Safe Practice Protocols & PPE Resources



Safe Practice Protocols & PPE Resources

MASKS

How exactly do N95 masks work to block virus transmission? Patients often come in wearing a variety of homemade masks. Are some better than others?

Can I allow my staff to use re-usable cloth masks?

How do I take off and put on a facemask?

How do I store and clean PPE?

What do I need to consider when planning to purchase respirators from outside the US?

We sometimes remove our masks while in our break room away from patients. Is that ok?

What is a user seal check? How can I be sure my face mask is working properly?

If an OD chooses not to see a patient who has a medical waiver for mask use, will they be legally liable for turning them away?

How effective are cloth face masks at preventing COVID19 transmission?

A patient recently asked me for a medical waiver to use alternative face covering at their work.

What are my obligations?
How effective are face masks worn by patients at preventing viral spread while at the slit lamp?

What concerns should I be aware of with indoor ventilation (HVAC)?

Is it mandatory for us to take the temperatures of all persons who enter the office?

How do we record this?

Our office sees many older patients who often have pre-existing conditions.

How can I decide if it is worth the risk to see them for their glaucoma follow ups?

Can COVID19 cause conjunctivitis?

I find lenses are always fogging up. Any tips?

TESTING

I have a patient who we have not seen yet who tested positive for COVID19 recently, but is asymptomatic.
When can we see them?
How effective are Home Self-Collected Swabs for SARS-CoV2 compared with Clinician Collected Testing?
How effective is rapid SARS-CoV2 antibody testing? What if someone in my office tested positive with this type of testing?
How useful are SARS-CoV2 antibody/serology tests?

TRANSMISSION

How else can SARS-CoV2 be spread besides contact with surfaces and droplets produced by coughing?
Are asymptomatic carriers of SARS-CoV2 really without any symptoms?

Our practice sees a lot of pediatric patients. Are younger children likely to spread the virus?

I have heard that dilating patients during this COVID time is discouraged.  Is this true?

Disinfection/Safety Protocols

How much time is required between occupants of a room to allow for adequate air circulation and minimize risk of virus transmission?
How do I know the state of COVID19 in my county?
What is recommended for contact lens disinfection?
How effective are slit lamp face shields?
How do I disinfect my hand held diagnostic lenses?
What is the newest information about sanitizer/cleaner recall?  
 

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MASKS

 

How  exactly do N95 masks work to block virus transmission?

This interesting video describes the physics of how N95 masks work..

Patients often come in wearing a variety of homemade masks. Are some better than others?

  • Mask quality is dependent on fit and filtering qualities of the material.
  • This paper argues that the "Duckbill" design was best fitting
  • PM1 filter material (not the PM 2.5 often included in commercial non-medical masks)  provided best protection
  • This paper claims that bandana type face coverings are not very effective and may increase airborne small droplet transmission
  • If we all wore more effective face masks, we could lower the reproductive rate of the virus.  

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Can I allow my staff to use reusable cloth masks?

Cloth masks are not in compliance with WA State Department of Health PPE Conservation Strategies for healthcare providers and are not considered PPE by the CDC.  Staff in health care offices should wear a mask at all times, including in break rooms or areas where they may encounter co-workers.  
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How do I take off and put on a facemask? How do I store and clean PPE?

Click here for information on how properly take off and put on a disposable respirator.  
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What do I need to consider when planning to purchase respirators from outside the US?

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/international-respirator-purchase.html  

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We sometimes remove our masks while in our break room away from patients. Is that ok?

  • Sharing a small room with others while not wearing a mask is not advised.
  • The CDC has confirmed that aerosol transmission of the virus is possible.
  • Mathematical modeling was done to estimate the amount of virus emitted by a COVID-19 positive person having a high viral load (aka 'super-spreader'). These persons can have no symptoms. They can emit a considerable amount of virus into a small space.
  • Health care workers can be at high risk of contracting the virus while in a small, poorly ventilated exam room with a 'super-spreader'.  

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What is a user seal check? How can I be sure my face mask is working properly?

  • Fit testing is a standardized procedure to choose the best fitting face mask. It is used in many hospitals to fit health care workers. This  is the gold standard in properly fitting masks.
  • A user seal check is a procedure to ensure your mask is retaining its original fit. Here is a good guide describing how to do a user seal check.  

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If an OD chooses not to see a patient who has a medical waiver for mask use, will they be legally liable for turning them away?  

  • The AOA provides some guidance on this difficult question. A doctor may refuse to see a patient refusing mask wear but must have an office policy in place to that effect that does not discriminate and applies to all.
  • Patients, like the above case, with physical or mental disabilities may require special accommodations.
  • This article describes two important concepts to consider; negligence and patient abandonment. Allowing an unmasked potentially infectious patient into your office might constitute negligence by creating an unsafe  environment for others.
  • Refusing to see a patient could constitute abandonment in normal times, but may not during a pandemic. For those with a medical prohibition to mask wearing, some suggestions include offering a telemedicine visit, delaying non-urgent care until the pandemic situation improves, offering to monitor pulse oximetry while the patient is wearing a mask, or referring to another provider who may be better equipped with PPE.

