Over recent months two things have become apparent. Firstly, that we are living in a world where COVID-19 infections are a reality and secondly, that winter is bringing an increase in other respiratory illnesses including influenza and RSV.
Over the winter months demand for consultations will continue to increase and we need to find ways to efficiently respond to that influx of patients.
The response to the COVID-19 pandemic has meant that we now have had to practise in very different ways from the past. Separating potentially infectious patients from others (red/green streaming) has been the norm as has been the wearing of personal protective equipment (PPE); however streaming and other infection control measures can at times impact on practice efficiency.
It is time to have a constructive debate to define what is the “new normal”, with a focus on acute respiratory infectious disease. It is important that both patients and staff are comfortable in our approach to viral respiratory infections.
With the inevitable increase in demand for care during winter there are several key factors to consider:
- Triage processes need to efficient and tailored to practice conditions
- Acute care needs to be prioritised
- Strict “red/green” streaming can be modified; however separating infectious patients from others still needs to be considered
- Infection control needs to be more focused on PPE use within practices to protect both patients and staff
- In the longer term we need to look at the design of practice premises in terms of airflow and sterility.
Each practice needs to make its own priority assessment and pragmatically weigh up the risks of infection transmission against the greater need for good clinical care of the individual. The patient should be at the centre of the decision making.
While the layout of premises is important in decision making about streaming, there are also differences in the type of care offered. Some practices will have a greater emphasis on urgent care than others and this also needs to be factored in to decision making.
Triage, particularly for identifying respiratory illnesses has become part of the “new normal”. It should facilitate good clinical care and not be perceived as a “barrier”.
Depending on the size of the practice, having someone effectively triaging and dealing with patients with respiratory symptoms is essential to both good outcomes and practice efficiency.
Triage processes and protocols should be regularly reviewed with feedback from patients.
Acutely ill patients need to be prioritised and specific triage protocols need to be in place.
Identifying patients with COVID-19 is a priority but this is now done within the context of containment rather than elimination of disease.
Evidence suggests that general practice is becoming very efficient at triaging acute respiratory patients and encouraging self-management where appropriate.
COVID-19 is not the only acute illness in the community, and we need to be alert to other acute conditions.
There are a variety of practice facilities around the country ranging from smaller, older buildings with limited waiting room capacity, through to large purpose-built premises that can easily separate patients into streams without having to have people waiting outside the practice before an appointment.
- We should aim for all consulting, treatment and waiting rooms to have adequate ventilation that efficiently dilutes and refreshes the air. Infectious diseases experts recommend that air flow should create a minimum of six air changes per hour. Possible methods of improving air flow and reducing viral load include:
- Ensuring good airflow by opening windows
- Using air filtration systems including HEPA filters
- Reviewing and enhancing air conditioning systems where they exist.
Plainly these changes may have cost implications and in the long term there may be the need for changes in the design of practice premises.
Disinfection and general practice cleanliness
At the beginning of the pandemic increased cleaning and disinfection of surfaces and equipment after each patient was the normal activity but was both labour intensive and time consuming.
In the absence of obvious respiratory contamination, a return to regular sessional cleaning should be the normal standard. There is no need for a “stand down” period for any consulting room.
PPE and other IPC requirements
It is essential that all staff must be protected from the risk of airborne respiratory infection. It is appropriate PPE is available to all staff when required. We should have appropriate stocks of:
- medical masks
- eye protection
- long sleeved gowns
- P2/N95 particulate respirators.
In addition to standard precautions the use of P2/N95 particulate respirators should be the minimum requirement for any member potentially exposed to airborne infections.
Other points to consider:
- If the clinician is in a high-risk area or undertaking a procedure that could generate splashes, then eye protection should be used along with gloves and either a long-sleeved gown or plastic apron to protect street clothing.
- If the clinical risk of infection is low, then gloves and gowns are not necessary.
- It has now become common for clinicians to wear a mask for an entire session and to not change masks after a COVID-19 encounter unless there has been obvious droplet or aerosol contamination, and this seems reasonable.
- Staff who can maintain physical distancing can wear surgical masks but P2/N95 respirators should be used by staff if the area is one of high infection risk.
- For reception staff dealing with the public the addition of added physical barriers such as Perspex screens is sensible.
- With appropriate physical distancing and physical barriers there should be no need for reception staff to be allocated to either a red or green stream as there is a real likelihood that infectious patients will inevitably appear in either stream.
- Patients should be required to wear a mask while in the practice and those who cannot, or will not, should be kept outside the practice or in a separate area until they are due to be seen. Explain to them that the practice is doing this to protect other vulnerable patients within the premises.
Within the practice waiting areas there should be the maximal physical distancing that the premises allow.
Good infection protection and prevention measures remain critical to safeguard the health of both patients and clinical staff. This is particularly important when there is increasing prevalence of respiratory infections as in winter; however implementing a pure “red/green” streaming protocol can be challenging for many practices. Notwithstanding, the shorter time patients have to wait in common areas the safer it is for them.
Where a practice has the luxury of two waiting areas, red/green streaming can be maintained; however, for those who do not have that ability, then practical steps should be made to maintain physical distancing and as noted above, an insistence on mask wearing by patients within the practice.
The reality is that in winter, keeping people outside the practice until they are seen may be impractical and an inefficient use of staff resources. In addition, it carries the additional risk that patients waiting outside the practice cannot be monitored for deteriorating signs and symptoms.
Some practices are allocating a specific time in the day for vulnerable but non-infected patients to be booked for an appointment. This does require a knowledge of the patient and an ability to define “vulnerable”. Indeed, as part of triage, it may be sensible to enquire what level of physical protection they themselves would like, as for example they may be happy to wait in a car.
We appreciate however that this concept may be thwarted if your practice allows “walk in” patients to arrive without an appointment.
COVID-19 has changed the face of primary care and we need to identify clearly what the new normal is and then deal as efficiently with that new normal.