OPD Practice Post COVID-19 Lockdown Lift

    

Clinical Practice Guidelines

June 2020

  

Introduction:

Developing a pandemic safety plan in the wake of covid19 is crucial. Healthcare workers are at the front line of the outbreak. Alongside concerns for their personal safety, they are anxious about possibly infecting their families and other staff working in the OPD/ nursing home/ Hospital, especially since majority of COVID 19 patients are asymptomatic.

Proper attention needs to be paid to the delivery of essential health care for patients while ensuring the safety of healthcare workers. Some essential steps to minimize exposure to covid-19 (SARS-CoV-2) virus and for protection of patients and healthcare workers without compromising the clinical practice are mentioned in this document

Objectives:

➢  To help reduce risk to facility and people without compromising practice

➢  To be completely prepared from infrastructure perspective

➢  To render best practices while navigating the COVID-19 crisis

  

June, 2020 CLINICAL PRACTICE GUIDELINES 2 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Stages of preparation

            

Preparation of the OPD setup

Steps taken before the arrival of patients

Steps taken during patient visit

Steps taken post patient assessment

Additional information

➢ 5 Dos for Healthcare Workers ➢ Annexures
➢ References

   

June, 2020 CLINICAL PRACTICE GUIDELINES 3 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD Setup a. General Considerations:

i. Understand which patients are at a risk of adverse outcomes from COVID-19

ii. Consider seeing patients by appointment only, with telephonic screening of patients at the time patients call for an appointment

iii. Opt for more teleconsultation/video consultation appointments

iv. All Pneumonia patients and all patients suspected of COVID-19 should be notified to NCD or IDSP immediately

v. Create an emergency contact list to reach your local (or municipal)/ state health department in an emergency

vi. Assess and restock supplies on a regular basis. Prepare a checklist of all the essential items. (Refer Table 1)

vii. Only those “delivered” items (including documents) to be received, which are packed and wrapped in material that can be wiped clean before opening

viii. Ask staff to stay home if they fall sick

ix. Prepare staffing plans in the event of absenteeism due to COVID-19 outbreak. Conduct cross-training of staff for all essential office and medical functions and on infection prevention and control

x. Train staff on how to appropriately don and doff protective equipment

xi. Institute EMR in clinic (as paper records necessitate multiple handlings by multiple people)

xii. Consider implementing e-payments

 

xiii. Post signs at entrances and in waiting areas to alert patients to wear a mask and about general preventive steps (Refer Figure 1)

xiv. Post signages for Address and Phone number of Chemists in the vicinity and their business timings and E-Chemist contacts

xv. Continuously update yourself and staff on COVID-19 local status and relevant COVID- 19 prevention, treatment and protection as outlined in MoHW bulletins

xvi. Ensure adequate Sunlight and Ventilation in the Clinic and disinfection and decontamination of all surfaces and equipment using Soap & Water and recommended EPA cleaners for the recommended contact times

Figure 1: Example of a Poster at the Clinic Entrance

June, 2020 CLINICAL PRACTICE GUIDELINES 4 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD Setup

 

Entry

WASH AREA (give mask)

TRIAGE (Form 1)

COVID Suspect Non COVID

     

Refer to DFRC/Notify

REGISTRATION

   

EXIT

DOCTOR’S CHAMBERS

LAB TESTING IF NEEDED

PHARMACY

 

June, 2020 CLINICAL PRACTICE GUIDELINES 5 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD Setup b. Norms for registers to be maintained

i. Records can be maintained also as soft copy

ii. Out patient / In patient register with following basic details

• NAME: AGE:

• MR NO IF MAINTAINED

• ADDRESS WITH MOBILE NUMBERS

• DIAGNOSIS

• IF REFERRED, WHICH CENTRE

iii. ILI/SIRS Register

iv. Form 1 triage as per govt

v. Form 1 a case details

vi. Form 11 lab/referral form/notification form

vii. Notification register

viii. Disinfection Register/ chart

ix. Staff Attendance register with date, time and area of duty

x. Staff training Register.

c. Staff Management

i. Training of doctors, nurses and all Hospital Staff for adapting to current protocols

ii. Have Only required no of staff in all areas

iii. In Reserve 30 % staff must be there

iv. Do not mix up staff between DFRC and normal OP

v. Chemoprophylaxis with HCQ for DFRC staff

vi. Vitamin C 100 mg or multivitamins once daily for 10 days and

vii. Zinc 20 mg for 10 days

 

June, 2020 CLINICAL PRACTICE GUIDELINES 6 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD Setup

 

Table 1: Checklist for In-Clinic Safety of Physician’s Office

  

✓ ✓

✓ ✓ ✓

✓ ✓

✓ ✓

Personal Protective Equipment (PPE) including Gloves/ Mask, Eye Protection, Face Shields, Gloves (and Gown for HCP)

Clear signage with pictures recommending patients to call first if they have symptoms of any respiratory infection (e.g., cough, fever etc.)

