This document guides safe clinical practice for small practices
RATIONALE FOR RECOMMENDATIONS: COVID-19 is now being locally transmitted in South Africa, unrelated to a travel history. Any patient coming in with flu symptoms could be having COVID-19. in fact, patients without any symptoms could be shedding the virus up to 24 hours before simply by talking or laughing. however, NICD testing criteria (2nd April) below remain stringent.
What is of importance in practice is the notion of close contact i.e. more than 15min at less than 1m in a closed space. This does not mean the virus cannot spread further but the risk is less. A cough, sneeze, laughing or talking sheds virus in two ways – either aerosolised and hanging in the air for hours in a closed space or droplets which get caught in the patient’s hand if they cover their mouth/nose or fall to the ground or any other surface. Anything touched by that hand is a source of transmission, including doorknobs, desks and chairs.
There are different types of masks. The N95, FFP2 and KN95 are equivalent respirators and considered more protective than surgical masks in an infectious environment. However, a systematic review comparing N95s and surgical masks found no evidence of difference in the real-world practice of health care workers largely due to poorly fitting N95 masks. Whilst cloth face masks are not first choice for healthcare workers, they can be efficacious. Experiments show that a double layered face mask made of pillowcase or 100% cotton t-shirt had protection against particles 5 times smaller than Corona Virus of 62% and 71% respectively, compared to 89% with a surgical mask.
The public primary health care service in Johannesburg has a plan for COVID-19.
- What should the process of seeing patients be?
- Practice patients should be informed by email, sms and/or paper that more than 80% of patients with COVID-19 are mildly symptomatic and need to just treat their symptoms but importantly self-isolate at home given clear directions as a patient information sheet.
- Telemedicine should be promoted to patients using available platforms including WhatsApp; Zoom; Skype; Microsoft teams etc. However, if they need to come then the practice needs to enforce strong physical distancing, hand hygiene and staff protection.
- Patients should be stopped from entering the practice doors without control. All patients should be sprayed with hand steriliser and told to wait outside. All patients should wear or be given a cloth face mask to reduce droplet spread.
- Patients who have flu-like symptoms (cough, fever, difficulty breathing) should be separated from patients presenting to a health facility for non-COVID illnesses and prioritised.
- The practice needs strong physical distancing. All patients should be made to wait outside the door and allowed to enter one at a time. Masking tape should be used outside the practice doors to create squares of 1.5m square stretching as far as is needed to cater to those waiting. Patients should be requested to stand. If chairs are used, then patients must not move one to the other. A reception staff member needs to collect people from their chairs and wipe them down with sanitiser to allow another to sit. This reception staff member must regularly monitor adherence to the lines outside. A square should be marked 1m away from the reception desk so that a patient does not touch anything, especially the desk. If a plastic chair is used there, then it must be wiped down with sanitiser after every person goes to see the doctor.
- All exchanges between patient and staff should be noted and/or reduced and/or removed, especially credit cards, cash, ID cards, pens, and clipboards.
- Patient should not be allowed to touch anything inside the practice and the use of the toilets should be carefully monitored with a thorough cleaning of surfaces after every use, including doorknobs and door surfaces.
- Clinical examinations need moderation. It is advisable to auscultate from behind the patient with the patient is still wearing the mask. A throat examination should be avoided if cervical lymph nodes are present and where there is no respiratory distress. Nebulisations should be replaced with the use of a spacer and an inhaler.
- The GP consultation room must be aired for 15min after every patient, especially with flu like symptoms. Patients should be seated away from the desk to reduce the patient touching surfaces that need cleaning. Any extra steps like a vitals station should be avoided with doctor managing vitals themselves. All re-used surfaces e.g. seats, examination couch, cuffs, ENT sets need to be thoroughly wiped down after EVERY patient with appropriate cleaning liquid (>70% alcohol). A UV box should be installed in all areas especially waiting and consulting rooms.
