The College of Optometrists primary eye care COVID-19 guidance: Recovery phase

  • 29 May 2020

This guidance is to help optometrists understand how to adapt their working practices as we move into the amber phase of the pandemic.

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1.    Introduction

1.1   This guidance is written to help optometrists understand how to adapt their working practices ahead of a move into the “amber phase” of the pandemic. This phase is defined as when optometry practices begin to provide care to people other than those need urgent or emergency and essential eye care services, more details are included in our accompanying table [see section 1.3].

1.2    The aim of this guidance is to help optometrists adapt their practice and working procedures following a period of lockdown, to make their practices safe for patients and staff while there is still a risk of COVID-19 infection. This guidance builds on, and should be read alongside, the guidelines we published during the pandemic. The Association of British Dispensing Opticians (ABDO) has developed guidance on dispensing.

1.3    We have produced a table which provides an overview of how eye care might have to be adapted during various stages of the pandemic at a national or local level. You can access that table here. The guidance below covers additional points to consider during the amber phase of the pandemic, as prioritised sight testing and other optometric services resume. Both the guidance and the table may change as the situation evolves and according to national guidance in the four countries of the UK, so you should check back regularly for the latest updates.

1.4    During the pandemic, the GOC issued a joint regulatory statement: ‘We recognise that in highly challenging circumstances, professionals may need to depart from established procedures in order to care for patients and people using health and social care services.’ They continue: ‘Uncertain times mean that our registrants may be called upon to work at the limits of their scope of practice and vary their practice for protracted periods of time and in challenging circumstances.’ 

The GOC also issued a series of statements by which they ‘hope to reassure our registrants and the education sector that when they act in good conscience, for the public benefit, exercising professional judgement in all of the circumstances that apply, the GOC will support them.’. You should refer to the GOC website - optical.org - for up-to-date information on whether these statements still apply during the various phases of recovery.

1.5    There is a growing number of resources to use during the pandemic available on the College website.

2    Procedures and protective measures 

Environment

2.1    Social distancing, currently recommended as a distance of two metres should be maintained during this phase of the pandemic, unless it is necessary to get closer to an individual for clinical reasons.

2.2    Consider how many people you can safely accommodate in your practice (patients and staff) to ensure that social distancing of two metres is maintained. Place markings on the floor to help. These should be clearly visible to help people with sight loss. Space chairs at least two metres apart. 

2.3    To ensure that people only attend the practice when necessary, provide services remotely where possible – for example, by posting spectacles or contact lenses to patients, and taking credit card payments over the phone.

2.4    Implement an exclusively pre-booked appointment system (do not encourage drop-ins), including for repairs or dispensing, or operate a ‘one in, one out’ entry policy to ensure people have space to maintain social distancing. Ask people to wait outside the practice (at a suitable distance) if the practice is at capacity. Alternatively, if there is parking nearby, a patient may choose to wait in their car and you can phone them when their slot is available.

2.5    Use acrylic (or similar) shields where necessary, for example around reception, if a two metre distance cannot be observed.

2.6    Remove all unnecessary items, such as magazines and toys, from the waiting/reception area.

2.7    Encourage contactless card payment. If handling cash, follow infection control/PPE guidance. If a signature is required, ask patients to use their own pen to sign any forms, or follow infection control procedures if the patient uses a practice pen. 

2.8    Use a cough guard on your slit lamp. The Royal College of Ophthalmologists has published advice on how you can make a temporary cough guard

2.9    Have hand sanitiser (at least 60% alcohol) available at the front door, and ask patients to sanitise their hands on entering the practice. The UK governments have produced guidance for people who work in or run shops, branches, stores or similar environments in England, Scotland, Wales and Northern Ireland.

2.10    Consider the practice layout and ventilation of enclosed spaces, such as the consulting room, opening windows and doors where possible to help air flow, and considering having breaks throughout the day when the room can be thoroughly aired.

2.11    Avoid consulting rooms being shared where possible, so that each practitioner works from their own consulting room rather than swapping between them on different days.