Signage in appropriate languages for patients to alert staff about respiratory symptoms and about correct hygiene and cough etiquette. It is helpful to have signage with pictures at the entrance of the clinic

Hand sanitizer and masks placed at the front of office/practice

Boxes of disposable tissues for distribution to patients

Single-use towels and tissues for use throughout the office

No-touch wastebaskets and disposable liners at Clinic entrance, Waiting room, Patient Checking areas with Waste Disposal as per appropriate CDC recommended disposal technique

Hand sanitizer for reception, waiting, patient care, and restroom areas

Single-use gloves

Moisturizer/Cream (to reinforce epidermal barrier which will get compromised due to frequent hand-wash and excessive sanitizer-use)

Routine Cleaning & Disinfection (using soap and water to pre-clean surfaces prior to applying EPA registered hospital grade disinfectant) to frequently touched surfaces / Medical devices for appropriate contract times as per Product Label

June, 2020 CLINICAL PRACTICE GUIDELINES 7 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD: Area-wise Norms d. Norms for washing areas e. Norms for triage areas

i. Water/ Soap/ preferably Elbow tap i. No attenders if the patient is stable

for hand wash (all the patients who are coming to the clinic should wash their hand and feet with soap and water)

ii. Details of the patient to be collected as per the form 1 (Annexure)

iii. Physical distancing should be maintained 4 feet from patient to patient and patient to staff preferably

ii. Tissues to wipe

iii. Posters on Hand Wash Techniques a barricade

iv. 3 Ply mask to be provided before iv. Sanitize the hands of each patient

patient enters the Triage area

f. Norms for waiting areas

i. Prefer not to make the patient wait

ii. Mark the areas with proper distancing of 3 to 4 feet

iii. Stool without arms preferred

iv. Not more than 10 patients in a well ventilated 400 sq. ft room at a time

g. Norms for Registration Area

v. VITALS – Temperature by Thermo Scanner, PR: ,SPO2: %, by Pulse Oxymeter, RR: immediately after cleaning the hand with hand sanitizer

vi. If suspect COVID refer to DFRC/ Notify to Authorities. Details to be notified to http://www.dphpm.com ( ID and Pass word can be obtained from DDHS)

vii. Allow non-COVID into registration Area

i. Prefer Appointment system and only one patient at a time

ii. No attenders if the patient is stable

iii. Patient enters the registration room with mask

iv. Physical distancing should be maintained 4 feet from patient to patient and patient to staff preferably a barricade

v. The staff manning this area can use a three layer mask / face shield ,gloves

vi. Sanitize the hand of each patient

vii. Details of the patient to be collected as per the form 1A (annexure)

viii. Document all the details in the form as well as in the Register or computer

ix. Do not hand over the Form to Patient

x. Send the form to Doctors chamber

xi. Fee can be collected preferably by electronic transfer/ cash by non touch technique in to a box with formalin.

June, 2020 CLINICAL PRACTICE GUIDELINES 8 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD: Specific Norms h. Norms for Pharmacy

i. Proper distancing must be followed in front of Pharmacy

ii. Better have Glass partition in front

iii. See that everybody wear mask including attender/ patient buying medicine, all staff in pharmacy

iv. Limitnoofstaffto2or3

v. Better avoid handling prescriptions and prefer electronic/ see through glass

vi. Place all medicines in a cover and place out through an opening

vii. Cash can be collected preferably by electronic transfer/ cash by non touch technique in to a box with formalin 8. Frequently disinfect the counter and follow hand sanitizing.

