浅析CDC新冠指南在普通门诊的应用

by ZHF

新冠疫情在美国已经不可避免，目前有80例本土感染，死亡人数达9位（数字每天在变）。疫情在社区蔓延开的时候，门诊医生们往往处在抗疫的第一线。然而很多普通门诊都没有负压隔离病房。在这种情况下，怎样才能更好地保护医护人员，又能正确处理具有急性呼吸道症状和发热的病人呢？
首先，根据CDC指南正确地评估和分诊具有急性呼吸道症状的病人，降低医护人员感染病毒的机会。需要做好一个分诊的流程图，让前台接待员在病人电话或者是电脑预约的时候可以使用。询问所有预约病人的症状，如果有发热、咳嗽、呼吸困难这些急性呼吸道感染症状，同时又有去疫区的旅行史或者跟确诊的新冠病人密切接触史，那么根据CDC的指南，他们是符合疑似新冠病人(PUI)的标准（见下表）。这时，需要立即给当地的卫生防疫部门或者是医院系统的传染病专家打电话，而他们会接手病人下一步的测试。病人暂时不要到诊所来，这样就减少了病毒感染整个诊所和医护人员的机会，从而进一步降低了医源性密集性传染社区的风险。
Contact your local or state health department
Healthcare providers should immediately notify their localexternal icon or stateexternal icon health department in the event of a PUI for COVID-19.

Criteria to Guide Evaluation of PUI for COVID-19

As availability of diagnostic testing for COVID-19 increases, clinicians will be able to access laboratory tests for diagnosing COVID-19 through clinical laboratories performing tests authorized by FDA under an Emergency Use Authorization (EUA). Clinicians will also be able to access laboratory testing through public health laboratories in their jurisdictions.This expands testing to a wider group of symptomatic patients. Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Decisions on which patients receive testing should be based on the local epidemiology of COVID-19, as well as the clinical course of illness. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza.Epidemiologic factors that may help guide decisions on whether to test include: any persons, including healthcare workers2, who have had close contact3 with a laboratory-confirmed4 COVID-19 patient within 14 days of symptom onset, or a history of travel from affected geographic areas5 (see below) within 14 days of symptom onset.

International Areas with Sustained (Ongoing) Transmission

Last updated February 28, 2020

• China (Level 3 Travel Health Notice)
• Iran (Level 3 Travel Health Notice)
• Italy (Level 3 Travel Health Notice)
• Japan (Level 2 Travel Health Notice)
• South Korea (Level 3 Travel Health Notice)
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其次，根据CD C的感染防控指南
infection prevention and control (IPC)，制定修改符合自己诊所的感染防控规章制度。因为有的病人不通过预约会直接到诊所来，另外根据CD C的指南，还有一类病人就是有急性呼吸道症状，但是没有旅行史或接触史，如果能够排除其他原因引起的症状，也符合上面所说的疑似新冠病人标准。这一部分病人就必须到诊所里来，才能排除其他原因。而这个过程就存在着污染整个诊所的可能性。在此之前，制定好整个诊所的感染防控规章制度，培训好诊所的所有员工就至关重要。这包括1. 照顾病人时的标准防护、接触防护、空气飞沫和眼睛的防护。2. 看病人之前和之后，接触到有可能污染物质之后，穿上个人防护用具之前和脱掉防护用具之后正确的洗手程序。3. 学习和训练如何正确地穿脱个人防护用具，以降低自身污染的可能性。4. 在可能产生气雾的操作过程中，正确使用个人防护用具和遵循正确的操作规范。
第三就是注意环境的清洁与消毒。常规的消毒和清洁诊所对新冠病毒的防控也是合适的，包括产生气雾操作过程中病人所在的区域。正确处理衣物，食品用具，医源性废物。
最后， 还要知道何时联系当地卫生防疫部门和职业健康机构。当医护人员在没有防护状态下接触到疑似或确诊的新冠病人，应该立即向职业健康部门汇报。如果医护人员出现了疑似新冠症状，如发烧，咳嗽，呼吸困难等，留在家里不要上班，并马上联系职业健康部门。
reference: 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients.html