Infection prevention and control on Covid-19 at

5 STAR CLINIC LTD

 

Introduction and organisational preparedness

  1. Introduction

This guidance outlines the infection prevention and control advice for health practitioners involved in receiving, assessing and caring for patients who are a possible or confirmed case of COVID-19.

This infection prevention and control advice is considered good practice in response to the COVID-19 pandemic. It is based on the best evidence available from previous pandemic and inter-pandemic periods and focuses on the infection prevention and control aspects of this disease only, recognising that a preparedness plan will consider other counter measures.

Note: The emerging evidence base on COVID-19 is rapidly evolving. Further updates may be made to this guidance as new detail or evidence emerges.

The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact. This is consistent with a recent review of modes of transmission of COVID-19 by the World Health Organization (WHO).

 

  1. Infection, prevention and control precautions

Standard infection control precautions (SICPs) and transmission based precautions (TBPs) must be used when dealing with a patient.

 

2.1 Standard infection control precautions (SICPs) definition

SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources.

Sources include: blood and other body fluids, secretions and excretions (excluding sweat), non-intact skin or mucous membranes, and any equipment or items in the care environment.

SICPs should be used by all staff, in all care settings, at all times, for all patients.

2.2 Transmission Based Precautions (TBPs) definition

TBPs are applied when SICPs alone are insufficient to prevent cross transmission of an infectious agent. TBPs are additional infection control precautions required when caring for a patient with a known or suspected infectious agent. In the case of Covid-19 they will be used by all staff, in all care settings, at all times, for all patients.

TBPs are categorised by the route of transmission of the infectious agent:

Contact precautions: Used to prevent and control infection transmission via direct contact or indirectly from the immediate care environment (including care equipment). This is the most common route of infection transmission.

Droplet precautions: Used to prevent and control infection transmission over short distances via droplets (>5µm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level. The maximum distance for cross transmission from droplets has not been definitively determined, although a distance of approximately 2 metres (6 feet) around the infected individual has frequently been reported in the medical literature as the area of risk.

Airborne precautions: Used to prevent and control infection transmission without necessarily having close contact via aerosols (≤5µm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level.

Interrupting transmission of COVID-19 requires both droplet and contact precautions; if an aerosol generating procedure (AGP) is being undertaken then airborne precautions are required in addition to contact precautions.

 

 

RECOMMENDATIONS, USE AND DISPOSAL OF PPE

Refer to the Table 1 and 4 from the GOV.UK website for recommended PPE :

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886707/T1_poster_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879111/T4_poster_Recommended_PPE_additional_considerations_of_COVID-19.pdf

In nutshell the staff at 5 STAR CLINIC will be using: disposable gloves, plastic apron, surgical mask(Type IIR), Eye protection or Visor will be used if at risk of droplets.

 

Sessional use of PPE

Aprons and gloves are subject to single use as per Standard Infection Control Precautions (SICPs), with disposal and hand hygiene after each patient contact. Respirators, fluid-resistant (Type IIR) surgical masks (FRSM), eye protection and disposable fluid repellent coveralls or long-sleeved disposable fluid repellent gowns can be subject to single sessional use in circumstances outlined in the next section.

A single session refers to a period of time where a health care practitioner is undertaking duties in a specific clinical care setting or exposure environment. A session ends when the health and social care worker leaves the clinical care setting or exposure environment. Once the PPE has been removed it should be disposed of safely. The duration of a single session will vary depending on the clinical activity being undertaken.

While generally considered good practice, there is no evidence to show that discarding disposable respirators, facemasks or eye protection in between each patient reduces the risk of infection transmission to the health and social care worker or the patient.

Indeed, frequent handling of this equipment to discard and replace it could theoretically increase risk of exposure in high demand environments, for example, by leading to increasing face touching during removal. The rationale for recommending sessional use in certain circumstances is therefore to reduce risk of inadvertent indirect transmission, as well as to facilitate delivery of efficient clinical care.

PPE should not be subject to continued use if damaged, soiled, compromised, uncomfortable or in other circumstances outlined below and a session should be ended. The duration of use of PPE items should not exceed manufacturer instructions. Appropriateness of single versus sessional use is dependent on the nature of the task or activity being undertaken and the local context.

 

PPE guidance and use:

Fluid resistant surgical masks

Fluid-resistant (Type IIR) surgical masks (FRSM) provide barrier protection against respiratory droplets reaching the mucosa of the mouth and nose. FRSMs should be well fitted and replaced and NOT be subject to continued use if:

  • it is damaged
  • it is soiled (for example, with secretions, body fluids)
  • it is damp
  • the facial seal is compromised
  • it is uncomfortable
  • it is difficult to breathe through

FRSMs are for single use or single session use  and then must be discarded.

Surgical masks should:

  • cover both nose and mouth
  • not be allowed to dangle around the neck after or between each use
  • not be touched once put on
  • be changed when they become moist or damaged
  • be worn once and then discarded – hand hygiene must be performed after

disposal

 

Sessional use

The use of masks for one HCW to use in one work area. This is currently recommended

in the UK Infection Prevention and Control guidance.

