Infection Control: PPE
1. What PPE should doctors use when performing eye consultations?
St Thomas’ Hospital Eye Department, UK: Public Health England Guidelines for Health Care Professionals coming within 2 metres of a patient are:
– Surgical pyjamas/scrubs which are changed daily,
– Clothes may be contamined on the way to/from the hospital or your home clothes may be contaminated at work. Washing clothes at 60 degrees eradicates the virus.
– Non sterile gloves
– Changed between each patient,
– Plastic apron,
– This is to protect your clothes from contamination and is changed if touched,
– A surgical fluid absorbent mask
– Lasts for up for to four hours, the mask is changed if touched
– Visor or goggles
– These are substituted by a slit lamp breath guard. We avoid slit lamp and/or routine ophthalmoscopy use unless there an obvious new clinical need.
Mario Romano, Milan Italy: Full expert agreement about what constitutes appropriate PPE during ophthalmic examinations has still to be reached, particularly regarding the use of respirators. Factors playing a role in this controversy area for certain PPE shortages and increased knowledge about asymptomatic infection spread and environmental virus contamination. According to Academy’s guidelines, regardless of COVID19 geographic prevalence, when practices that require physical proximity doctor-patient are performed, the patient should wear a surgical mask. The best choice for the surgeon would be a N95 respirator, if there is not a PPE shortage. A N95/FFP3 is the best option because Ophthalmology entails a very close physical proximity with the patient and asymptomatic carriers are estimated between one third and more than a half. During routine assessment the following PPE are necessary: a disposable plastic apron, disposable gloves, N95 respirator and eye protection. Eye protection is recommended; however, it can prove uncomfortable during slit-lamp examination and thus it can be temporarily removed if a breath-guard is placed on the instrument. Minimal respiratory protection recommended for consultation is with an ASTM III surgical mask, which can work if everyone wears it, as the filtering capacity towards inside is only 20%. Surgical masks, independently from their ASTM level, do not provide enough protection due to their poor adhesion to the face and modest filtration, so for maximum safety, especially in endemic areas, we think it could be a sensible option to use N95 for all routine cases.
Noemi Lois, Clinical Professor of Ophthalmology at Queen’s University Belfast: Everyone has surgical masks, gloves and aprons. Gloves are tricky; people put them on and then touch everything with them including their faces so defeating the purpose! So, I keep telling everyone to clean them all the time with alcohol, even when wearing them, just as my colleagues we do in the labs when manipulating viruses. This is truly important.
Theo Stappler: Since the virus is known to persist on fabric for about 24 hours and the slit lamp splash guard can only protect as much from some few droplets, I have suggested for surgeons and nurses to wear surgical scrubs at work rather than an apron on top of your own clothes – this may add a layer of protection from spreading bugs from work to our families at home.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: Wearing surgical masks is mandatory here.
2. Is there a benefit from patients wearing a mask as well?
St Thomas’ Hospital Eye Department, UK: An opinion is that this follows a precautionary principal. The aim is to reduce the risk of patients infecting other patients or non-protected staff. There is not as much social distancing in hospital corridors as you might expect and patients have to get to and from the clinic. A cloth face covering may be adequate. The mask might reasonably be removed when the patient is being examined or having an injection, the member of staff is protected at that point and the mask may make an injection harder to perform or increase the risk of it being performed. The down sides of patients wearing masks are that patients often touch masks and so might increase the contamination of surfaces with their fingers, masks might also have to be supplied to those not wearing them.
Mario Romano, Milan Italy: All patients should wear a surgical mask: because of the asymptomatic infection spread, it is necessary to regard all patients as being infected. We perform an outpatients screening combining triage and serology, but serology testing has currently some limitation in the sensitivity and sensibility departments. Thus, we require every patient to wear a surgical mask, even if screening results are negative. In Italy, people should wear a surgical mask when going out of their homes, so it would not make sense to discard it when entering the hospital. Surgical mask can work if everyone wears it, as the filtering capacity towards inside is only 20%.
Noemi Lois, Clinical Professor of Ophthalmology at Queen’s University Belfast: Our microbiologists mentioned that masks were not needed for patients which I am sorry makes no sense to me, so I still ask all my patients to put a mask.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: All patients have to wear an adequate mask.
3. Is there a possible disadvantage for patients wearing a mask?
Boris Stanzel, Bonn, Germany: One might argue that wearing a mask immediately after an IVI or intraocular surgery poses the patient at greater potential risk for endophthalmitis, as the breath/air flow is channeled towards the ocular surface. It may therefore be reasonable to advice postOP patients to avoid or even NOT to wear face masks to avoid the risk of postoperative endophthalmitis. Mask are better removed during postoperative examination, and the patient requested to hold them in their hands, rather than placing them on available surfaces nearby to avoid potential cross-contamination.
4. Are eye doctors at greater risk of getting and/or dying from COVID than other doctors?
Mario Romano, Milan Italy: Ophthalmologists are thought to be a high-risk category because they have close contact with a high number of patients. Slit-lamp examination should be avoided when possible, because it entails a prolonged physical proximity. To this date, we still don’t know whether Ophthalmic surgery creates aerosol, we are currently working on this topic.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: Early reports from China have indicated that ophthalmologists are at higher risk.
5. Shall I measure daily my temperature?
Mario Romano, Milan Italy: Personnel from the ophthalmology department are at high risk and should be monitored frequently. We suggest constant monitoring, including employing a tracing app, serology and swab tests at least every 15 days. The daily measurement of temperature can certainly be done, but it is far from enough.
Frank G. Holz, Department of Ophthalmology, University of Bonn, Germany: We do not perform routine temperature checks.
6. Since the virologic status of asymptomatic patients is not known should they be considered covid positive or negative?
St Thomas’ Hospital Eye Dept London UK: At this phase of the pandemic it is sensible to consider every human that you or the patients in your clinic come into contact with are capable of infecting each other. At a later stage and as a result of combinations of: lower rates of infection in the community, immunisation, antibody testing and patient pre testing it may be reasonable to somewhat relax this assumption.
Mario Romano, Milan Italy: Outpatients with risk factors, symptoms or positive serology should undergo a throat-nose swab. In this way it is possible to know how to manage them.
7. Do I wear gloves when typing or writing case records?
St Thomas’ Hospital Eye Dept London UK: It is hard to get into a suitable routine. The virus can persist on hard surfaces. It is probably safest to assume that the keyboard (or paper records although this may be less likely) are contaminated. If you use gloves you will need to change them before examining a patient. I personally alcohol gel my hands before and after touching a keyboard and restrict the gloves to patient contact. It may be that keyboards in clinical areas should be changed to wipe clean designs.
Mario Romano, Milan Italy: The virus can survive for many hours on inanimate surfaces and put back into the air when there is physical disturbance of the surfaces. We usually put on gloves, visit the patient and then keep the gloves on to write because keyboard can be contaminated. After writing we discard the gloves. Of course, keyboard should be sanitized as far as possible.
8. Can paper case records be contaminated with COVID?
Mario Romano, Milan Italy: COVID-19 can survive some days on inanimate surfaces, paper is not exception to this. Every part of doctor’s office can be contaminated by patient’s droplets and aerosol. We ask our patients to keep surgical mask on at all times and take care of having adequate ventilation of the room to minimize the risk, but of course paper records represent a problem in this regard, even because they can’t be sanitized just like others part of medical environment; hospitals with computerized medical records are better off in this regard.