How to handle a patient who seems to be under the weather

Everyone should’ve learned about it in grade school: If you’re sick, stay home. Unfortunately, there are times when patients don’t heed that advice and show up for their scheduled visit, putting the practice’s staff and the other patients at risk. What should be done if a visibly ill patient shows up for his or her visit? Send him or her home.

“Per the CDC, you’re not supposed to see them,” says Dr. Lisa Kane, DMD, a dental consultant at Dental Office Compliance of New England. “I know that’s not what most people do, but you’re not supposed to treat them. It’s dangerous for the staff and for other patients. If there’s someone in the office who’s elderly or immunocompromised, it’s also dangerous for that patient because they could get an infection. I tell people that if you have someone who’s contagious in any sort of way, send them back-unless it’s an emergency. If it’s an emergency, then find some place that has proper airborne precautions, like a hospital.”

Screening

The starting point is to prevent patients who may be ill from coming into the practice. That can be accomplished when appointments are confirmed. Screening efforts should continue as patients arrive for their visits.

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“The first thing that happens is that prescreening occurs by administrative personnel who confirm appointments, and if they detect any type of illness, they should be trained to make the determination whether or not the patient should be seen that day,” says Dr. Marie Fluent, DDS, an educational consultant for The Organization for Safety, Asepsis and Prevention (OSAP). “Hopefully, the office has policies in place where they can make that decision by themselves. However, if they cannot make that decision, they should consult with the dentist or the infection control coordinator to say, ‘The patient is experiencing these symptoms. What do we recommend?’ Typically, if the patient is scheduled for routine care and has symptoms such as a high fever, upper respiratory infection, vomiting or diarrhea, obviously, the appointment should be rescheduled.”

Suspect symptoms should be fairly obvious.

“If someone’s in there coughing or sneezing or can’t breathe out of their nose or they have a fever, then that’s when they shouldn’t be seen,” Dr. Kane says. “People will come in and tell you it’s allergies, and you’ll have to make a call. If they’re actively coughing or sneezing, then that’s pretty clear that they can’t sit in the chair, so it’s not beneficial for them. You’re not going to be able to do a good job on them. If you have someone who needs to take a break every few seconds because they have to sneeze or they can’t breathe, then you can’t keep a dry field and you can’t do what you’re supposed to do.”

Training

Front desk staff members are the first line of defense against patients who may be under the weather. Being able to properly identify those patients requires some vigilance as well as knowledge. One tool that can help with that endeavor is signage advising patients to let staff know if they’re ill.

“There should be a sign or poster in the reception area for patients who are symptomatic to identify themselves,” Dr. Fluent says. “But, anything that is obvious should be noted and addressed. For instance, if there is a patient in the reception area who is coughing, sneezing, has a runny nose, or just looks visibly ill, front desk personnel should inquire whether they are feeling okay. While protecting privacy, they may discretely ask the patient about their symptoms. Patients are used to hearing such screening inquiries by administrative personnel, and it really shouldn’t catch them off guard.”

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The CDC offers guidance in managing sick patients.

“If the patient falls through the cracks and arrives to the office while displaying signs of illness, CDC guidelines provide policies and protocol,” Dr. Fluent says. “First, it is important to spatially separate ill patients from healthy patients if your reception area allows. If not, the patient should be taken out of the reception area and into the operatory as soon as possible. In addition, all offices are required to have a poster in or near the reception area that says, ‘Cover Your Cough,’ which provides instructions to the patient or family member or guest who might be accompanying them. The poster shows how to stop the spread of germs and includes information such as covering the mouth and nose with a tissue, disposing of the tissue after use, coughing or sneezing into the upper sleeve or elbow if you do not have a tissue, washing hands or using an alcohol-based sanitizer, and noting that a face mask may be provided to protect others. ‘Cover Your Cough’ posters may be downloaded for free from the CDC website.”

“The front desk is the point of entry,” Dr. Kane adds. “So, they are supposed to screen people and they’re supposed to have tissues, hand sanitizer, a trash can, that kind of stuff.”

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Emergency care

In the event that the patient who is ill is being seen for a dental emergency-such as a broken tooth or pain-Dr. Fluent advises those patients should be seen same-day, if possible.

“In an emergency situation only, the urgent treatment should be performed and routine procedures rescheduled. If it’s an emergency procedure, the dentist should see the patient as soon as possible, so they are not in the reception area and transmitting infection to other patients or guests.

“Clinical personnel who see the patient who is ill should be attentive to their personal protective equipment-as they should for all patients,” she continues. “That would include wearing protective eyewear, gowns, masks and gloves. Standard precautions protect dental personnel from infection and prevent the spread of infection from patient to patient.”

Dr. Kane suggests an even more assertive approach: refer those patients to an emergency room.

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“A typical dental office does not have appropriate airborne precautions,” Dr. Kane says. “Everyone’s wearing personal protective equipment and you have a mask and you have gloves and everything, but you’re not 100 percent protected, especially with something that’s airborne. I tell people that if there’s someone who has an emergency, they should go to a hospital setting. You should not see the people that are going to contaminate you or other people or of themselves.”

Patient acceptance

While a patient may be advised to reschedule his or her appointment, it may take some effort to get the patient to do so. But, the practice can remove any surprises by ensuring there’s a written policy in place.

“I get it. It’s a pain in the neck,” Dr. Kane says. “You don’t want to go out of your way. You’re taking time out of your day. You’re afraid you’re probably going to be charged. The office should have a nice written policy that says that you need to reschedule if you’re sick. And then I always tell people to explain it to the patient. If you go in and you explain to them why it’s detrimental to them and to others if they come in sick, then I would imagine most patients would understand.”

Identifying ill patients should be seemingly straightforward, but for some, there can still be a certain level of ambiguity.

“If you work in a pediatric office, every other child who comes through the door, particularly in the winter months, seems to have a runny nose or scratchy throat or some other symptom of illness,” Dr. Fluent says. “So, of course, if you turned away every patient who exhibits any symptoms whatsoever, you may have an empty schedule. While practicing dentistry, I reappointed patients who had symptoms such as fever, diarrhea, vomiting and strep throat (if on antibiotics less than 24 hours).”

If and when sick patients do show up for a visit, properly identifying, rescheduling (if possible) and minimizing their exposure to other patients and staff is vital in the prevention and spread of infection. If the ill patient is treated, standard precautions, based on a risk assessment, will protect healthcare providers from infection and prevent the spread of infection from patient to patient.