Clinic organisation in COVID 19 Recovery Phase
1. Should we be screening patient’s case records and by phone a few days before a clinic appointment?
Mario Romano, Milan Italy: We think that preventing transmission is a key factor in the correct management of the Ophthalmology department during this second phase of the COVID-19 outbreak. In our clinic, upon visit booking, a virtual triage is made, investigating patient’s risk of having been exposed to COVID-19 and the severity of his/her clinical condition. Of course, patient’s case records are taken into account. We perform a risk stratification based on minimum clear data, so we can assess whether the patient can be managed via telemedicine or should attend the clinic.
University Hospital Bern, Switzerland: All patients receive a written notice for their appointment. This encloses COVID-19 specific questions for risk assessment. Positive answers would trigger that the patients will be sent to the COVID track. The same questions are asked at the reception desk and patients with positive answers are guided to the COVID track.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We did so during the lockdown period, but now returned to ‘normal’, i.e. do no longer screen patient’s case records.
2. How do you socially distance an eye clinic? We usually have packed waiting rooms.
St Thomas’ Hospital Eye Dept London UK: The aim of social distancing measures is to keep patients apart to prevent them infecting each other. A clinic visit will involve a production line of checking in, having a vision test, an OCT, an assessment of the OCT, perhaps a diagnostic assessment, perhaps an injection or laser and then check out/home. Each of these only take a few minutes, some longer than others. The waiting rooms are needed because the arrival of patients is not timed to the availability of the required Health Care Professional in the slowest step. UK NHS Clinic booking profiles are rarely configured in this way. You could say that we use patient time as a free resource. Patients will also game the system by turning up early trying to cut their wait, which in turn makes everyone behind them late by one appointment! It is a complete paradox that in the UK no one expects to wait, be either early or late for a dental appointment. Dentists run to time.
This can be achieved in an injection or diagnostic eye clinic. Patients need to be booked at a smooth arrival rate that matches the availability of staff. Staff should be in place to do their task, one for check in, one for vision, one for OCT, one for diagnostic assessment if required and one for injection. Some of these jobs might be doubled up: an acuity and OCT might be done in less than 15 minutes by one trained technician. If a patient is on a treat and extend regimen the OCT and vision, and therefore the retreatment interval, might be reviewed virtually after the patient has left. The waiting room should be seen as a sign of inefficiency in the system, after all most clinics start and finish at about the same time each week with a similar number of patients, doctors and technical support staff, if that is the case then the capacity is there, its an organisational challenge to match arrival to supply of HCPs. Leadership and on the floor trouble shooting are required.
Mario Romano, Milan Italy: We implemented strategies to avoid crowded waiting rooms, but we also do a careful outpatients screening combining triage and serology testing for outpatients. Moreover, every patient is required to wear a surgical mask. We strive to avoid crowded waiting rooms, but we also try to identify infected, asymptomatic patients. The outpatient clinic, whenever possible, should be divided to have a segregated area dedicated to COVID-19 positive patients. In order to reduce the number of people in the waiting rooms we suggest to postpone any routine check-ups and perform check-up visits of chronic patients with a reduced frequency. Furthermore, in our clinic, upon visit booking, a virtual triage is made to decide whether the patient can be managed via telemedicine or should attend the clinic. When patients come to our clinic for a fundus examination, they are asked to self-administer dilatating single use eye drops to avoid unnecessary wait. Of course, we strongly advise to book less appointments per day in order to avoid a crowded waiting room. Accompanying adults are discouraged from crowding the waiting room.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We do not allow accompanying persons in the hospital and clinics. As we, fortunately, have ample space, we can manage with social distancing measure in place.
3. Does opening clinic and waiting room windows help?
Mario Romano, Milan Italy: Yes, of course. It is part of the good practices that should be generally put in place. We also suggested to leave the door of the doctor’s office open in order to maximise ventilation, privacy is guaranteed by the fact that we strive to have almost empty waiting rooms. Indoor air is increasingly being recognised as a vehicle for pathogens, e.g. COVID-19 has proven to remain viable and infectious in aerosol for many hours. So, air decontamination is a mandatory step in controlling the infection spread: natural ventilation is the most important process of air decontamination. When it is not applicable because of building design or climate, a variety of technological systems have been developed in order to purify air from pathogens. Mechanical ventilation can be very effective. Portable air filtration cleaning systems or UV irradiation do not filter large volumes of air.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We keep windows open in the clinic and waiting rooms
4. Should we screen patients when they arrive at the clinic?
Mario Romano, Milan Italy: We strongly believe in the importance of having a segregated area dedicated to COVID-19 positive patients and this approach makes a careful screening a necessary preliminary step. For patients attending the clinic we believe a simple entrance triage with a questionnaire and temperature assessment is not an enough thoughtfully procedure, since literature reports more than 30% of transmissions occur from asymptomatic people. Thus, we combine triage and serology testing for outpatients. If serology shows positive result, the patient must undergo a swab test. We know serology testing currently has limited sensitivity and specificity, but we think it is currently the most suitable tool for outpatients screening. The swab test is very accurate in the case of positive results, but takes a few hours in the best-case scenario. On the other hand, serology testing is economical and only takes few minutes to get results after the fingerpick to collect blood. As far as intravitreal injections are concerned, we follow the same procedure carried out for outpatients We use throat-nose swab as a screening tool for inpatients: we require two throat-nose swabs 48h prior to admission and 24 h apart if the first is negative. We advise all patient to self-isolate for a minimum of 7 days prior to the surgery. We don’t employ CT scans of the chest as a screening tool, since it has low sensitivity.