i. Norms for Doctor’s Chambers

i. Avoid AC room. If used , AC 25 to 30 degree at humidity 40-70%

ii. Non touch technique

iii. Doctor and only one staff with N 95 mask/ face shield/gloves and cloth full gown if felt needed with plastic apron

iv. 4 feet distance from patient to doctor

v. Prefer stool without arm chair for the patient

vi. No attenders if patient is stable

vii. Prefer not to touch the patient / if necessary auscultate on the back .Avoid other system examination

viii. Sanitize the stethoscope immediately

ix. Prefer to see the Patients old / other records without touching from distance.

x. All suspected COVID Patients (FEVER/ ILI / SARI / CONTACT HISTORY ) to be
immediately isolated in a separate area/room, inform 108/ Refer filling the Referral form and Notify

xi. Make Entry and preserve the form 1 A

xii. For others generate prescription preferably computer generated and send directly to pharmacy or hand over to patient after collecting the fee

xiii. Stools should be cleaned with 1 % sodium hypochlorite or Lysol as soon as patient gets up

xiv. Next patient only after clearing the current patient. 15.Hand hygiene to be followed by all Health care professionals in between patients.

 

June, 2020 CLINICAL PRACTICE GUIDELINES 9 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD: Specific Norms j. Norms for Labs

i. Only one patient at a time to be allowed in with mask

ii. Staff with 3 layer mask/ face shield/gloves and cloth full gown and if felt needed with plastic apron

iii. Proper distancing to be followed

iv. Follow universal precautions and proper BMW protocols

v. If taking swab for COVID separate area with Full PPE kit must be followed as per protocols

vi. Fee can be collected preferably by electronic transfer/ cash by non touch technique in to a box with formalin

vii. Results can be sent by e mail

viii. Follow proper hand hygiene in between patients.

 

June, 2020 CLINICAL PRACTICE GUIDELINES 10 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Preparation of the OPD Setup
k. Guidelines for maintenance of the Waiting Area

i. Adequate supplies of tissues, hand sanitizers and soap at sinks

ii. Ensure multiple trash cans in multiple locations is crucial

iii. Adequate supply of masks in case patients come without masks

iv. Arrange for temperature check using infrared thermometers

v. Place of seats as far apart as possible (ideally 3-6 feet apart). If possible, use of barriers such as screens should be encouraged

vi. Remove unnecessary items from waiting area and regularly clean the frequently touched surfaces

vii. Patient and Staff body temperature and Spo2 (as required) should be monitored everyday

viii. Its advisable to ask patients to remove footwear outside the clinic

l. Guidelines for examination in the Consultation Room

i. Use, if possible, a Glass/Plastic partition on consultation table

ii. Place examination table as far away from the main table and keep patient chair as far away from the physician desk as possible

iii. Place sanitizer in the room at an accessible location

 

June, 2020 CLINICAL PRACTICE GUIDELINES 11 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Steps taken before the arrival of patients

a. Teleconsultation / Video consultation Considerations

I. Reschedule non-urgent appointments

II. Provide non-urgent patient care via teleconsultation or video consultation as per the Appendix 5 of the Indian Medical Council Telemedicine Guidelines

III. Set up separate appointments for patients with respiratory symptoms

IV. Set up separate appointments for patients who are
more susceptible to COVID-19 such as elderly or those with comorbidities

V. Walk-in patients should be avoided as far as possible

VI. Share current information about COVID-19, the potential for surge, and your facility’s preparedness strategies

b. Basic Possible Teleconsultation/Video consultation Script:

        

Greet the caller Assess for life threatening conditions

Assess for COVID 19 symptoms as per guidelines

(MOHFW/ICMR)

Provide appropriate advice / seating / seclusion

June, 2020 CLINICAL PRACTICE GUIDELINES 12 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Steps taken during patient visit

a) Place staff at the clinic entrance to ask patients about their symptoms
I. Provide symptomatic patients with facemasks if they do not have one II. Allow only one accompanying visitor per patient

b) Segregation of patients with respiratory symptoms and identification of a containment area in the facility for any such person(s) upon entering

I. Ask patients to wait outside or in the car if they are medically able

II. Create separate space in the waiting areas for symptomatic patients
c) Patients with suspected SARS-CoV-2 infection should be referred to COVID19

designated hospitals as per latest guidelines (MOHFW/ICMR)

. d)  Strictly regulate traffic between Waiting Area & Consultation Room

. e)  Dedicate separate time for non-patient visitors such as pharma reps to reduce
chances of cross-infection

