Opinion Piece – Practical tips based on experiences in the UDCH
Having worked in and operated 2 hubs in Sussex over the last 2 and a half months I have managed to identify certain practical tips that may help general practices returning to practice. These are based on my experiences in managing the SOP and experimenting with different options for PPE.
Practice set-up
1) Sneeze guard for reception. This is usually a perspex clear sheet placed in front of a single section of the reception desk, to prevent patients from coming into close contact with the reception. These can be obtained from https://www.perspexsheet.uk/?
2) Contactless thermometers: These are used to take a temperature at the door as a further screening. These are readily available online
3) All excess chairs are removed from reception, and any chairs that are left are spaced 2 metres apart.
4) Patient toilets are preferrable left out of bounds, but if used are disinfected after every use.
5) Surgery arrangements: Surgeries are decluttered and any files, printers and paperwork removed. Whatever is left behind should be able to be wiped and cleaned fully. In the case of our hub we used 2 surgeries interchangeable. A patient was seen in one room, and then the team moved over to the second room, while the first treatment room remained fallow. Because AGPs were done in both rooms and it couldn’t be accuratelty predicted where AGPs would take place, both rooms were completely emptied out, and all materials and equipment was moved outside the surgery. This necessitated a runner nurse be available to provide materials and equipment required for each procedure from a location outside the surgery. There appears to be no reference to this in the “transition to Recovery” SOP, which means that the need for a runner nurse and emptying of the surgeries fully is not required.
If a surgery exclusively used for AGPs is not available, you might have to use your existing surgery for AGPs and non-AGPS. In terms of surgery arrangements what I think would work better is a surgery appointment arrangement as follows:
8:30 to 10am – Consultations and non-AGPs (30 min appt)
10-11 – AGP
11 – 12 Fallow period
12 – 1pm AGP
1 – 2pm Fallow period
2pm – 4:30pm – Consultations and non-AGPs
4:30 – 5:30 AGP
5:30 – 6:30pm Fallow Period
6) Cleaning after AGPs: The product that seems to be the most recommended is Hypochlorous acid (Salvesan) which is still available. Sprays should be avoided as they could generate further aerosols on cleaning.
A solution of this can be used to mop the floor in the surgery after AGPs. According to the latest SOP a solution of detergent/disinfectant can be used, but I need to look at this more carefully.
PPE
1) FFP3/2: A huge concern for practices is the cost of PPE. I can say with certainty that the quality of FFP2 masks is questionable, and there is a high failure rate on fit-testing. 90% of FFP2 masks that underwent Fit testing at our hub did not pass. FFP3 masks are much better quality, but are very expensive. If you are to secure a supply of FFP3 masks, ensure that you get a large enough quantity of the same make and model. Each seperate make and model needs to be fit-tested, and after you have passed a fit-test for a particular make and model, you can wear that make and model going forward. However securing a large enough supply of the same type of mask is very challenging at the moment. If you can get FFP3 masks try to make sure they are valved. The valved masks do not fog up your visors or glasses, wheras the unvalved masks do.
2) P3 Half masks: The advantage of these masks over disposable FFP3 masks is as follows:
- They are valved and therefore do not fog up visors or glasses
- They are re-usable. Therefore a mask costing about £30 is re-suable. The only thing that needs to be changed is the filter, which costs about £15 per pair, and according to manufacturers instructions need to be replaced every 4 weeks. This significantly reduces ongoing costs, considering that the cheapest disposable FFP3 mask costs £8 and lasts no more than 1 AGP.
- They are made of plastic and the outside can be disinfected with Hypochlorous acid or alcahol wipes.
- The straps are made of material and are more difficult to disinfect, but can be worn under a head cap.
- They can be dismantled and the parts can be washed fully with detergent
- Speaking is a problem because you can’t be heard. What we do is conduct the examination using Level 2 PPE, and only wear the mask when we commence the AGP
- They are bulky, but they can be worn with glasses and loupes quite easily. There are visors that cover the whole face that are worn perfectly with these masks.
