This document (updated 25th May 2020) guides safe clinical practice for small solo practices. Practices with more than one consulting room would find this useful in conjunction with the Johannesburg Health District Guidelines.

RATIONALE FOR RECOMMENDATIONS

COVID-19 is now being locally transmitted in South Africa, unrelated to any travel history. Any patient coming in with flu symptoms could be having COVID-19. In fact patients without any symptoms could be shedding the coronavirus up to 24 hours before simply by talking or laughing. See the latest guidance for NICD testing here.

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 a difference in the real world practice of health care workers largely due to poorly fitting N95 masks. Whilst cloth face masks are not the 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 the 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. See here for details.

RECOMMENDATIONS

What should the process of seeing patients be?

  1. 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.
  2. 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
  3. Patients should be stopped from entering the practice doors without control. All patients should have their hands sprayed with hand sanitiser. All patients should wear or be given a cloth face mask to reduce droplet spread.
  4. 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 small crosses 1.5m apart, stretching as far as is needed to cater to those waiting. Patients should be requested to stand on the crosses.
  5. If chairs are used then use plastic and stop all chairs inside from being used. Patients must carry their chairs with them until they are called in. A square should be marked 1m away from the reception desk so that a patient stands or places their chair there and does not touch anything, especially the desk. The patient can then place their chairs on a stack. These can later be wiped down by the reception staff member with cleaning liquid, a mix of 3 parts bleach to 17 parts water, before being used again. This reception staff member must regularly monitor adherence to the crosses and stacking/cleaning inside.
  6. 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.
  7. All exchanges between patient and staff should be noted and/or reduced and/or removed, especially credit cards, cash, ID cards, pens, and clipboards.
  8. The 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.
  9. The best option is for a solo GP to have two consulting rooms, one for cough and one for others. Both rooms need the same treatment below.
  10. The GP consultation room has to 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 an appropriate cleaning liquid (>70% alcohol). A UV lightbox should be installed in all areas especially waiting and consulting rooms.
  11. Clinical examinations need moderation. Auscultation of the chest and throat examination should be avoided. If a patient is auscultated it should be from behind with the patient wearing the mask. Nebulisations should be avoided.
  12. If the patient is clinically stable but with evidence of COVID e.g. acute onset of cough, sore throat, fever and anosmia that is less than 14 days 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 a testing site 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
  13. If the patient with an acute onset of respiratory distress (RR > 25/min) or oxygen saturation of <93% on room air using a pulse oximeter then this patient should be referred to hospital for admission.
  14. 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?

  1. A minimum of a surgical face mask is required by all staff.
  2. Those cleaning chairs and surfaces should use gloves, plastic aprons, and disposable paper towels.
  3. All staff members need to engage in rigorous hand hygiene after EVERY patient including exchanges of credit cards, cash, ID cards, pens, and clipboards.
  4. Hand sanitiser should be applied generously and as if it were washing with soap and water.
  5. 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 gloves (if used) 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.
  6. 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?

  1. All practices should adapt this protocol and ensure all staff is trained on it and adhere to it.
  2. This protocol should be posted visibly outside and inside the practice
  3. Consulting rooms should be dedicated to infective and non-infective patients, if possible. Alternating consulting rooms is advisable where high patient volumes are experienced to facilitate disinfection activities
  4. 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
  5. 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 the facility or vice versa taken home to family. It is advised that lockers or drawers be provided to house personal belongings. All staff should be provided with workwear 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?

  1. If the practice has not been practicing full PPE as prescribed then any staff members who has had close contact with a confirmed COVID patient (>15min and <1m away) should be tested as it meets the NICD case management criteria. The practice can simply be cleaned with disinfectant and open again.
  2. If the practice has been practicing full PPE as prescribed above then the practice may continue. However, all staff needs to monitor themselves for symptoms within 14 days of contact. The staff member should self-isolate and be tested if any symptoms show.
  3. The practice should support the NICD in locating confirmed COVID patients and tracing contacts
  4. 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.

Authors

Prof. Shabir Moosa, Dr. Riyas Fadal, Prof Anwar Hoosen, Prof. Abdullah Laher, Dr. Atiya Mosam, Dr. Shoyab Wadee, Dr. Salim Choonara, Dr. Tom Boyle, Dr. Lynne Wilkinson.