I. Designate a box in your Waiting Area, where the Pharma Rep can leave

Samples, Literature. Try to maintain e communication via WhatsApp,

Email with Pharma for Knowledge Sharing and Ordering of Medicine Stock II. Encourage e-Patient education materials from Pharma

. f)  Infection Control Guidance/In-Clinic Safety Habits to be adhered

. g)  Usage of Personal Protective Equipment (PPE) (Refer Annexure A on details of
Donning and Doffing PPE). PPE is needed by:

I. Patients with suspected SARS-CoV-2 infection need to wear a facemask II. Healthcare professionals need to observe Standard and Transmission-

based Precautions when caring for suspected patients (Refer Figure 2)

PPE Guidelines

Staff including doctors:

Full cover cloth dress Plastic apron over full cover Leggings
N95 mask
Cloth mask over that
Face shield
Gloves

Patient:

Face mask, preferably 3ply mask

   

Figure 2a: All other staff including doctors

Figure 2b: Visiting patients

June, 2020 CLINICAL PRACTICE GUIDELINES 13 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Steps taken during patient visit

   

h.

i. j.

Figure 3: Housekeeping front and side-view

House keeping PPE:

Plastic apron Elbow level gloves Leggings
Cloth mask

Hand Hygiene (Refer Figure 4 for technique)

Hand hygiene, including hand washing or the use of alcohol-based hand sanitizers to prevent infections is connected to the reduction of viable pathogens that transiently contaminate the hands.1 Conducting hand hygiene at the right time, using the right technique is critical

Schedule a teleconsultation / video consultation follow-up for the patient, whenever possible
Encourage electronic payment. If cash payment, insist on exact change and ask patient to place in a container instead of hand- to-hand exchange

Figure 4: Hand Hygiene – Right Technique

Figure 5: 5 Moments for Hand Hygiene

June, 2020 CLINICAL PRACTICE GUIDELINES 14 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Steps taken post patient assessment

a. After patients leave, clean frequently touched surfaces using EPA- registered disinfectants—counters, beds, seating

b. Regular cleaning of instruments after periodic use (stethoscope, tuning forks, hammers, etc. as per the outlined Disinfection Guidelines

c. Consider teleconsultation/ video consultation options for follow up patients

d. Inform local/state health department of patients with symptoms suggestive of COVID-19
5 Dos for Healthcare Workers

. 1)  When entering a room with a suspected COVID-19 patient, use:

• disposable gloves

• a clean, long-sleeve gown

• medical mask that covers your mouth and nose

• eye protection such as goggles

. 2)  Personal protective equipment needs to be changed between use and for each new patient. If wearing single-use personal protective equipment (e.g. single-use masks, gloves, face shields), discard in a waste bin with a lid and wash your hands properly

. 3)  Perform a seal check. If doing an aerosol generating procedure, such as intubation, use a particulate respirator (like N95) and other such procedures like Nebulization should be performed with patient isolation

. 4)  Boots and coverall suits are not needed

. 5)  Avoid touching your eyes, nose or mouth with gloves or bare hands until proper hand hygiene has been performed

  

June, 2020 CLINICAL PRACTICE GUIDELINES 15 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Annexure

Steps to Put On PPE Gear (Donning the PPE)

i. Identification of the proper PPE to don and ensuring the choice of gown size is correct

ii. Performing hand hygiene using hand sanitizer

iii. Putting on an isolation gown and tying all of the ties on the gown

iv. Using NIOSH-approved N95 filtering face-piece respirator or higher (use of facemask if a respirator is not available). In case the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Pinching of the nosepiece with one hand should be avoided. Respirator/facemask should be extended under chin. Both your mouth and nose need to be protected

v. Respirator: Respirator straps should be put on crown of head (top strap) and base of neck (bottom strap). A user seal check should be performed each time you put it on

vi. Facemask: Mask ties need to be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them properly around your ears

vii. Putting on face shield or goggles. Face shields provide excellent full-face coverage. Goggles also provide protection for eyes, but fogging may happen

viii. Performing hand hygiene before putting on gloves. Gloves should cover the cuff of gown

