CME INDIA Presentation by Dr Santhosh Babu M R, Senior Medical Consultant, National Institute of Physical Medicine & Rehabilitation, Thrissur, Kerala with no conflict of interest. Contact: santhoshbabudr@gmail.com / 9846088468.

30 Very Important Advices for Prevention of Occupational COVID19 Infection in General Practicing Doctors in Private or Personal Medical Practice setups or Standalone Clinics.

(Updated on 29th August 2020).

1. Note that maximum number of Indian doctors who were victims of the current pandemic are general practitioners. They belong to high risk category irrespective of any guidelines as they are exposed to maximum number of non-triaged patients and care givers.
2. COVID 19 is here within us and near you now looking for opportunity of even a minor error from us. Consider every patient, person & staff as potential infection source of COVID 19.
3. Consider shifting your consultation room to safer venues if you are practicing in a room attached to your house where your family also lives.
4. If you are aged above 65yrs or below having two co-morbidities, consider stopping practice for few more months even though IMA only advice extreme caution.
5. Switch over to Digital Medical Practice as early as possible. This can also help yourself to avoid touching patients’ previous prescriptions and related Medical Records. Most of these software support paid Telemedicine Platform too.

6. Plan your practice time slot by prior appointment. Avoid overcrowding at a time. Limit your patient input during this pandemic. Limit your practice time to reduce exposure risk.
7. Consider a small scale outdoor tress work if not available for patients to wait outside decently.
8. Display posters Relevant Health Education Posters and Sign Boards in regional language in the Single-Entry Point and waiting area.
9. Ensure a wash basin with long lever tap near the entry point. Provide a liquid soap dispenser. A poster of proper hand hygiene technic should be exhibited near this source.
10. Ensure a hands free pedal operated sanitizer dispenser on your entrance.

11. If you don’t have trained staff, recruit and train at least one staff/Physician Assistant in reception counter. Train staff to record and enter Temp, PR, BP, HT, WT etc. safely and correctly in practicing software without your help. They can also help filling the COVID relevant questionnaire.
12. They will ensure all Safe COVID Prevention Practices of patients and caregivers in your front office if trained and updated properly. This investment takes away lot of human direct contact risk away from you.
13. Avoid consultation in closed cabins or closed or poorly ventilated rooms. Keep your windows and doors open without curtains. Ventilation holds the key. Practicing in multiple such venues on a single day is not recommended.
14. Consider Engineering Alterations in your Practice Facility Ergonomics to improve natural cross ventilation and room air management. Consider installation of powerful but Low Noise Exhaust/Fresh Air Fan (Rs1200) appropriate for your room size with good air displacement capacity above and over the patient seat. This removes stagnant air in your room and ensure fresh air circulation.
15. No ceiling fan or A/C recommended. But you can easily convert your AC unit to a Virus Grade Room Air Filter Unit by adding 3M HEPA filters to the existing filters (Rs.750) and using in fan mode. Use a table fan (Torque fan Rs.900) or wall fan or preferably a tower fan with powerful airflow to intercept away any aerosol directed towards you. You can install it in a position to cut off the airflow between you and the patient. But take care to minimise air agitation and air turbulence within the room.

16. Always maintain, ensure minimum 2 meters physical distancing with patients, bystanders and your own staff and among them. It’s better to use a Tailor’s tape to measure the distance and mark than assuming.
17. Use only an original branded good quality N95 or FFP2 or above respirators with NIOSH or equivalent certification. Appropriate leak-proof personal fitment of a Respiratory Protection Device is of paramount importance. These respirators aren’t one-size-fits-all. N95 face masks/respirators require correct donning/doffing sequence, a seal test preferably in front of a mirror before exposure to ensure maximum respiratory protection. If your spectacles or goggles are fogging your respirator is not protecting. If the mask doesn’t seal effectively to your face, you won’t receive the expected required protection. It is also recommended that all facial hair be removed as this can impede the ability of the mask to form a good seal on the user. After the initial fit test, you must continue to perform a seal check each time that you wear a respirator. Moulded respirators protect better than folded masks. Wearing Surgical and cloth masks will not protect you now.
18. Avoid masks having breathing valves without filters in medical set up for all. If you feel very comfortable during breathing while using a mask, it may not be working or protecting. Change it. 3M 1860 NIOSH Certified N95 Particulate Respirator is the best recommended quality brand available in India for a health care worker or doctor. Alternatively, you can use 3M 8210 NIOSH Certified N95 Particulate Respirator You can reuse it few times as per AIIMS guidelines even though 3M doesn’t recommend it. Beware of fraudulent and poor quality masks labelled as N95/KN95. KN95 suits more to Chinese type of face morphology than Indian.
19. Always use a Reusable Polycarbonate Full Face Shield during practice. Branded ones from STEELBIRD/VEGA have better protective design but a bit costlier.
20. Always use good quality gloves or preferably double gloves sterile or non-sterile. Keep sanitising your gloves before and after any touch. Nitrile gloves of your size is also a good option than latex. Ensure biomedical waste disposal as per guidelines in yellow container.

21. Limit consulting time to minimum for each patient. Follow a Rapid Relevant Examination Protocol. Examine from patients back, side lying away from you or in prone position. Educate your patients to not to talk during examination. Don’t ask for deep breaths. Avoid face to face encounters to maximum while you do clinical examination. Don’t allow the care giver or staff to stand near you while you examine even if they are wearing masks.
22. If you can provide 3ply Surgical Masks (Rs 5) to all your patients, care givers with necessary instructions irrespective of the masks they are wearing, it will give you a tremendous amount of additional protection to you and to your staff.
23.  Prefer Rexene cover to examination table, pillows, bed & cot. Avoid all upholstery works in clinic furniture. Ask your cleaner to sanitise used furniture tops and foot cover ground after each patient examinations.
24. Use an overhead wireless or wired mini personal voice amplifier to make yourself audible (Rs.1200) if patients feel that your audibility is poor. Consider using a unilateral low cost in-ear hearing aid for better listening when necessary.
25. Fumigate your clinic in door set up after working hours at least twice weekly after practice as per guidelines. RAPP- G/CLORITAB are cheap, safe, effective, available and user-friendly and requires no helper. If you prefer fumigation Silver-Hydrogen peroxide combination is better. Alternatively consider diluted VIREX 256 with a handheld power sprayer.

26. Bleach or Clorox or Lysol is sufficient for outdoor & common latrine sanitation on daily basis. CIDEX is better for your minor surgical instruments.
27. Use good quality Medical Grade Automatic UV-C Box for disinfection of your non washable articles, N95 Respirators, utilities like spectacles, keys, stethoscope, knee hammer, ophthalmoscope, otoscope, masks, face shields, mobile phone, currency, laptops, books, posts, parcels, samples, compliments etc. except liquids.(Available for Rs.6500-/).
28. Avoid attending your mobile or land phone during consultation period directly. Instead use a good quality Bone Conduction Bluetooth device which will not block your ear. Never remove your Respiratory Protection Devices in intervals and in urinal. No group snacking please. Use flush of your latrines only after closing he lid.
29. If you are still allowing the Medical Sales Personals, keep them at least 3m distance with minimum contact time with additional 3ply surgical masks. Keep a visitors’ log book with contact phones. Please keep a Personal Daily Route Map.
30. Train, keep training yourself and your staff. Monitor them closely. Check temp of yourself, patients, bystanders and all staff daily. Be vigilant about sickness and travel details of your staff and their household members. Ask them to remain in home quarantine for at least seven days if they or their household members develop COVID like or influenza like illnesses. Be aware of the local policies and situations where a Medical Practitioner becomes a primary contact and avoid it.

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