Most clinics should limit visitors though this varies considerably even after utilizing telemedicine options, whenever possible. Expenditure is involved in putting a system in place for scheduling appointments for patients, though not always possible in Indian scenario. Number of accompanying persons has to be restricted to reduce crowding. Expenses are also incurred on pre-appointment screening of patients including measuring temperature, acquiring epidemiological history, and triaging according to clinical symptoms. Suspected cases have to be isolated and reported immediately. Cleaning and sanitization of the visitors room and out-patient area is required periodically to provide safe environment to visiting patient and staff [8].

Personal protective equipment (PPE) use is a prerequisite for patient interactions by all healthcare workers. According to current guidelines from the Centers for Disease Control and Prevention, appropriate PPE for patients with suspected or confirmed COVID-19 entails the use of respirators, isolation gowns, surgical caps, gloves, water-resistant boot covers and face shields and goggles [9].

Separate washing area accessible to patients and their attendants has to be created where they can wash their hands with soap and water before and after interacting with doctors. Repeated hand sanitization is to be done by the doctor as well as other staff using a virucidal hydro-alcoholic solution (HAS). Frequent washing of hands with soft soap followed by drying their hands with single-use hand towels is recommended for all healthcare workers.

Social distancing measures are to be followed by everyone in reception and waiting areas thereby making reorganization of standing as well as sitting area depending upon the premises area. Standard hygiene measures are to be taken and a surgical mask has to be provided to those entering without face masks.

Hygiene messages are to be displayed as well as counseling is to be done.

The following must be provided in the waiting room: single-use tissues, bins with bags and lids, HAS for disinfecting hands, a sink with soft liquid soap and single-use hand towels for washing hands. Waste from potentially ill people must be eliminated.

The risk that contaminated aerosols originating from droplets emitted by COVID-19 positive patients could contaminate the waiting room (chairs, furniture, work surfaces, floor, etc.) must be taken into account.

In practice, it is recommended to clean high contact surfaces regularly with 1% Sodium Hypochlorite, standard virucidal disinfectant cleaning wipe, paying particular attention to surfaces in direct contact with patients (door handles, furniture, toilet flush, sink, etc.), to ventilate the premises extensively and regularly, and to schedule a complete bio-cleaning once a day (preferably in the evening). The equipment itself is disinfected by wiping the surface using 75% ethanol [10].

A variable expenditure per day will be incurred depending upon the number of out-patients visitors. Following table shows approximate additional expenditure (Covid related) for an Out-patient catering to about 30 patients daily (Table 1).

Covid pandemic has increased the cost of running an Otolaryngology practice world over but in India and other low and middle income countries the impact is huge as penetration of health insurance/social security is minimal. As out of pocket expenditure forms a significant proportion of healthcare spending by majority in India, any transfer of additional cost incurred because of COVID-19 pandemic to the patient will burn a bigger hole in their pocket. With decreasing number of elective surgeries, decreasing OPD attendance and dwindling indoor occupancy, increasing cost of running a routine out-patient is stretching a practicing otolaryngologist’s resources to the maximum, making it unviable for those with limited resources, both doctors and patients. This underlines the need for hand holding by policy makers to keep the healthcare sector afloat during this crisis [11].