  • it should be disposed of if it becomes moist, damaged, visibly soiled
  • the duration (number of hours) of sessional use is dependent on local (for

example, heat, activity length, shift-length) and individual factors. In practice, this may vary from 2 to 6 hours

  • if masks are touched or adjusted, hand hygiene should be performed

immediately

  • if the mask is removed for any reason (for example, upon exiting the ward area, taking a break or completing a shift), they are disposed of as clinical waste, unless they can be safely reused as outlined below

Reuse

Important requirements are:

  • the mask should be removed and discarded if soiled, damaged, or hard to

breathe through masks with elastic ear hooks should be re-used (tie-on face masks are less suitable because they are more difficult to remove)

  • hand hygiene should be performed before removing the face mask
  • face masks should be carefully folded so the inner surface is held inward and

against itself to reduce likely contact with the outer surface during storage

  • the folded mask should be stored between uses in a clean sealable bag/ box

which is marked with the person’s name and is then properly stored in a well defined place

  • hand hygiene should be performed after removing the face mask
  • some models of PPE cannot be physically reused as they deform once being

donned and do not go back to original condition (meaning it would be difficult to re-don and achieve a fit check) – fit checks should be performed each time a respirator is donned if it is reused.

At 5 STAR CLINIC the staff advised to Reuse any mask.

Eye and face protection

Eye and face protection provides protection against contamination to the eyes from respiratory droplets, aerosols arising from AGPs and from splashing of secretions (including respiratory secretions), blood, body fluids or excretions.

Eye and face protection can be achieved by the use of any one of:

  • a surgical mask with integrated visor
  • a full face shield or visor
  • polycarbonate safety spectacles or equivalent

Regular corrective spectacles are not considered adequate eye protection.

Sessional use

This is currently recommended in the UK Infection Prevention and Control guidance.

The goggles or face shield should be removed upon exiting the ward area per standard practice.

Reuse

This is currently recommended in the UK Infection Prevention and Control guidance, where the eye protection is not relabelled as single use only.

The standard method of cleaning is to use a detergent product either combined sequentially with a decontamination product.

 

Disposable aprons and gowns

Disposable plastic aprons must be worn to protect staff uniform or clothes from contamination when providing direct patient care and during environmental and equipment decontamination.

Disposable fluid repellent coveralls or long-sleeved gowns must be worn when a disposable plastic apron provides inadequate cover of staff uniform or clothes for the procedure or task being performed, and when there is a risk of splashing of body fluids such as during AGPs in higher risk areas or in operative procedures. If non-fluid resistant gowns are used, a disposable plastic apron should be worn. If extensive splashing is anticipated then use of additional fluid repellent items may be appropriate.

Disposable aprons are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact as per SICPs. Hand hygiene should be practiced as per SICPs and extended to exposed forearms.

Disposable fluid repellent coveralls or long-sleeved gowns are for single use or for single session use in certain circumstances but should be discarded at the end of a session or earlier if damaged or soiled.

Re-use of aprons is not recommended.

Disposable gloves

Disposable gloves must be worn when providing direct patient care and when exposure to blood and or other body fluids is anticipated or likely, including during equipment and environmental decontamination. Disposable gloves are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact, as per SICPs, followed by hand hygiene. Double gloving is not necessary.

These gloves are available in a variety of materials, are single use and must be disposed of after each use. Non-powdered, nitrile gloves are the most commonly recommended for healthcare.

Sessional use or of reuse examination gloves for clinical care should be avoided.

Best practice in use of PPE and hand hygiene

COVID19 is no longer categorised as a high consequence infectious disease and therefore enhanced PPE is not recommended. PPE should be worn as described in this guidance.

Refer to the correct order of donning and doffing PPE for AGPs and nonAGPs. PPE should always be used in accordance with SICPs and requirements for

hand hygiene. Hand hygiene should extend to include washing of exposed forearms.

Follow Gov.uk guidance for:

DONNING:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878677/PHE_11606_Putting_on_PPE_062_revised_8_April.pdf

DOFFING:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878678/PHE_11606_Taking_off_PPE_064_revised_8_April.pdf

Guidance will be exposed in the building at 5 STAR CLINIC LTD.

  1. Organisational preparedness for preventing and controlling COVID-19

Limiting transmission of COVID-19 in the healthcare setting requires a range of infection prevention and control measures which can be considered as a hierarchy of controls. Administrative controls are implemented at an organisational level (for example the design and use of appropriate work processes, systems and engineering controls, and provision and use of suitable work equipment and materials) to help prevent the introduction of infection and to control and limit the transmission of infection in healthcare. The control of exposure at source, including adequate ventilation systems and effective environmental decontamination will physically reduce exposure to infection.

The 7 factor advice settled in the CSP guidelines is followed at 5 STAR CLINIC LTD to ensure COVID-19 pandemic management(see dedicated document) + has been produced a Standard Operating Procedures (SOPs) for risk assessment and management.

