The new normal: 11 questions on PPE, cleaning and ventilation answered

Eye care professionals tuned into an Optometry Scotland webinar on Wednesday (24 August) for insight into how the profession has evolved 18-months after the outbreak of a global pandemic.

Community optometry: returning to the new normal was hosted through a Facebook live event, with a recording available to watch on the Optometry Scotland page. 

Many of the questions fielded on the night related to practical concerns – such as triage, infection control and personal protective equipment (PPE).

Vice chair of Optometry Scotland, Julie Mosgrove, highlighted that much has changed since the last Optometry Scotland webinar more than a year ago, with developments in infection control, social distancing, vaccinations and the introduction of new shared care clinics across Scotland.

“I’m so proud that the profession has done so much to adapt to these changing environments,” she said.

Below OT summarises a selection of questions that were covered by panellists on the night. The guidance below is for optometrists in Scotland, although there will be common ground with other UK nations.

Independent prescribing optometrist and AOP clinical adviser, Kevin Wallace, shared that optometrists should be wearing a Type IIR face mask when they are within two metres of a patient.

He added that other forms of PPE that were commonly worn earlier on in the pandemic – such as gloves, an apron or visor – should be risk assessed depending on what the clinician is doing.

For example, if an optometrist is coming into contact with a patients’ tears, they should use single use gloves.

“Wear a face mask all the time. Wear other protective equipment when there is a risk of being exposed to bodily fluids,” Wallace advised.

Mike Stewart, community eye care team leader for the Scottish Government, shared that PPE cannot be directly returned to NHS National Procurement, which is responsible for PPE supply in Scotland.

However, if practices have equipment that they cannot use, they can contact other primary care providers or their local health board and supply the PPE to them if needed.

Stewart noted that visors are the main item where he has heard that some practices have excess stock.

“Practices should be ordering PPE based on their anticipated usage and their current stock level,” he noted.

The panel clarified that whereas PPE was previously considered clinical waste, the latest guidance confirms that it can be treated like any other waste.

PPE does not have to be disposed of using a special process or in a designated waste bin.

Kathy Kenmuir, primary care cell co-lead for Public Health Scotland, highlighted that cleaning is defined as a process that physically removes infectious agents in the organic matter in which agents thrive, but does not necessarily destroy them.

“Cleaning must be performed before disinfecting or sterilising an item as any residue left on the instrument can affect the disinfection or sterilisation,” she said.

“Disinfection is a process used to reduce the number of viable microorganisms but might not inactivate some infectious agents. It can be performed using heat or chemicals,” Kenmuir observed.

Scotland chair for FODO, Kathryn Trimmer, observed that it is good practice to clean every piece of equipment that a patient touches.

Non-touch points, such as floors and shelves, can be cleaned on a daily basis.

In response to a question about how often to replace disposable plastic seat covers on fabric chairs, Wallace observed that these would not have to be disposed of between each patient but could be replaced on a sessional basis.

Kenmuir emphasised the importance of regularly cleaning communal areas, such as a staff tea room.

“That’s possibly where the largest transfer of COVID-19 happens. Be mindful of disinfecting those spaces,” she said.

Stewart noted that the current two-metre rule is under review by the Government at the moment. However, no changes have yet been announced.

“Until further notice, please still follow the two-metre rule. That applies to both primary and secondary care,” he confirmed.

Kenmuir noted that ventilation is encouraged across primary care settings.

“Obviously that can be challenging in some environments within optometry,” she said.

“The bottom line is that ensuring good ventilation in indoor environments will help reduce the risk of COVID-19 spreading,” Kenmuir highlighted.

She emphasised that the amount of fresh air entering the room should be maximised wherever possible.

Natural ventilation can be achieved by opening windows and doors, while some buildings have mechanical ventilation.

Kenmuir added that carbon dioxide monitors are being assessed for their utility in identifying poorly ventilated areas.

Wallace shared his view that cotton trousers and a cotton shirt are “absolutely appropriate”

“You don’t have to wear scrubs,” he said.

He also noted that work clothes do not need to be washed using special settings.

“Detergent and an ordinary wash cycle is really quite effective in killing viruses. It certainly doesn’t have to be 60 degrees,” Wallace shared.

Stewart confirmed that having a locked door policy is not a legal requirement.

“However, many practices consider it the most appropriate means of ensuring that they are complying with the infection, prevention and control requirements – in particular, for social distancing and triaging patients for suspected COVID-19 symptoms,” he highlighted.

Kenmuir noted that with cases rising in Scotland it is important to take triage seriously and minimise the risk of overcrowding in waiting areas.

“It is key to have a process that works well for you that allows you to put patients in the right pathway at the right time to safeguard those who are most at risk,” she emphasised.

Stewart advised against seeing the patient in these circumstances.

“You should be advising them to follow the normal pathways for anyone who has COVID-19 symptoms which is to self-isolate and get tested as soon as possible,” he said.

Wallace added that the steps followed by the clinician also depend on the details of the patient presentation.

“If the patient tells you that their vision is a bit blurry, then maybe you would see them in a few weeks’ time. If they have a sticky eye then maybe a remote consultation would be the best way to deal with that,” he observed.

For serious, potentially sight-threatening disease, Wallace recommends taking advice from local ophthalmology colleagues.

“They have a red pathway where they can see a potentially positive patient with a face-fitted mask and do retinal detachment surgery, for example,” he shared.

Trimmer noted that under the College of Optometrists amber guidance, a number of elements of the eye examination should be done as clinically necessary.

“This involves an assessment of the risk of a particular procedure resulting in the clinician or patient contracting COVID-19 versus the risk of missing any pathology by not doing that procedure,” she explained.

“The balance of risk has shifted from when we first moved into the amber phase to where we are now. We have a largely vaccinated population – we have established IPC procedures. On the other hand, we also have delays within healthcare and the risk of finding pathology is probably greater,” Trimmer emphasised.

“You need to make an assessment, but I think the risk is erring towards missed pathology rather than contracting COVID-19. If you decided not to dilate someone based on the risk assessment, then you would need to note that on the record as well as your reasoning behind that,” Trimmer noted.