- If the patient with an acute onset of cough, respiratory distress (RR > 25/min or (Saturation of <92% on room air using oximeter), and fever that is less than 14 days then this patient should be referred to hospital for admission.
- If the patient is clinically stable but with evidence of COVID-19 e.g. pneumonia, anosmia or having risk factors like elderly, HIV+ and or with pre-existing respiratory comorbidities e.g. COPD then the GP should refer patients with suspected COVID-19 to public sector testing sites rather than testing in the practice. If the GP is testing then a well-ventilated isolation room needs to be used with full PPE, testing consumables and forms available. See NICD Technical Resources.
- All contact details and a full contact/travel history for the past 14 days should be obtained for any suspected COVID-19 patients.
- What protection should the practice staff wear?
- A minimum of a surgical face mask is required by all staff.
- Those cleaning chairs and surfaces should use gloves, plastic apron and disposable paper towels.
- All staff members need to engage in rigorous hand hygiene after EVERY patient including with exchanges of credit cards, cash, ID cards, pens, and clipboards.
- Hand sanitiser should be applied generously and as if it were washing with soap and water.
- Any clinical staff member especially the GP with close clinical contact needs to wear an N95 mask (if available), a visor and a plastic apron. The plastic apron and visor need to be managed as infected after every patient encounter, removed without touching potentially infected surfaces and discarded as medical waste. The N95 must be changed after 3-5 patients, especially patients at high risk of COVID-19.
- N95 masks can be reused (also CDC) after the following cleaning: steamed (although wetting renders them ineffective), placement in a UV box for 20-30 minutes or stored in a tightly wrapped bag to dry for 4-5 days.
- What should the practice be doing generally otherwise?
- All practices should adapt this protocol and ensure all staff are trained on it and adhere to it.
- This protocol should be posted visibly outside and inside the practice.
- Consulting rooms should be dedicated for infective and non-infective patients, if possible.
- Use of disposable linen savers and other consumables should be used where possible.
- Alternating consulting rooms is advisable where high patient volumes are experienced to facilitate disinfection activities.
- All practices should invest in and use one of the following: steam and heat disinfecting apparatus; chemical disinfectants; UV apparatus.
- Practices should have the necessary waste management, including separating medical waste from routine waste, all needle and sharp containers safely mounted or stored and all used and full medical waste bins and sharps containers in a designated and locked area.
- A staff disinfection and hygiene protocol should be implemented. All workspaces should be kept clean and tidy. There should be an on-shift and off-shift protocol, ensuring that contaminants are not brought into facility or vice versa taken home to family. It is advised that bathrooms be provided and where possible lockers or drawers to house personal belongings. All staff should be provided with work wear or an apron to protecting their clothes from surface contamination. If a separate pair of shoes cannot be provided, disposable shoe covers should be available for wear whilst in the health facility.
- What if the practice is exposed to a confirmed COVID-19 patient?
- If the practice has not been practicing full PPE as prescribed, then the practice should shut down and all staff members should be tested as it meets the NICD case management criteria. This can be enhanced with a second test 24hrs later to address false negatives.
- If the practice has been practicing full PPE as prescribed above, then the practice may continue. However, all staff need to monitor themselves for symptoms within 14 days of contact. The staff member should self-isolate and be tested if any symptoms show.
- The practice should support the NICD in locating this patient and tracing contacts.
- It is advised to have a daily 5-minute routine to pray, check in on staff well-being and to focus staff on the objectives of patient centeredness, and patient safety and staff safety. Please keep debriefing resources such as helplines easily visible to all staff should they feel the need to seek counselling.
Prof. Shabir Moosa, Dr Riyas Fadal, Prof. Abdullah Laher, Prof Anwar Hoosen, Dr Atiya Mosam, Dr Shoyab Wadee, Dr Salim Ahmed, Dr Salim Choonara, Dr Asma Salloo, Dr Ahmed Vachiat, Yakub Moosa Essack & Dr AKC Peer