5 STAR CLINIC LTD –will ensure to adequately control the risk of exposure to hazardous substances where exposure cannot be prevented. Will ensure the provision and use of personal protective equipment PPE in line with this document to protect staff, patients and visitors. Will make full and proper use of any control measures, including PPE.

The principles below are listed as a hierarchy of infection prevention and control measures.(Note that this list is not exhaustive but includes key principles and illustrates a useful approach to preventing and controlling COVID-19).

 

Hierarchy of control measures:

  • early recognition or reporting of cases
  • early assessment or triaging of cases
  • implementing control measures, including educating staff, patients and visitors about Standard infection control precautions (SICPs) and transmission based precautions (TBPs)
  • prompt implementation of TBPs to limit transmission
  • avoid crowding in the waiting area
  • instructing staff members with symptoms to stay at home and not come to work until symptoms resolve
  • avoid congregation, conduct handover sessions in a setting where there is space for social distancing and consider staggering staff breaks to limit the density of healthcare workers in specific areas(unless strictly necessary to be in the same room, handover it will be done online using Zoom software). If needed to obtain a social distancing can be used one of the empty room upstairs.
  • defining engineering, administrative, and personnel requirements that can be efficiently implemented during a pandemic COVID-19 event, for example ensuring good ventilation (including in admission/waiting areas) to minimise opportunistic airborne transmission risk(see environmental decontamination below).

 

Transmission characteristics and principles of infection prevention and control

  1. Routes of transmission

Infection control advice is based on the reasonable assumption that the transmission characteristics of COVID-19 are similar to those of the 2003 SARS-CoV outbreak. The initial phylogenetic and immunologic similarities between COVID-19 and SARS-CoV can be extrapolated to gain insight into some of the epidemiological characteristics.

The transmission of COVID-19 is thought to occur mainly through respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact.

During AGPs there is an increased risk of aerosol spread of infectious agents irrespective of the mode of transmission (contact, droplet, or airborne), and airborne precautions must be implemented when performing aerosol generating procedure (AGPs), including those carried out on suspected as well as confirmed cases of COVID-19.

Initial research has identified the presence of COVID-19 virus in the stools and conjunctival secretions of confirmed cases. All secretions (except sweat) and excretions, including diarrhoeal stools from patients with known or possible COVID-19, should be regarded as potentially infectious.

 

  1. Incubation and infectious period

The incubation period is from 1 to 14 days (median 5 days). Assessment of the clinical and epidemiological characteristics of COVID-19 cases suggests that, similar to SARS, most patients will not be infectious until the onset of symptoms. In most cases, individuals are usually considered infectious while they have symptoms; how infectious individuals are, depends on the severity of their symptoms and stage of their illness.

The median time from symptom onset to clinical recovery for mild cases is approximately 2 weeks and is 3 to 6 weeks for severe or critical cases. There have been case reports that suggest possible infectivity prior to the onset of symptoms, with detection of SARS-CoV-2 RNA in some individuals before the onset of symptoms.

Further study is required to determine the frequency, importance and impact of asymptomatic and pre-symptomatic infection, in terms of transmission risks.

From international data, the balance of evidence is that most people will have sufficiently reduced infectivity 7 days after the onset of symptoms.

 

  1. Survival in the environment

In light of limited data for SARS-CoV-2, evidence was assessed from studies conducted with previous human coronaviruses including MERS-CoV and SARS-CoV. Human coronaviruses can survive on inanimate objects and can remain viable for up to 5 days at temperatures of 22 to 25°C and relative humidity of 40 to 50% (which is typical of air-conditioned indoor environments).

Survival on environmental surfaces is also dependent on the surface type. An experimental study using a SARS-CoV-2 strain reported viability on plastic for up to 72 hours, for 48 hours on stainless steel and up to 8 hours on copper. Viability was quantified by end-point titration on Vero E6 cells. Extensive environmental contamination may occur following an AGP.

The rate of clearance of aerosols in an enclosed space is dependent on the extent of any mechanical or natural ventilation and the size of the droplets created. The greater the number of air changes per hour (ventilation rate), the sooner any aerosol will be cleared.

The time required for clearance of aerosols, and thus the time after which the room can be entered without a filtering face piece (class 3) (FFP3) respirator, can be determined by the number of air changes per hour (ACH) as outlined in WHO guidance; single rooms there should be a minimum of 6 air changes per hour.

A single air change is estimated to remove 63% of airborne contaminants, after 5 air changes less than 1% of airborne contamination is thought to remain.

 

Transmission precautions Covid-19 at 5 STAR CLINIC LTD

Standard precautions

1.Hand hygiene

Hand hygiene is essential to reduce the transmission of infection in health and other care settings. All staff, patients and visitors should decontaminate their hands with alcohol-based hand rub (ABHR) when entering and leaving areas where patient care is being delivered.

 

Hand hygiene must be performed immediately before every episode of direct patient care and after any activity/task or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination and waste handling. Refer to the guidance Hand hygiene poster (contact with a patient 5 steps).