Noemi Lois, Clinical Professor of Ophthalmology at Queen’s University Belfast: We do have here a “screen” system by which patients get their temperature checked and go through a few screening questions (cough? Temperature at home? Anosmia? Etc) and, if any is positive, the patient will be seen in a different area (i.e. will not go to the common waiting area). I tell my patients to “quarantine” the clothes (a week and then wash them) they wear to clinic as soon as they get home (this is what I do too myself) as it is clear the virus survives in clothes. I also advise them to clean the sole of their shoes with diluted bleach (which also kills the virus) before entering their houses.
Boris Stanzel, Bonn, Germany: This would be an important practice when the virus is not so prevalent in the community. Specifically, screening patients with certain symptoms or who has been to the high risk area would help preventing nosocomial infection. Once the virus got prevalent and many individuals without symptoms walking around, the strategy obviously does not work.
University Hospital Bern, Switzerland: COVID-19 specific questions for risk assessment are asked at the reception desk and patients with positive answers are guided to the COVID track.
5. What if they say they have already had Covid-19
Mario Romano, Milan Italy: Ideally, the patient should meet the following criteria: normal temperature in the last three days, no respiratory symptoms and we ask to take two consecutive RT-PCR swaps 24 h apart. In this way we try to know if he is still contagious, so to decide how to handle the outpatient consultation needed. Of course, if the condition is deemed as an emergency, the consultation will be performed managing the patient as he/she was COVID-19 positive.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We take a detailed history to assess the risk of a person who had COVID-19 to be still contagious. If emergency examination/treatment is necessary, we have specific areas to do so.
6. Should everyone have their temperature checked on arrival?
Mario Romano, Milan Italy: Yes, of course. Temperature assessment by itself is not enough, but it is a simple and mandatory part of the triage we apply in our clinic.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We have not implemented regular temperature checks
7. Do we advise patients to self-monitor and get in touch if they deteriorate badly?
Mario Romano, Milan Italy: Yes, of course. Patients should self-monitor and call the hospital if they have subjective symptoms worsening: this was a good rule to follow even before the outbreak, but it becomes all the more important now because every hospital visit carries a risk for contagion. This is the reason why we decided to make check-up visits of chronic patients more spaced in time. In this moment we should develop telemedicine tools that will be useful even in the post-COVID-19 era. Patients should pay attention to BCVA worsening of each eye and perform self-evaluation with tools like the Amsler chart M-chart (also on the tablet). Should they notice symptoms worsening, they should call the hospital: a virtual triage will allow to know if they can be managed via telehealth or not.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We routinely advise patients to self-monitor.
8. How often should doctors be screened for COVID-19?
Mario Romano, Milan Italy: Ophthalmology personnel are at high risk and should be monitored frequently: we suggest employing a tracing app, serology and swab tests at least every 15 days. In case of positive results, the doctor should immediately self-isolate and redeploy to smart working at home. Ideally, they could handle the virtual clinic. The following criteria has to be met to be readmitted to work: normal temperature lasting longer than three days, absence of respiratory symptoms and two consecutively negative RT-PCR swabs separated by at least one day.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: In Germany, we have not yet a regulation in place that demands regular tests for hospital medical staff.
University Hospital Bern, Switzerland: COVID-19 screening will be performed following the guidelines of the health authorities. The guidelines currently include symptoms and contact to a COVID-19 positive person.
9. We have all but stopped activity. How do we get going again, is there a magic bullet that will let us go back to normal?
Mario Romano, Milan Italy: We think the aim shouldn’t be “going back to normal”, because according to some predictive models “normal” is very far away in time. We think the best approach is to make a completely rearrangement of our department activity, it will require of course a lot of expense and effort, but it is necessary for performing our clinical activity within the appropriate safety standards. An important issue is the reorganisation of the entire hospital in order to have two different environments: one COVID-19 free and one for COVID-19 positive patients. Moreover, some of the arrangements put in place could be useful even after the outbreak, because they will make medical care easier to access thanks to telehealth. Many tools for self-monitoring have already been developed: devices for evaluating visual acuity, perimeters and macular function are available. This kind of technology is still in his infancy and cannot be a substitute for face-to-face consultation, but we think the implementation of these tools in medical practice will greatly benefit our patients allowing for a more frequent monitoring, especially for working-age patients. Additionally, we can imagine a future in which this kind of skills will come in handy because of yet another pandemic. During this outbreak some South-Asia countries were already prepared to manage such a circumstance because of their previous experience with SARS.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We have gone back to normal with all security meaures in place (masks mandatory, social distancing, protection t examination devices etc.)
10. How have the Chinese and South Koreans organized their consultations, imaging etc… it is the country that has been most successful in managing this health crisis?
Mario Romano, Milan Italy: As previously stated, South Asia countries were in a better position to deal with this outbreak, because SARS proved to be a sort of bootcamp for COVID-19. One important lesson we should learn is the extensive use of tracing apps. In China it was made easier by looser privacy regulation and a general more wide-spread use of technology, especially in elderly population. In Europe these apps must be voluntary and we don’t know if the required 60% participation required for them to be successful will be attained. Another useful lesson is the widespread use of telehealth, Asian countries already used health app and remote medical-care more than we do, but we need to catch up. They also implemented from the start a more widespread use of testing, which is really important because a major part of the transmission happens through asymptomatic patients, they already had the infrastructure to do this because they developed it at the time of SARS flu.