12. N-95 masks will be reused no more than 5 times and 2 masks will be alternated, using each every other day, with the last used mask kept in a paper bag for 38+ hours between reuses.  Personnel are to wash hands before and after touching any mask to avoid contaminating it or themselves.  They are to take off a mask by grasping the strings or bands. They are to perform a user seal check when donning the N-95 mask and then wear it continuously without touching it to readjust it for comfort or to allow the nose out.  They must never pull it down to eat and then pull it back up. Any mask should be immediately discarded if it is contacted by any patient body fluid or if it is used within 6 feet of a patient with known or suspected Covid-19 infection.  Eye shields, goggles or glasses are to be disinfected after removal before they are reused, and personnel are to wash hands before and after touching them.

13. In the lunch room only plastic eating utensils and cups, and paper plates and bowls, are to be used.   All tables and counters are to be disinfected daily after lunch.  Drug representatives and other vendors are not to come into the office until the epidemic has sufficiently subsided.  Personnel are to keep a 6 foot distance between each other in the lunch room, unless they are wearing surgical or N-95 masks. .

14. Precautions must be taken in receiving and opening shipments of drugs and supplies that have gone through the transportation system and potentially been exposed to the virus.  If possible, wait 24 hours to open cardboard containers to allow for any virus to become nonviable.  Wash hands for 20 seconds with soap and water after handling any shipment.

15. Also follow the same precautions in opening and distributing the mail.

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SECTION 2: Exposures to COVID-19 Patients by Medical Personnel

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a. 4 Types of Exposure

Very High Risk:  Performing aerosol-generating procedure on infected patient or collecting/handling specimens from living or dead victims.

High Risk:  Prolonged close contact at less than 6 feet for more than a few minutes with an infected patient who is not wearing a mask when the medical worker is not wearing a mask and eye cover

Medium Risk:  Brief interaction without contact with a patient who is not wearing a mask, when the medical worker is not wearing a mask, or several minutes of close contact with a patient wearing a mask when the medical worker is not using a mask, or with a patient not wearing a mask when the medical worker is wearing a mask but not wearing eye cover.

Low Risk:  Prolonged close contact with a patient wearing a mask when the medical worker is also wearing a mask but not using either eye cover, gown, or gloves or is using a non-N-95 mask

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b.  Management of Exposures by the Medical Facility:

High or Medium Risk: Medical worker is quarantined for 28 days starting with the date of exposure, or for 14 days after a positive test.
 

Low Risk: Careful Self-Monitoring with supervision

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SECTION 3: Criteria for Exclusion from Cancer Center During COVID-19 Pandemic

A. Natural History—Phases of infection:
   

1. 60-75% become symptomatic

Incubation Period (From Exposure to 1st Symptoms)—average 5 days (2-14 days)

Symptomatic Period (From 1st symptoms to Resolution)—average 8 days (2-14+ days)

Contagious Phase (Test positive, shedding virus)—average 9 days (6-14 days)

Prior to symptoms:  2-3 days
After symptoms resolve:  average 2.5 days (1-8 days)
During Symptoms:  average 4.5 days (3-10 days)

2.  25-40% Never have symptoms
 

3.   Worst-Case Contagion Periods (Contagious 14 days)

Asymptomatic Infection, and untested or false negative tests:  Contagious starting up  to 12 days after and ending up to 26 days after exposure (26 day risk period)                                       

                                            
Symptomatic infection:  Contagious starting up to 3 days before and ending up to 12 days after onset of symptoms (15 day risk period)

Positive test:  Contagious up to 14 days before and ending up to 14 days after test (28 day risk period)

B. Quarantine of employees with confirmed or suspected COVID-19 or high/intermediate risk exposure:

1. Standard guidelines  (Suboptimal for care of patients at high risk of death from Covid-19)

a. When employee can return to work—(2 ways to qualify):

1. Afebrile without Tylenol, cough/dyspnea improved (not resolved), and 2 tests negative at >24 hours apart

2. Afebrile without Tylenol, cough/dyspnea improved, both for >3 days, and >7 days since onset of symptoms or >10 days since date of 1st positive test if never symptomatic

b. After returning to work:  must wear mask constantly until all symptoms resolved, or 14 days after onset of symptoms, whichever is longer. No contact with any Hematology, Oncology or other immunocompromised patients for 14 days after onset of symptoms

2. Bryson Cancer Care policy for employees—(Based on Worst Case scenarios)
 

a. High/Intermediate Risk exposure (on or off duty), asymptomatic

With negative or no test:  Quarantine for 4 weeks after exposure.
With positive test:  Quarantine for 2 weeks after date of test.  Evaluate other employees for high/intermediate risk exposures to that employee during the 14 days before date of test, which would require them to be quarantined 4 weeks from the date of test or 14 days from the date of their own positive test.        

                                     
b. Symptomatic Infection:  Quarantine 2 weeks from onset of symptoms or from date of positive test, whichever is earlier.

C. Criteria for excluding asymptomatic persons from Cancer Center:  High risk exposures (Travel outside U.S. or to large U.S. cities, contact with persons testing positive and/or symptomatic, or contact with persons who have been to a nursing home or who work with Covid-19 positive patients).  This policy is based on the worst case scenario of each asymptomatic person having Covid-19 infection with a false negative test and maximum length of incubation and contagious phases.
 

1. Contact tests positive:  if last exposure to contact was >14 days before test, not at risk

2. Contact tests negative or not tested:  If last exposure to contact was >28 days after the contact had exposure, not at risk. If last exposure to contact was >28 days ago, not contagious.

3. Anyone not meeting the above criteria will be excluded from the Cancer Center until they do, or else for 28 days after last contact.

4. Anyone who has traveled to a high risk area alone (including the return trip in public transportation), visited a nursing home alone, or had any other high risk exposure alone, will be excluded from the Cancer Center for 28 days after the exposure ended or for 14 days after their own positive test. 

5. Anyone who has travelled, visited, or had other high risk exposures in a group of one or more persons, and has continued to contact members of that group, will be excluded from the Cancer Center for 28 days after the last contact with any member of the group, up to 56 days from the end of the joint exposure, or for 14 days after their own positive test.

D. Patients with proven or suspected Covid-19 Infection (Positive test or infectious Symptoms)
 

Excluded from Cancer Center and Quarantined, for 14 days from date of positive test or from onset of symptoms.  If not yet tested, referred to a testing center.