Before performing hand hygiene:

  • expose forearms (bare below the elbows)
  • remove all hand and wrist jewellery (a single, plain metal finger ring is permitted but should be removed (or moved up) during hand hygiene)
  • ensure finger nails are clean, short and that artificial nails or nail products are not worn
  • cover all cuts or abrasions with a waterproof dressing
  • If wearing an apron rather than a gown (bare below the elbows), and it is known or possible that forearms have been exposed to respiratory secretions (for example cough droplets) or other body fluids, hand washing should be extended to include both forearms. Wash the forearms first and then wash the hands.

 

Hand dryers are not recommended for use in clinical areas. Hands should be dried with soft, absorbent, disposable paper towels from a dispenser which is located close to the sink but beyond the risk of splash contamination. Guidance on hand hygiene, including drying should be clearly displayed in all public toilet areas as well as staff areas.

 

2 Respiratory and cough hygiene – ‘Catch it, bin it, kill it’

Patients, staff and visitors should be encouraged to minimise potential COVID-19 transmission through good respiratory hygiene measures:

disposable, single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose; used tissues should be disposed of promptly in the nearest waste bin tissues, waste bins (lined and foot operated) and hand hygiene facilities should be available for patients, visitors and staff hands should be cleaned (using soap and water if possible, otherwise using ABHR) after coughing, sneezing, using tissues or after any contact with respiratory secretions and contaminated objects encourage patients to keep hands away from the eyes, mouth and nose some patients (such as the elderly and children) may need assistance with containment of respiratory secretions;

  1. Patient use of face masks

In clinical areas, common waiting areas or during face to face treatments patients is required to wear a surgical face mask. The aim of this is to minimise the dispersal of respiratory secretions and reduce environmental contamination. A surgical face mask should not be worn by patients if there is potential for their clinical care to be compromised (such as when receiving oxygen therapy).

 

 

  1. Waiting area

The area will be decontaminated between each patient and the appointment will be distanced of at least 15min between each other to avoid crowding.

In the waiting area will be allowed a maximum of 2 people at time at a distance>2m. The patients will know where to sit, because will be left only 2 chairs.

The patient is required:

  • to arrive on the time of the appointment, to do not arrive before or late to avoid crowding on the waiting area.
  • to come alone unless strictly necessary to be accompanied. After entered the building, the companion will be allowed to enter only if strictly necessary (see below chaperone/translator). On the other hand, will be asked to leave and wait in the car.
  • In case of chaperone/ translator is required will be asked to stay 2m apart of all the time from everyone, also they will need to complete a pre-screening questionnaire.
  • To wear a surgical type mask during the waiting and the treatment
  • To wash or clean the hands with hand sanitizer on the arrival and before leaving and whenever may be needed to reduce the risk of contamination.
  • The door is open for the client on entrance and exit
  • The client will avoid to touch anything as much as possible

 

  1. Environmental decontamination

There is evidence from other coronaviruses of the potential for widespread contamination of patient rooms or environments so effective cleaning and decontamination is vital. The frequency of cleaning the care environment in will be increased.

Cleaning Procedures:

  • Rooms or areas where PPE is removed must be decontaminated, ideally timed to coincide with periods immediately after PPE removal by staff. The increased frequency of decontamination/cleaning should be incorporated into the environmental decontamination schedules for all areas, including where there may be higher environmental contamination rates.
  • Cleaning of frequently touched surfaces will be provided between each patient, including for example:

medical equipment and relative surfaces, door/toilet handles and locker tops, bed tables and bed rails – Electronic equipment, such as keypads, telephones, intercoms, hard surfaces, pay terminals, such as mobile phones, desk phones and other communication devices, tablets, desktops and  waiting area surfaces.

– Hand towel have been removed and only Paper towels are available also only disposable material is used between clients(such as disposable couch cover or disposable couch roll)

Note that gloves should be removed and hands decontaminated before touching equipment.

 

AIR CHANGES:

  • Where possible for confidentiality the door will be left open and will be carried frequent air changes per hour.
  • An average of 6 air changes per hour will be carried out in each room if any AGP are carried out.

 

 

 

 

 

 

 

 

 

 

CLEANING OF THE BUILDING, performed twice daily or more if needed:

SurfacesNeutral detergent + Virucidal solution
ToiletsVirucidal solution
TextilesHot water cycle(90dg) and regular laundry detergent or lower temperature cycle(60dg) + bleach or other laundry products
EquipmentClinell or disposable paper with Virucidal solution
PPE cleaning staffSurgical mask, Visor, Gloves, Apron/Gown. FFP2 or 3 if cleaning facilities where has been performed AGP procedure.

 

  • The cleaning material should be properly cleaned (see Table 1) at the end of every cleaning section.
  • Hand hygiene should be performed each time PPE such as gloves are removed.
  • Waste material produced during the cleaning should be placed in the unsorted garbage.
  • Avoid creating splashes and spray when cleaning.
  • Any cloths and mop heads used must be disposed of and should be put into waste bags as outlined below.
  • When items cannot be cleaned using detergents or laundered, for example, upholstered furniture and mattresses, steam cleaning should be used.
  • Any items that are heavily contaminated with body fluids and cannot be cleaned by washing should be disposed of.

