Dr Dipesh K Gupta
At this hour in our country when everyone is under lockdown, health facilities also are not an exception, though partially. Though there is no definitive data, most centers have their regular OPDs closed. Fever OPDs are running with emergency services. Even not all government hospitals have opened regular OPDs. Those who are giving regular services at this difficult time need special appraisal.
Should we be really opening OPDs at this hour? - Pros and cons
Closing regular OPDs help with the norms of lockdown, lowering the number of patients who would visit hospital with minor complaints treatable with home remedies or over the counter drugs. It would be increasing the burden of indoor if planning for regular OTs, hampering the management of suspected or confirmed Covid patients. Furthermore, chances of cross infection would be high to such patients during their travel to the hospital, or during visit inside the hospital. Anyway, most if not all are getting e- consultation.
On the contrary, as we have seen the pattern of positive cases in Nepal where most of the cases bear low morbidity, probably health institutions need to have some ease regarding such OPDs. If we predict that coming time has similar scenario, we will have to live with rather than excluding cases of Covid. Semi emergencies including those who have genuine complaints, though mild are visiting emergency rooms increasing the burden of ER as well as crowding the space.
It’s time we should rethink and make some policies regarding reopening of OPDs and then gradually regular OTs and other works. Here are few measures while thinking to reopen regular services.
Measures to follow if we really start OPDs!
Guidelines may be subdivided for health facilities (administration), doctors, and for patients. This may be of some use to stake holders and health personnel themselves.
1. For health facilities
a. Shifting of whole Fever OPD Unit to another safe building (includes scrub area, OPD, waiting area, Waste disposal area)
b. We can start indoor gradually depending upon the hospital level, now only for emergencies or semi-emergencies.
c. Establishment of Isolation area to separate building if possible.
d. Set up a facility to screen OPD patients via a closed window-protected interview by a trained health personnel using mike system, before being allowed into the hospital.
This facility could even be set up outside the main OPD complex. Those reporting any suspicious symptoms (even the mildest) should be redirected to where they can be tested for COVID-19. Open walk-in access to OPDs should be banned.
The job of this particular unit would be to
i) identify the emergency/non emergency conditions (patient identification & triaging).
ii) take consent that they don’t lie about their disease/travel history.
iii) divert the patient accordingly to concerned department with minimum number of patient party (preferably only one)
iv) counsel the patients with simple/minor ailments and dispose
v) make sure patients and attendants enter the hospital with masks on
e. Set up different respiratory OPD other than fever OPD where unless proven otherwise we can take the patient as positive. This way other regular medical cases which are often in large number will not be mixed up.
f. Cohorting of staff prevents the mingling of those who work in high risk areas with those who work in other parts of the hospital. This reduces risk of infecting colleagues.
g. Not more than 4-5 patients to be allowed in front of each OPDs. It depends upon the space available there. We can preplan making circles or with barriers so as patient along with attendants can be managed in waiting area.
h. Compulsory provision of sanitizer and/or hand wash facilities before entering OPDs.
i. OPDs must have proper ventilation and not with closed space. As the role of air conditioning is not clear at present, we can wait till strong data comes.
j. Having posters of hand hygiene, cough etiquette, corona disease, and warning about asymptomatic carriers, pasted at appropriate places in the hall.
k. Regular disinfection of OPD area inside and outside- every 4-5 hrly or so.
l. Regular and proper sterilization for OPD instruments.
m. Every hospital must have a strong and efficient IPC (Infection prevention committee) that decides local policy based on established guidelines, trains personnel and audits the outcome. The hospital administration must take these recommendations seriously. Lack of IPC has been blamed as a major factor in healthcare worker deaths.
n. Housekeeping, laundry and biomedical waste disposal departments play a major role in disinfection and prevention. They must be involved in infection control meetings.