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How effective are cloth face masks at preventing COVID19 transmission?

The effectiveness greatly depends on the type of mask. Bandana-type masks are the least effective in stopping aerosols in this simulated experiment.  

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A patient recently asked me for a medical waiver to use alternative face covering at their work. What are my obligations?

  • WA state requires the use of face masks in all public spaces. The exceptions include people with certain disabilities or health conditions, people who are deaf or hard of hearing and children under age 2.
  • There are  very few health conditions that might be impacted by mask use. Dr. Albert A Rizzo, Chief Medical Officer of the American Lung Association states that, "In general, the breathing of people with mild asthma, both young and old, should not be impeded by the wearing of facial coverings...Exemptions for mask wearing for mild asthma should be discouraged...I do not recommend automatically exempting individuals from wearing masks, even many of my pulmonary patients."
  • The consensus of the OPW COVID19 Task Force is that  OD's should direct patient requests for mask waivers to the patient's primary care physician.

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How effective are face masks worn by patients at preventing viral spread while at the slit lamp?

This is a very interesting re-creation of droplet spread caused by poorly fitting masks vs. well fitting ones. Bottom line: a well fit face mask makes a noticeable difference in blocking droplets.  

What concerns should I be aware of with indoor ventilation (HVAC)? 

  • This document provides an excellent overview on indoor building ventilation during COVID-19:
  • Portable HEPA air purifiers may be particularly helpful when additional ventilation with outdoor air is not possible without compromising indoor comfort (temperature or humidity). 
  • Relative humidity (RH) may be inversely proportional to the incidence of COVID-19.  https://onlinelibrary.wiley.com/doi/full/10.1111/tbed.13631 
  • Economizers regulate the percentage of outdoor air:recycled indoor air when outdoor temperature is warmer or colder than indoors.  Relative humidity decreases with higher indoor air percentage.  Here is a good document describing this. 
  • It may be helpful to discuss this with your building maintenance or HVAC professional.

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Is it mandatory for us to take the temperatures of all persons who enter the office? How do we record this?

  • The short answer is YES.
  • Here is the Governor's Proclamation 20-24.1, which states that temperature screening is a requirement for returning to non-urgent care.  
        "Use on-site fever screening and self-reporting of COVID-19 symptom screening for all patients, visitors and staff prior to (the preferred approach), or immediately upon, entering a facility or practice"
  • OPW participated in the meeting that adopted this rule and a more recent one that clarified that actual fever testing (taking a temperature) is the intent of this rule.
  • There is no set requirement for recording this. Recording in the chart notes is a good method.

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Our office sees many older patients who often have pre-existing conditions. How can I decide if it is worth the risk to see them for their glaucoma follow ups?


  • Researchers used academic ophthalmology clinic data to create an algorithm to guide making appointments for glaucoma patients during periods of restricted health care access during the pandemic
  • The algorithm balances the risk of contracting COVID for patients at high risk of COVID-19 complications (elderly, pregnant, comorbidities) with the risk of glaucoma related vision loss due to delay. 
  • Higher risk for glaucoma progression included incisional surgery in last 3 months, history of very low (<6mmHg) or very high IOP ( >30mmHg) in last year, considerable VF loss in one or both eyes (-12dB or
    worse) or monocularity (BCVA 20/40 or better in one eye and 20/80 in fellow eye)  

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Can COVID19 cause conjunctivitis?

 

  • This case study describes a COVID19 patient whose conjunctival samples tested positive for up to 17 days after onset of disease. 
  • They describe typical signs of  viral  conjunctivitis, such as moderate bulbar injection, watery discharge, inferior conjunctival follicles and palpable preauricular nodes.    

I find lenses are always fogging up. Any tips?

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TESTING

I have a patient who we have not seen yet who tested positive for COVID19 recently, but is  asymptomatic. When can we see them?

  • According to the CDC, for patients with mild to moderate COVID19 symptoms, isolation can generally be discontinued 10 days after symptom onset, a resolution of fever for at least 24 hours without the use of fever reducing medication, and an improvement of other symptoms. This is referred to as a symptom based strategy.
  • Persons with more severe COVID19 symptoms or with immunocompromise may shed viable virus longer than 20 days. A test based strategy to end isolation restrictions is advised in this case. 
  • For asymptomatic COVID19 patients who never develop symptoms, isolation can be discontinued 10 days after their first positive RT-PCR test for SARS-CoV2
  • Asymptomatic COVID19 patients may shed virus for longer than 14 days according to this study. It is unknown if virus fragments picked up by RT-PCR testing are capable of  being infectious. 
  • BOTTOM LINE: The doctor's professional judgement is always key, guided by the best evidence available. Make sure you have an office policy in place to deal with these situations. Consider the urgency of the patient's ocular complaint in your timing as well. A referral to a facility equipped to deal with COVID19 positive patients may be indicated in urgent cases.    