 

Laundry

Wash items in accordance with the manufacturer’s instructions. Use the warmest water setting and dry items completely. Dirty laundry that has been in contact with an unwell person can be washed with other people’s items.

Do not shake dirty laundry, this minimises the possibility of dispersing virus through the air.

Clean and disinfect anything used for transporting laundry with your usual products, in line with the cleaning guidance above.

 

Waste

Waste from possible cases and cleaning of areas where possible cases have been (including disposable cloths and tissues):

  • Should be put in a plastic rubbish bag and tied when full.
  • The plastic bag should then be placed in a second bin bag and tied.
  • It should be put in a suitable and secure place and marked for storage for 72hours(Outside storage available in the backyard)
  • Waste should be stored safely and kept away from children. You should not put your waste in communal waste areas until negative test results are known or the waste has been stored for at least 72 hours.
  • After at least 72 hours and put in with the normal waste

If storage for at least 72 hours is not appropriate, and it is deemed necessary it will be  arranged for collection as a Category B infectious waste either by local waste collection authority or otherwise by a specialist clinical waste contractor. They will supply with orange clinical waste bags to place the waste bags into so the waste can be sent for appropriate treatment.

  1. Equipment

Patient care equipment should be single-use items if possible. Reusable (communal) non-invasive equipment should as far as possible be allocated to the individual patient.

 

Reusable (communal) non-invasive equipment must be decontaminated:

  • between each patient and after patient use
  • after blood and body fluid contamination
  • at regular intervals as part of equipment cleaning

 

Crockery, plates  and cutlery can be washed after use either by hand or in a dishwasher, using household detergent and hand-hot water.

 

  1. Staff uniform

The appropriate use of personal protective equipment (PPE) will protect staff uniform from contamination in most circumstances. Will be provided changing rooms/areas where staff can change into uniforms on arrival at work.

Each the uniform will need to be properly washed and a fresh one is to be used the following day.

How uniforms should be washed:

  • A minimum temperature of 60°C should be used in a wash cycle of at least 10 minutes
  • Uniforms should be stored (pre-wash) and washed separately from other items
  • Healthcare uniforms should always be laundered after every shift
  • A detergent should be used

 

For Environmental decontamination after suspected or confirmed case of COVID-19 seek appropriate document.

 

Cleaning Log

Type of LogItemsFrequency of Cleaning
Daily cleaning log and when visibly soiledFrequently touched surfaces such as: medical equipment and relative surfaces, door/toilet handles and locker tops, bed tables and bed rails – Electronic equipment, such as keypads, telephones, intercoms, hard surfaces, pay terminals, such as mobile phones, desk phones and other communication devices, tablets, desktops and waiting area surfaces.

 

Between each patient(log to be implemented in the physiotherapist notes)
Daily cleaning log and when visibly soiledSurfaces, toilets, tea room, staircase, textiles and uniforms, WasteTwice a day
Daily cleaning log and when visibly soiledAir changes15min per hours with 3to 6 air changes depending if AGP in place

 

 

 

Environmental decontamination after suspected or confirmed case of COVID-19

 

Disinfectants Overview

Disinfectants are classified as biocidal products and are regulated by the Biocidal Products Regulation (BPR) (EU)No 528/2012 [7] to ensure that risks are properly assessed before they are placed on the market in EU/EEA

countries.

Currently, for most disinfectant products available in the European Union market for SARS-CoV-2 disinfection, the transitional measures of the BPR apply, as set out in Article 89 [7]. This means that most disinfectants are placed on the market subject to national legislation until the evaluation of the contained active substance(s) is finalised in the EU review programme.

In general, alcohol-based disinfectants (ethanol, propan-2-ol, propan1-ol) have been shown to significantly reduce infectivity of enveloped viruses like SARS-CoV-2, in concentrations of 70-80% with one minute exposure time [8,9].

However, ethanol has not yet been approved under the BPR, so biocidal products based on ethanol are not authorised under the BPR but are available under transitional measures. Most Member States do not have an authorisation or registration system for the products under transitional measures and, therefore, do not have an exhaustive overview of the disinfectant products on their market.

Biocidal products having virucidal activity and authorised under the BPR are efficacious against SARS-CoV-2 coronavirus. This also applies to products used as hygienic hand and skin disinfectants, which state they have limited virucidal activity or activity only against enveloped viruses.

 

Cleaning after the management of a suspected or confirmed case of COVID-19

Healthcare setting areas (patient rooms, waiting areas, procedure rooms) where a suspected or confirmed case of COVID-19 has been assessed or treated should be first ventilated well(fresh air for 1–3 hours), before cleaning and admitting new patient(s).