Steps to Take Off PPE Gear (Doffing the PPE)

i. Removal of gloves. Ensure glove removal does not lead to additional contamination of hands. (e.g., glove-in-glove or bird beak)

ii. Removal of gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Avoid a forceful movement by doing it in a gentle manner. Reach up to the shoulders and pull gown down and away from the body carefully. Rolling the gown down is an acceptable method. Discard in trash receptacle appropriately

iii. Healthcare personnel may now leave the patient room

iv. Performing hand hygiene

v. Careful removal of face shield or goggles by grabbing the strap and pulling upwards and away from head. Avoid touching the front of face shield or goggles

vi. Remove and dispose respirator/facemask. Avoid touching the front of the respirator or facemask.

vii. Respirator: Removal of the bottom strap by touching only the strap and getting it carefully over the head. Grasping the top strap and getting it carefully over the head, and then pulling the respirator away from the face without touching the front of the respirator

viii. Facemask: Carefully untie (or unhook from ears) and pull away from face

ix. Performing hand hygiene post removal of the respirator/facemask and before putting it on again if your facility is practicing reuse

 

June, 2020 CLINICAL PRACTICE GUIDELINES 16 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Annexure: Donning PPE

  

June, 2020 CLINICAL PRACTICE GUIDELINES 17 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Annexure: Doffing PPE

  

June, 2020 CLINICAL PRACTICE GUIDELINES 18 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

Annexure: Norms For Disinfection And BMW

i. DISINFECTION PROTOCOLS (As per the Guidelines)

• Dedicated infection control teams to be formed

• Disinfection chart should be displayed at every ward, toilets, nursing stations, lab, pharmacy, X-ray and other diagnostic places etc.

• Every 2 to 4 hrs. whole area

• Seat and touchable areas as frequently as needed

• Use 1 %Sodium Hypochlorite Solution for cleaning the floor and surfaces

• 5%Lysol Solution for ward / theater

• 3 Bucket system/ sprayer to be used for floor cleaning

• 2.5 % Lysol Solution for Door handles, Various surfaces touched by the patients Vehicles, other buildings

ii. PREPARATION GUIDELINES

• Preparation of 5 % Lysol (1 litre of Lysol in 9 litres of water)

• Preparation of 2.5 % Lysol (1 litre of Lysol in 19 litres of water)

• Preparation of 1 % sodium hypochlorite solution : 28.4 grams of dry bleaching powder to 1 litre of water or 284 grams ( 2 scoops) to 10 litres of water

• Preparation of 0.5 % sodium hypochlorite solution : 14.2 grams of dry bleaching powder to 1 litre of water or 142grams (1 scoop) to 10 litres of water.

• The instruments to be left in dilute bleach for less than 10 minutes and should be cleaned in boiled water immediately after decontamination to prevent discolouration and corrosion of metal

• BMW management and disposal must be as per the COVID BMW protocols. (Refer http://www.imatn.com )

 

June, 2020 CLINICAL PRACTICE GUIDELINES 19 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

References

1. https://www.cdc.gov/coronavirus/2019-ncov/index.html Assessed on 27th April, 2020

2. https://www.aafp.org/dam/AAFP/documents/patient_care/public_hea lth/COVID-19%20Office%20Prep%20Checklist.pdf Assessed on 27th April, 2020

3. https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Out patientGuidance-COVID19.pdf Assessed on 27th April, 2020

4. https://www.health.nsw.gov.au/Infectious/covid-19/Pages/community- outpatient.aspx Assessed on 27th April, 2020

5. https://www.who.int/infection-prevention/campaigns/clean- hands/WHO_HH-Community-Campaign_finalv3.pdf?ua=1 Assessed on 27th April, 2020

6. https://www.who.int/docs/default-source/coronaviruse/risk- communication-for-healthcare-facilities.pdf?sfvrsn=2a5b0e0b_2 Assessed on 27th April, 2020

7. https://www.canada.ca/en/public-health/services/diseases/2019- novel-coronavirus-infection/health-professionals.html Assessed on 27th April, 2020

8. https://www.mohfw.gov.in/pdf/EssentialservicesduringCOVID19update d0411201.pdf Assessed on 29th April, 2020

9. Guidance for Cleaning and Disinfecting /cdc.gov

10. https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

11. https://www.who.int/emergencies/what-we-do/prevention- readiness/disease-commodity-packages/dcp-ncov.pdf?ua=1

12. COVID-19 – Response & Containment Measures, MOHFW, GOI

13. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings/ cdc.gov

                   

June, 2020 CLINICAL PRACTICE GUIDELINES 20 OPD PRACTICE POST COVID-19 LOCKDOWN LIFT

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