o. Provision of following essential equipments in OPD as per NMC guidelines ( Different level of PPEs have been described based on type of services- aerosol generating or non aerosol generating)
i) Masks - Surgical
ii) Masks - N95 (For Dental/ ENT/Ophthalmology)
iii) Gloves
iv) Sanitizer
v) Cap
vi) Visor
vii) Goggles
viii) Shoes
ix) Surgical gown
x) Air/water proof plastic/ synthetic cover for upper half of body/ plastic screen for ENT/Dental
p. Adequate manpower to manage patient and attendants outside.
q. Establish and motivate taking prior appointments so that OPD crowd in a given day is under control
r. Limit OPD number as per department. Like 15 patients a day for medicine OPD would be equal to 20 patients in surgical OPD. This must be considered even if crowd goes on increasing. This should be followed for months to come. This will make patients take prior appointments.
s. Encourage cashless transactions. People at cash counters to frequently scrub hands with sanitizers, wash hands.
t. Establishment of paperless lab reporting system. We can follow all reports in OPD computers and write reports in short in OPD tickets only. We can provide papers if they ask or if they are being referred to other centers
2. For Patients
a. Discourage healthy patients with very minor complaints from coming to the clinic for routine check-up
b. Patients must be educated about cough etiquette, Do’s and Don'ts, proper use of masks instead of using them indiscriminately and inefficiently; and personal hygiene. Hospitals should put up posters, video stations etc. to increase awareness amongst patients on Do’s and Don’ts regarding COVID 19.
c. Patients must be counselled against attaching any kind of stigma to Corona virus patients or to facilities where such patients are admitted. They must be made aware that quick disclosure of symptoms and undergoing testing if advised is the surest way of battling COVID 19.
d. Patients should be told about their behavior inside hospital, what to touch and what not to.
e. Limit the number of persons who accompany the patients to the OPD clinics. No senior citizens to accompany patients to the OPD.
f. Plan for follow up over phone or proper follow up with minimum required.
3. For Doctors
a. Change Scrub, dress when you enter the hospital. Dispose any purse/ belts in the locker so as to minimize things you carry.
b. Ward visit maintaining distancing
c. OPD – regular use of sanitizer/ hand wash after each patient
d. Maintain safe distance from the patient
e. Limiting conversation in closed spaces, maintaining universal social distancing and again asking all patients to wear a mask before entering the room or facility
f. Use minimum papers /reports.
g. Must use mask, visor during patient visit.
h. ENT/Dental doctors need special precaution to take
i. Monitor regular disinfection of OPDs and furniture inside- (Use 1% hypochlorite solution freshly prepared) - Every 4 hrs: railings, doorknobs, surfaces (reception desk, doctors table) - Floor every 24hrs - Stethoscope and thermometer (prefer axillary) between every patient
j. Avoid touching your face, nose, eyes in between
k. Having a person standing at the entrance spraying sanitiser/ spirit over the hands of all who come to the OPD.
l. No medical representatives to visit doctors for many weeks to come
m. Self-quarantine (self-isolation) if you have any symptom, you can save others getting infected.
n. Periodic surveillance of healthcare workers by testing is necessary to detect infected people early and to isolate them
o. Those healthcare workers taking care of sick relatives at home must be careful not to bring the virus to the workplace
p. Avoid longer working hours and fatigue, they contribute to risk of infection
q. Doctors to change dress when going home, clean fomites (Mobile phones, stethoscope) before going home). Leave stethoscopes preferably in the hospital only.
Periodic multidisciplinary meetings with all stakeholders within a hospital will help make the place safer for everyone. Such meetings must involve those who work in engineering, maintenance, pharmacy, microbiology, lab, nursing, housekeeping, human resources, doctors and administration.
All healthcare workers are vulnerable. The risk applies not only to nurses and doctors, but also to pharmacists, technicians, physiotherapists, receptionists, paramedics, attendants, ambulance drivers and other staff. All healthcare workers therefore require training and protection according to their level of exposure to the virus.
Reopening all other hospital services needs another consideration. Special precautions are to be taken inside operation theatres. We, health personnel can’t ignore non Covid patients. For months and years to come, we will have to live with this fear but we must keep on and do what we are meant for.
-(Dr Gupta is Associate Professor in Nepalgunj Medical College)