After ventilation, the above mentioned areas should be carefully cleaned with a neutral detergent, followed by decontamination of surfaces using a disinfectant effective against viruses. Several products with virucidal activity are licensed in the national markets and can be used following the manufacturer’s instructions.

Alternatively, 0.05% sodium hypochlorite (NaClO)1 (dilution 1:100, if household bleach is used, which is usually at an initial concentration of 5%) is suggested. For surfaces that can be damaged by sodium hypochlorite, products based on ethanol (at least 70%) can be used for decontamination after cleaning with a neutral detergent.

Cleaning of toilets, bathroom sinks and sanitary facilities need to be carefully performed, avoiding splashes.

Disinfection should follow normal cleaning using a disinfectant effective against viruses, or 0.1% sodium hypochlorite.

All textiles (e.g. towels, bed linens, curtains, etc.) should be washed using a hot-water cycle (90°C) with regular laundry detergent. If a hot-water cycle cannot be used due to the characteristics of the material, bleach or other laundry products for decontamination of textiles need to be added to the wash cycle.

(The use of 0.05% of sodium hypochlorite in the cleaning of surfaces in healthcare and non-healthcare settings is suggested in order to reduce the irritant effects on the mucosae).

 

The use of single-use disposable cleaning equipment (e.g. disposable towels) is recommended. If disposable cleaning equipment is not available, the cleaning material (cloth, sponge etc.) should be placed in a disinfectant solution effective against viruses, or 0.1% sodium hypochlorite. If neither solution is available, the material should be discarded and not reused.

The use of different equipment for cleaning the different areas of healthcare settings is recommended.

 

Staff engaged in environmental cleaning in healthcare settings should wear PPE. Due to the current shortage of PPE, the following minimal PPE set is suggested for use when cleaning healthcare facilities likely to be

contaminated by SARS-CoV-2:

  • surgical mask
  • disposable long-sleeved water-resistant gown
  • visor
  • Heavy-duty gloves.

Hand hygiene should be performed every time PPE, such as gloves, are removed

Staff engaged in waste management should wear PPE. Waste will be managed as stated in the infection prevention and control policy.

 

 

5 STAR CLINIC LTD policy in following the CSP’s 7 factor advice

Factor 1: Legal, regulatory and professional responsibilities

5 STAR CLINIC LTD will ensure to work within the legal, regulatory and professional frameworks that guide the safe management of patients, the safety of the wider public and everyone who works in the practice environment for which you are responsible.

 

Legal

5 STAR CLINIC LTD is following any updates on the Current Government guidance on business operation, social distancing and shielding.

5 STAR CLINIC LTD and his member will follow CSP’s Duty of Care guidance

Regulatory

5 STAR CLINIC LTD and associates strive to follow taking care of respecting and taking into account at all the time the following points:

1)HCPC guidance on Adapting my Practice in the Community: https://www.hcpc-uk.org/covid-19/advice/applying-our-standards/adapting-your-practice-in-the-community/

2)HCPC Standards of Proficiency- consider how they relate to your practise, and practices: https://www.hcpc-uk.org/standards/standards-of-proficiency/physiotherapists/

3)HCPC Guidance on Covid-19:

  • SCOPE OF PRACTICE:

-You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for.

 

-You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice.

 

-You must keep your knowledge and skills up to date and relevant to your scope of practice through continuing professional development.

 

-You must keep up to date with and follow the law, our guidance and other requirements relevant to your practice.

 

-You must ask for feedback and use it to improve your practice.

At 5 STAR CLINIC the scope of practice for our practitioners is not a risk to undergo any particular changes. But every member will take care to keep update on the Covid-19 regulations outlined from HCPC and CSP, risk assessment screening process, PPE donning and doffing and infection control policy.

 

  • Managing risk: infection prevention and control:

-You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

-You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.

-You must make changes to how you practise, or stop practising, if your physical or mental health may affect your performance or judgement, or put others at risk for any other reason

At 5 STAR CLINIC is in place an infection prevention and control policy, Standard Operating Procedures (SOPs) and risk assessment and management for workers and service users.

 

  • Communicating during the COVID-19 pandemic:

-You must be polite and considerate.

-You must listen to service users and carers and take account of their needs and wishes.

-You must give service users and carers the information they want or need, in a way they can understand.

-You must make sure that, where possible, arrangements are made to meet service users’ and carers’ language and communication needs.

-You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.

-You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.

 

At 5 STAR CLINIC we understand that service users and carers will likely have heightened levels of anxiety and stress at this time and also Personal protective equipment (PPE) significantly reduces the ability for service users to see body language, in particular facial expression. Each practitioner will be mindful of this when treating service users and, wherever possible, adapting the communication style appropriately. In this time will also ensure that there is a proper communication between colleague in order to keep delivering the best service and experience for the patient.

  • Resilience

Resilience is our capacity to recover quickly from difficulties – to bounce back – and to adapt in the face of challenging circumstances, whilst maintaining a stable mental wellbeing.

At 5 STAR CLINIC we are following the advice from HCPC on learning the skills that help to become more resilient:

Seek support

We are surrounded by people that we can trust and confide in and sometimes just telling the people close to us how we are feeling can make a big difference.