Infection control

2.12    Disinfect everything the patient has come into contact with and frequently clean surfaces that are touched by staff if possible. This would include clinical equipment and other surfaces, such as a clipboard, that may have been contaminated with body fluids. Use a suitable disinfectant [see para 2.14]. All surfaces must be clean before they are disinfected. Open doors for patients, to avoid them touching the handle. If the patient touches the door handle, disinfect it.

2.13    Workstations should be assigned to one individual as much as possible. If they need to be shared, they should be shared by the smallest possible number of people.

2.14    Cleaning agents containing sodium hypochlorite 0.1% or 0.5% have been shown to be effective against SARS—CoV-2 when in contact with the surface for more than one minute. Ethanol of a concentration of 70% has also been shown to be effective. It is important to ensure the surface or equipment is cleaned before it is disinfected. The World Health Organisation (WHO) recommends 70% ethanol solutions to disinfect reusable equipment such as chin rests, handles, trial frames and other hard surfaces. For commonly touched surfaces, the WHO recommends 0.5% sodium hypochlorite. You should check the manufacturer’s advice to ensure these disinfectants are not likely to damage instrumentation or surfaces. Microbial wipes may be used, provided that they contain the correct concentration of ethanol. Wear an apron and disposable or washing up gloves when cleaning. These should be double bagged and stored securely for 72 hours, then thrown away in the regular rubbish once cleaning is finished

2.15    If you need to focimeter patients’ spectacles, ask the patient to take them off and provide the patient with a wipe to sanitise their frames before you touch them.

2.16    Support good practice for the use of tissues by patients and staff ( ‘Catch it, Bin it, Kill it’) by having tissues and covered bins readily available. Empty the bins regularly throughout the day.

2.17    Tell patients and staff to practise regular hand hygiene and provide hand sanitiser in multiple locations. If you are using soap and water, you should wet your hands, apply liquid soap and then rub the soap into your hands, covering all areas of your hands for at least 15 seconds, before rinsing the soap off and drying your hands with a paper towel. If you are using hand sanitiser, you should apply the sanitiser to your hands, and rub all areas of your hands until the sanitiser is dry

2.18    Frequently clean work areas using your usual cleaning products, and frequently clean objects and surfaces that are touched regularly, such as kettles.

2.19    All practice staff should wear appropriate PPE if they need to see patients at a distance of less than 2 metres, unless this is behind a screen. National guidance is that, even if the patient is not currently a possible or confirmed case of COVID-19, clinicians should wear single-use disposable aprons and gloves (changed for each patient). 

2.20    In addition to gloves and aprons, national guidance advises optometrists to risk assess whether they need to wear a fluid-resistant surgical face mask (type IIR) (a ‘surgical mask’) and/or eye/face protection if there is an anticipated or likely risk of contamination with splashes, droplets of blood or body fluids. If masks and/or eye/face protection are worn they can be worn for the whole session (‘sessional use’) rather than changed for each patient, unless they become soiled, damaged or uncomfortable.

2.21    We recommend that all optometrists working within two metres of a patient should wear a fluid-resistant surgical mask (‘surgical mask’). The same surgical mask may be worn for examining multiple patients, but you must be fastidious to avoid transmitting any potential virus on the front of the mask via your hands or your clothes. Do not take the mask on and off between patients, do not touch it and do not allow it to dangle on your chest. Instructions on how to put on and take off PPE can be found here or videos here and here.

2.22    Hand hygiene should be practised and extended to exposed forearms, after removing any element of PPE.

2.23    Do not deliver face-to-face care at less than two metres, if you do not have appropriate PPE.  Direct the patient to an alternative primary care optometry service that does, where possible.

3    Staff

3.1    Ensure all staff are appropriately trained in infection control policy and are kept up to date with changes in national public health guidance and government policy.

3.2    Ensure all staff are aware of the symptoms of possible COVID-19 and do not attend the practice if they, or any of their household, display these symptoms, as per government advice.