- The unvalved FFP2 masks cause fogging of the visors, so it is more comfortable to wear a P3 half mask than to wear an FFP3
- I have attached types of P3 masks below
The links for P3 half masks are as follows:
These are the Force 8 masks. You can find out all the specs from the link.
This is the company we bought the masks from.
This is an alternative
This company has been very good for disposable FFP3 masks. They may also have the Stealth masks, and other P3 masks which were still in stock, although they might limit the order size.
Another alternative which I have seen
3) Visors: The traditional visor worn on glasses does not offer the level of facial coverage as the new visors that have reached the market. At the Hub we have used these visors which have been quite good. They cost only £3.50 each when bought as a box of 100. They are realy good in that they cover the face extensively and can be worn over a P3 Half-mask
4) Re-usable gowns: Another ongoing concern is the cost of single use fluid resistant surgical gowns for AGPs. I have 2 tips regarding this
- Fluid resistant gowns that are designated as single use should be disposed of after an AGP. We found that these can be placed in a pouch and autoclaved in a vacuum autoclave. They are still fluid resistant, and although very creased can be worn again. We have autoclaved gowns as many as 5 times before discarding. The cost of disposable fluid resistant gowns varies from £7 to £12.
- A better option is using re-usable hospital gowns. These can be washed at a high temperature using detergent. What we tried was wearing a reusable gown, then removing it after the AGP and placing it directly into an empty pillow case. At the end of the session, we then placed our scrubs into the pillow case and this was washed at 60 degress with detergent. The cost of re-usable gowns varies from £15 to £25, but you only have to wear it 2 or 3 times to get good value for money.
5) Face-fit -testing capability:
Not many people are exactly aware what face-fit-testing is.
There are 2 types of tests available, a qualitative test (using bitter solution and a hood) or a quantitative test (using a portacount machine). 99% of fit testing is carried out using the qualitative method that I will describe below.
A face fit test is largely made up of 3 componants. A plastic hood, a pair of vaporisers, and a pair of testing solutions. The person being tested wears the hood without a mask initially. The first solution (sensativity solution) is inserted into the vaporiser and sprayed into the hood. This acts as a control to test how sensative the persons “taste buds” are. After 2 or 3 sprays, most people can taste the bitter taste. If you taste it between 1-10 sprays you are supper sensative, after 10-20 sprays you are moderately sensative, and if you can only taste it between 20-30 sprays you are mildly sensative. If you can’t taste it at all after 30 sprays you have a problem, and might need to be tested using the quantitative method or a sweet solution (which is not readily sold commercially, but face fit testing companies do have it)
The whole process is then repeated, but with the testee wearing the P3/FFP3/FFP2 mask of choice and the tester switching to the second vaporisor and solution (fit test solution) . While the sprays are being applied every 30 seconds into the hood, the person being tested is required to undertake normal breaths, deep breaths, side to side head movements, up and down head movements, reading from a script, leaning over and then lastly normal breaths again. Each action is carried out for 1 minute, so the test lasts exactly 7 minutes. Every 30 seconds the tester is spraying into the hood and the point of the exercise is to not taste the bitter taste through the mask. If you taste the bitter taste anywhere along the line, the mask has failed to seal your mouth and the mask has failed the test. Some masks work on some individuals and not others, while some masks are just better quality than others. In my experience FFP2 masks just don’t pass the fit test.
I would strongly recommend that each practice send one or two members of the team to be trained as fit testers. This is also available on-line through companies such as https://www.dust2noise.com/
Another obstacle is getting a face-fit-testing kit to purchase. These are very difficult to come by but I was told today that 3b training (link above) is still selling them if you do the online course with them. Please look into it.
You could also borrow a kit from a colleague. Some colleagues are reluctant to borrow you a kit because the solution is in short supply. This company is still selling them https://www.
Emmanuel Lazanakis