At work, we can speak to and share our experiences with our peers, line manager, HR, union representatives, or employee assistance scheme.

At home, we can speak to our friends and family.

Other options include calling Mind or the Samaritans, or using an online resource such as Big White Wall.

Focus on what you can control

We can easily become overwhelmed by the things that are not within our control. Identifying what is within our control and the steps, small or big, that we can take to improve those areas or situation can improve our sense of control and resilience.

Believe in our abilities

Our self-esteem plays an important role in coping with stress and recovering from difficult events. Taking a moment to remind ourselves of our strengths and accomplishments will help to maintain our self-esteem.

Also replacing any negative thoughts with positive ones, such as ‘I can do this’ and ‘I am good at my job’, will also help. At the end of your working day remind yourself of at least one of thing you achieved that day. There will be many to choose from!

  • Supervision and delegation:

-You must only delegate work to someone who has the knowledge, skills and experience needed to carry it out safely and effectively.

-You must continue to provide appropriate supervision and support to those you delegate work to.

 

At 5 STAR CLINIC, whenever a practitioner delegate, does it safely and effectively. This means ensuring is only delegated work within that person’s scope of practice and is continually provided appropriate supervision and support to them. Also, will be considered the guideline for an:

 

Effective supervision

-Sharing/enhancing knowledge and skills supports professional development and improves service delivery.

-Effective supervision can help to reduce stress and anxiety, creating a more supportive work environment and lead to improved patient care.

-Flexibility is important and you may need to develop new approaches to supervision to respond to the demanding operational environment and the emotional strain colleagues may be experiencing during the COVID-19 pandemic.

-Supervisors should be willing to meet on an ad hoc basis to respond to staff issues, although this may be more challenging in the current circumstances.

-Supervision is most effective when offered regularly; this is especially relevant when facing extreme operational demands.

  • Speaking up during an emergency:

-You must report any concerns about the safety or well-being of service users promptly and appropriately.

-You must support and encourage others to report concerns and not prevent anyone from raising concerns.

-You must take appropriate action if you have concerns about the safety or well-being of children or vulnerable adults.

-You must make sure that the safety and well-being of service users always comes before any professional or other loyalties.

 

At 5 STAR CLNIC each worker has a path to raise a concern or to follow the Whistleblowing procedure as needed. This means reporting concerns, including concerns for a registrant’s own safety and wellbeing, is as important as ever. These procedures are available on the shared company cloud.

  • Data protection and Record keeping in exceptional times:

-You must treat information about service users as confidential.

 

-You must only disclose confidential information if:

you have permission;

the law allows this;

it is in the service user’s best interests; or it is in the public interest, such as if it is necessary to protect public safety or prevent harm to other people.

-You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

-You must complete all records promptly and as soon as possible after providing care, treatment or other services.

-You must keep records secure by protecting them from loss, damage or inappropriate access.

At 5 STAR CLINIC, Records need to be completed promptly to ensure continuity of care. Records should provide evidence of the decisions that have been made and the care and interventions provided.  They should help to ensure that service users receive appropriate treatment that is in their best interests. Records should also help you to evidence your decision-making processes if later queried or investigated. It is important that records are kept safe from being lost, damaged or accessed inappropriately. At 5 STAR CLINIC we have software in place (zoom, physitrack, clouds etc.) to maintain a record keeping and data protection procedures in place for Online consultations as well.

Professional

At 5 STAR CLINIC we Follow the CSP flowchart: COVID-19-How to decide if face-to-face consultations are appropriate, for each and every patient attendance and follow-up.

We inform each client that we are taking a Virtual First approach at all times.

We have  triage system in place in the Standard Operating Procedures (SOPs) Risk 5 STAR CLINIC LTD.

Principal/employer

Demonstrate through documented evidence that you are compliant with Health and Safety at Work Act (HASAWA) in relation to Covid-19 and your duty to provide a safe workplace(see Health and safety policy and Risk assessment documents)

Demonstrate through documented evidence that you are compliant with Health and Safety Executive (HSE) requirements in relation to Covid-19 and your duty to provide a safe workplace(see Health and safety policy and Risk assessment documents)

Put procedures in place to manage staff self-monitoring of Covid-19 symptoms including any need to self-isolate(see Staff and Covid-19 document)

Put procedures in place to manage staff access to testing for Covid-19(see Staff and Covid-19 document)

Implement Standard Operating Procedures (SOPs) that clearly demonstrate how you are(see

Standard Operating Procedures (SOPs), Risk Assessment On Covid-19,Infection prevention and control during Covid-19 documents) :

  • Identifying risk
  • Managing risk
  • Establishing a safe environment

Implement Standard Operating Procedures (SOPs) to show that:

  • The clinic has a decision-making process for offering virtual and/or face-to-face appointments(we are following CSP flowchart and Triage process)
  • The clinic has robust record keeping procedure for both virtual and face-to-face appointments(software in place for that)
  • Implement a system to identify which patients are in the clinic at any one time should the need for contact-tracing arise(we have software in place to do that at the moment of writing is WriteUpp).