3.3    Consider how you can best use the space in your practice to ensure you can meet social distancing requirements of staff and patients; for example, by using a spare consulting room to conduct non-clinical tasks that cannot be done from home. 

3.4    To minimise the number of staff in the practice, follow national government advice and implement home working where possible (England, Northern Ireland, Scotland and Wales).  Administrative tasks should be done from home if at all possible.

3.5    NHS Employers has advice on enabling and supporting staff to work from home.

3.6    Keep the same teams of people working together where possible, so each person only works with a few other people, to minimise mixing of colleagues. This may involve altering staff rotas.

3.7    Reduce the number of people a patient has contact with during their patient journey; for example, have the same person doing the pre-screening as doing the dispensing for that patient, or have the optometrist do all clinical tests, including those that would normally be done by an assistant.

3.8    Non-clinical members of the practice team who are unable to maintain a two metre distance from others (including other members of staff) should wear a face covering to cover their nose and mouth. Depending on the staff member’s role, this does not have to be a surgical mask and can be homemade. The government has issued is advice on how to make a face covering.

3.9    Some people are more at risk of contracting COVID-19 than others. You should therefore consider each individual member of staff’s risk when assessing the most appropriate working environment for them. People at particular risk, or those who live with people who are ‘extremely clinically vulnerable’ should work from home, or away from others, where possible. An example of a risk assessment tool can be found here.

3.10    Keep in regular contact with staff, including those who are working remotely. Be mindful of the mental health and general well-being of staff, particularly those who are isolated and not in frequent physical contact with other people.


4    Patients

4.1    When a patient makes an appointment, and on the day of the appointment, ask them to confirm that they are well, and that no one in their household is exhibiting relevant symptoms (new, continuous cough; a high temperature and/or loss of or change in taste or smell). Patients with these symptoms, or with someone in their household with these symptoms, should not attend the practice, and should self-isolate.

4.2    If the patient has symptoms of COVID-19, as well as symptoms of a life- or sight-threatening condition, do not see them in your practice. Follow local protocols or contact your local hospital eye service for advice, telling them that the patient has symptoms of COVID-19.

4.3    If a patient has to attend the practice, ask them to come alone where possible. If a companion is necessary, for example to support someone with sight loss, ask the companion to wait outside if possible, whilst the patient is seen. It is recommended that a child should only be accompanied by one parent if possible. If a patient needs a translator, consider whether this can be done by video or phone, to avoid too many people being in the consulting room.

4.4    Ask patients to sanitise or wash their hands on entering and leaving the practice.

4.5    If a two metre social distance cannot be maintained throughout the patient’s journey, ask the patient to wear a face covering (see 3.8 above) in line with current public health guidance.1 2 The WHO has information about the dos and don’ts of wearing a fabric mask safely here and here.

5    Consultations

Triage 

5.1    When the patient contacts the practice for an appointment, ask them why they need to come in and ensure your local booking process is responsive to the current COVID-19 alert level. See our table. Where possible, postpone face to face visits until the social distancing measures are over if this can be done safely. If you advise the patient that they can safely postpone their visit, tell them to contact you again if things change, or in a set period of time so that you can review them again and decide if their needs have changed. 

5.2    To help with staffing, consider asking whether the patient intends to purchase spectacles during their visit, so you know whether or not you will need dispensing cover.

Reduce physical contact:

5.3    Contact the patient before they attend the practice and take as much of their symptoms and history as you can remotely, by phone or video. Be mindful of people who cannot talk confidentially at home and of those with other communication needs, such as those who have hearing loss, or who are deaf, and might prefer to do this at the practice. If this is not done on the day of the appointment, confirm with the patient on the day of the appointment that nothing has changed since you spoke. It should be clear from the record which conversations were had when. If you need to discuss things with the patient when they are in the practice (before or after the consultation), do so at a safe distance of at least two metres.

