Challenges of infection control for ophthalmologists

Universal precautions, reorganising office and workflows reduce COVID risk

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Matthew McCarthy MD
One of the biggest challenges in re-opening an ophthalmic practice in the era of COVID-19 is that it is impossible to tell who has the disease. So, the only safe course is “assume every patient has coronavirus for the time-being”, said noted infectious disease specialist Matthew McCarthy MD of Weill Cornell Medical Center in New York City, USA. Speaking at the ASCRS Virtual Annual Meeting 2020, Dr McCarthy, who has treated more than 300 COVID-19 patients, advised taking universal infection control precautions in the office and surgery centre. While a lot of general COVID-19 infection control information is available from government authorities such as the USA’s CDC and CMS, ophthalmic practice poses some unique challenges, such as clinicians spending several minutes in close proximity to patients’ faces during exams. ASCRS’ cornea clinical chair and noted ophthalmic infectious disease expert Francis S Mah MD, of Scripps Health, La Jolla, California, USA, outlined several steps ophthalmologists can take. The goal is to protect patients, staff and themselves while projecting confidence in a safe work environment, and delivering high-quality eye care. Wearing masks While there has been a lot of debate about wearing face masks and face coverings, the latest research finds it is critical for controlling the spread of COVID-19, Dr Mah said. He highlighted one paper suggesting that 100% community compliance in wearing masks of moderate to high filtering efficacy would substantially halt the spread (Tian L et al. Calibrated Intervention and Containment of the COVID-19 Pandemic. 2020, https://arxiv.org/abs/2003.07353). So, who should wear what mask? The short answer is all healthcare professionals and staff should wear a surgical-type mask at all times, and patients should be required to wear surgical masks, cloth masks or face coverings as well, Dr Mah said. “Any face covering at all is better than no face covering.” N95 masks, which filter out 95% of particles 0.3 microns or larger, are among the most effective, and are appropriate for professionals to wear during surgical procedures in areas with high COVID-19 incidence, Dr Mah said. However, he warned against using masks with valves that release exhaled air. These are designed for industrial use and do not guard as well against the wearer spreading disease, which is the whole point. “My mask protects you and your mask protects me.” Dr McCarthy noted that N95 masks mostly are needed to protect personnel from aerosols created in procedures such as intubating patients. In clinic, he himself normally uses a surgical mask with an eye shield. However, since ophthalmologists spend so much time so close to patients’ faces, he suggested using an N95 mask for slit-lamp exams and procedures is not unreasonable. Limiting contact Minimising direct contact and ensuring appropriate social distance among patients, staff and clinicians is another critical infection control element that touches many aspects of practice design, organisation and workflow. To protect staff from unnecessary exposure, Dr Mah suggested dividing them into separate teams where possible. For example, billing and insurance staff might be isolated from front-desk employees. All staff meetings when needed can be conducted by telephone or video conference. To minimise patient exposure in the office, Dr Mah suggested adopting alternative check-in processes. Screening for COVID-19 symptoms or exposure and triage of whether patients need to be seen in person can be done by telephone, as can registration and insurance checks. In the office, protective screens should be installed in front of counters, and any paperwork or payments handled by staff wearing medical masks and gloves. To avoid patients congregating in the waiting area, Dr Mah suggested having them wait in their cars for a call or text, or escorting patients from waiting cars at their appointment time, though this is not possible in all areas. Inside, chairs should be spaced appropriately and floors marked where patients should stand. High-risk surfaces such as magazines, brochures, coffee, water and toys should be removed. In the clinic, workstations should be spaced two metres apart and shared workstations and phones eliminated. All equipment and surfaces should be disinfected in each room after each patient. Current USA CDC guidance calls for diluted bleach or 70% alcohol solution or Clorox or Lysol products for general disinfection. Follow manufacturer recommendations for cleaning delicate instruments, Dr Mah said. Signs and weekly check Signage on what to do if you are sick or experience COVID symptoms should be placed at the practice entrance and check-in areas. Staff reminders to practice distancing and appropriate hand hygiene should be prominent. Finally, take a weekly walk around your office or surgery centre to identify any need for physical modifications. Invite staff and physicians to offer feedback and suggestions, Dr Mah said. “We as eyecare specialists need a commitment to adopting protocols to prevent the transmission of the disease to healthcare personnel and patients.”
Tags: ASCRS Virtual Annual Meeting 2020, covid-19 infection control