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How effective are Home Self-Collected Swabs for SARS-CoV2 compared with Clinician Collected Testing?[18] 

  • This study compares home-based mid-nasal swab testing for SARS-CoV2 with clinician collected naso-pharyngeal swab testing.
  • Compared to clinician collected samples, home based testing had an 80% sensitivity and a 97.9% specificity.
  • Although the authors recommend this method since it relieves strain on clinician based testing, an 80% sensitivity rate means 20/100 people will test negative for the virus but might actually be carrying the virus. 
  • There are some limitations to this study including the fact that participants in the home testing version were health care workers themselves, whose skill in sample collection  may be  different than lay public.
  • More data on the effectiveness on home based testing is needed.
  • Rapid antibody testing may have serious limitations and limited usefulness on its own.
  • A positive antibody test without recent illness does not restrict one from work or other activities when legally permitted.  

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How useful are SARS-CoV2 antibody/serology tests?[19] 

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TRANSMISSION

How else can SARS-CoV2 be spread besides contact with surfaces and droplets produced by coughing? 

  • Aerosol transmission  of the virus is now accepted as a possible route for infection under certain conditions.
  • This well designed study looks at the dynamics of aerosol (< 5 micron)  transmission in closed spaces with various ventilation scenarios.
  • Potential implications for optometry in small exam rooms and the use of ventilation.
  • Describes possible etiology of 'super spreaders'
  • Breathing produces a "cone" of aerosols that dissipates beyond 1 foot from the emitter.
  • Breathing generates aerosols. Talking causes even more and "super-spreaders" emit a significantly greater amount of aerosols.
  • Supports the frequent cleaning of surfaces on which larger aerosols may deposit  in a variety of locations due to room air flows. (PDF of paper here.)  

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Are asymptomatic carriers of SARS-CoV2 really without any symptoms?

  • Here is a meta-analysis of 41 studies, which may have some study design limitations.
  • 48.9% of initially asymptomatic positive cases ended up being pre-symptomatic (ending up later developing symptoms during follow up).
  • Children had higher rates of asymptomatic SARS-CoV2 infection.
  • Abnormal CT findings and blood work were common among asymptomatic COVID19 patients and may be useful in identifying prior asymptomatic infection.

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Our practice sees a lot of pediatric patients. Are younger children likely to spread the virus?

  • Possibly. This study compared the amount of viral RNA in the nasopharynx of children under 5 with older children and adults.
  • Young children (<5) harbor large amounts of viral RNA
  • More research needed to determine if high amounts of viral RNA correspond to greater risk of infection.
  • Although some research suggests young children may have a lower susceptibility to SARS-CoV2 infection, the role they play in transmission is unclear.  

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I have heard that dilating patients during this COVID time is discouraged.  Is this true?

There is no recommendation to avoid dilation according to the AOA and AAO.  Here are recommendations for returning to care, distributed by the American Academy of Optometry.  Similar guidance from the American Academy of Ophthalmology can be found here.    In general, comprehensive eye exams are allowed, which would include dilated examination of the peripheral fundus.  AAO advocates the use of BIO or fundus photography to maximize distance during fundus examination.  

Disinfection/Safety Protocols

How much time is required between occupants of a room to allow for adequate air circulation and minimize risk of virus transmission?

Here is guidance from the CDC. Time required depends on the presence of clinical symptoms, time spent in the room, room ventilation, and any procedures performed.  There is some evidence that droplets caused by talking may linger in the air of an enclosed space for 8-14 mins. Consider adjusting the patient schedule and keeping exam times to a minimum.  

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How do I know the state of COVID19 in my county?

  • This excellent website is the official Washington State COVID19 source for all sorts of virus metrics. You can search all the key metrics by county by selecting from the menu on the left side of the chart.      

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What is recommended for contact lens disinfection?

Here is the joint statement from American Optometric Association, American Academy of Optometry, CLMA and GPLI.  

 How effective are slit lamp face shields?

  • Face mask shields are effective at blocking a majority of large expelled droplets, but not at stopping small droplets or aerosols.
  • This paper describes the dynamics of droplets and aerosols while in close contact with patients. It confirms that droplet and inhalation transmission dominate over surface contact transmission.
  • Bottom Line: Slit Lamp shields alone are not sufficiently protective. Mutual mask use is best.  Growing evidence of aerosol transmission argues for the use of respirator-type face masks for optometrists.  

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How do I disinfect my hand held diagnostic lenses?

  • Due to their frequent handling and proximity to respiratory droplets, indirect lenses, gonioscopy lenses and other handheld lenses are vectors for infection
  • According to their lens Cleaning and Care Guide, Volk recommends using a 9:1 diluted bleach solution, Cidex OPA, 2% glutaraldehyde or other approved commercial products. Be aware bleach solutions can cause  damage to the integrity of handheld lenses.  

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What is the newest information about sanitizer/cleaner recall?

The FDA recalls dangerous methanol contaminated sanitizer. Can cause toxic effects via skin absorption, which include central nervous system damage.    


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