5.4    Adapt your routine to reduce the risk of cross-infection and close contact with patients. For example:

  • use SL-BIO instead of direct ophthalmoscopy. If the patient cannot reach the slit lamp, use another form of indirect ophthalmoscopy. If this is not possible, for example when examining a young child, you should risk assess whether to perform direct ophthalmoscopy, and minimise the infection risk by asking the patient to wear a face covering if possible (this may not be possible for very young children)
  • do not talk when at the slit lamp, other than to tell a patient where to look
  • perform retinoscopy at an increased working distance where possible (adapting the working lens where appropriate)
  • consider using a refractor head instead of a trial frame because it may be easier to disinfect. Some refractor heads can be operated without you needing to be as close to the patient, thereby reducing close contact
  • if you use a trial frame, increase the back vertex distance (BVD) to reduce the likelihood of trial lenses touching the patient. Remember to adjust the spectacle prescription for the increased BVD where necessary. Disinfect trial lenses that touch the patient
  • If you need to do tonometry, to maintain a safe distance, use a slit lamp mounted (such as Goldmann) or stand mounted tonometer where possible. If this is not possible, you should risk assess whether to use a hand held device such as an iCare, Perkins or Pulsair. If you use a hand held device you should ask the patient to wear a face covering. 

5.5    Because of the potential to generate aerosols:

  • do not use Alger brushes. If you need to remove a rust ring, use a needle instead
  • do not use BlephEx – use alternative blepharitis management, such as lid spuds, tweezers etc.

5.6    If you need to conduct a visual field test, consider using an enclosed visual field screener rather than a bowl type, because an enclosed visual field screener is easier to disinfect. Only use a bowl type perimeter where absolutely necessary, and consider what added value using that equipment will have for that particular patient. Follow these instructions for disinfecting a Humphrey perimeter. If you need to use a bowl perimeter to reduce the risk of patients breathing contaminated air into the bowl, ask patients to wear a face covering when using it. Ensure that the face covering does not interfere with the results, for example by altering how the patient’s spectacles fit on their face.

5.7    To reduce physical contact between the patient and equipment, as well as the time the patient spends in the practice, only conduct examinations that are clinically necessary or required by law, rather than doing blanket tests on everyone (for example as part of pre-screening).

5.8    If you have adapted your routine to alter or remove tests that the patient would normally have completed, explain to the patient why you have done this and what the implications will be, for example, they may need to return earlier than usual for a follow-up.

Record keeping:

5.9    Make it clear on your record the adjustments you have made to your routine or clinical decision making, and that these were because we are in the COVID-19 pandemic. Examples would include delaying a referral or a domiciliary visit because the patient is at greater risk of COVID-19.

Other support and guidance

5.10    Please stay up-to-date with our general COVID-19 guidance and support. This includes open source guidance and support covering:

  • How to make modifications to the practice setting to aid social distancing 
  • Remote consultations – including guidance, template forms and a visual acuity check
  • FAQs covering a range of clinical issues – including PPE 

You should also be familiar with other guidance published by UK governments. FODO summarises this here.

 

Other useful information

College of Optometrists guidance on conducting remote consultations

College of Optometrists guidance on risk stratification of patients during the COVID-19 recovery phase.

Risk reduction framework for NHS staff at risk of COVID-19 infection

UK Government advice on working safely during COVID-19 

Coronavirus in Northern Ireland

Coronavirus in Scotland

Coronavirus advice in Wales

FODO: Meeting eye health needs and preventing vision impairments during Covid-19, a framework for primary eye care providers, dated 17 May 2020 

FODO: How to nagivate out of lockdown

ABDO – Practice recommendations, patient pre-appointment screening form and resources  

Public Health England: COVID-19: infection prevention and control guidance 

Public Health England: Appendix 2.  This includes a visual guide to PPE (including the impact of facial hair on respirator masks) and hand washing as well as how to manage blood and body fluid spillages

The Social Care Institute for Excellence has information for supporting adults with learning disabilities or autistic adults understand the changes through the COVID-19 crisis 

 

References

https://www.gov.uk/government/publications/staying-safe-outside-your-home/staying-safe-outside-your-home

In Wales a three layer face covering is recommended indoors where social distancing is difficult.

 

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