 

Factor 2: Risk assessment of the working environment for which you are responsible

A full risk assessment of the working environment for which you are responsible must be undertaken and documented, and you must demonstrate that all measures designed to mitigate risk and fulfil legal and regulatory obligations are in place.

 

  • Maximise all opportunities for a remote virtual consultations(5 STAR CLINIC is following the virtual approach first)

Reducing footfall

  • Complete a remote triage to screen for Covid-19 symptoms in patient and their household members (see Triage document)
  • Implement a system to ensure all written communication is sent electronically or by post (software in place)
  • Implement systems and processes to enable electronic prescribing if applicable (N/A)
  • Implement a system for remote review of patients seen face to face if possible(zoom + physitrack software)
  • Place appropriate signage to advise that walk-in services are not available(In place)
  • Implement a system to ensure appointments are only made by phone/e-mail to minimise contact with reception staff (in place)

PPE

  • Procure appropriate PPE stock for use by staff(staff is provided with the necessary PPE)
  • Consider whether you will ask patients to wear a face-covering(see infection control and prevention on Covid-29 policy)

Social Distancing

  • Government guidance on Social Distancing
  • Consider if you can conduct sessions outdoors(N/A)
  • Consider how people enter and leave your premises (risk assessment document)
  • Consider check-in/check-out procedures to ensure patients are kept 2m apart including cashless payments risk assessment document)
  • Adapt your waiting rooms to ensure patients to not overlap (1 in 1 out) and people are kept 2m apart(risk assessment document)
  • Consider using floor markings to map out 2m distances(The patients will know where to sit, because will be left only 2 chairs).
  • Consider installing screens and barriers at receptions areas
  • Consider how people flow through the clinic, ideally in a one-way system(in place)
  • Develop a protocol for when patients ask to be accompanied by a relative (in place)
  • Develop a protocol for when patients ask to have a chaperone and/or translator present (in place)
  • Enable staff to work remotely whenever possible(virtual approach first in place)

Limiting Spread

  • Place relevant posters in the clinic to raise awareness (in place)
  • Remove all non-essential items from waiting rooms and consider how you will clean non-disposable items such as clipboards and pens
  • Implement hand decontamination facilities (hand-washing and hand sanitiser)(in place)
  • Develop a policy and protocol for cleaning clinic rooms after each patient(in place)
  • Train all clinic staff in infection control procedures(in place)
  • Consider reducing the numbers of appointments offered to allow for cleaning between patients(15min gaps)
  • Implement policies and procedures for cleaning of phones, desks and other tools used by staff in clinical areas (in place)

 

Factor 3: Infection prevention and control (IPC) measures

You must follow Public Health England (PHE) Covid-19 infection prevention and control (IPC) guidelines.

 

  • PHE guidance on Infection Prevention & Control for Covid-19(infection prevention and control on Covid-19 document)
  • Develop protocols and systems to manage and monitor and any risks that the clinic environment may pose(infection prevention and control on Covid-19 document)
  • Develop a protocol for cleaning clinic rooms after every patient and other clinic areas as required(infection prevention and control on Covid-19 document)
  • Procure all appropriate cleaning products(in place)
  • Provide suitable accurate signage on Covid-19 IPC for people coming into clinic(in place)
  • Implement telephone screening of all patients before their appointment to ensure those with suspected Covid-19 symptoms do not enter the clinic to reduce the risk of transmitting infection to other people
  • Train all your staff so that they are aware of and discharge their responsibilities in the process of preventing and controlling infection
  • Put a system in place to manage the occupational health needs and/or obligations of your staff in relation to, symptom management and self-isolation(see staff and Covid-19)
  • Put in place appropriate hand decontamination facilities(hand-washing and hand-sanitising in place)
  • Procure a sufficient supply of relevant PPE suitable for the clinic activities undertaken and patients who may be treated(in place)
  • Procure the correct colour coded waste bags
  • Safe management of healthcare waste( see infection prevention and control policy)
  • Implement arrangements for the storage of waste bags before collection
  • Procure appropriate services to collect and dispose of waste in line with current legislation
  • Train all your staff in appropriate hand decontamination processes, PPE requirements and waste collection, storage and disposal(all the staff is trained and aware of this documentation)

At 5 STAR CLINIC all these points are in place and stated in the different documents produced.

 

 

Factor 4: PPE

You must provide and use appropriate personal protective equipment (PPE) and have systems and policies in place that govern its use.

 

  • PHE requirements for PPE in community and outpatient settings for Covid-19 positive or suspected patients
  • PHE PPE requirements for treating non Covid patients
  • Consider whether to ask patients to wear face coverings if they attend for face to face appointments
  • Know the PPE that any non-clinical staff in my practice will be required to use, including for any cleaning that must be undertaken?
  • Know how to risk assess for the correct level of PPE at each consultation (see PHE tables)
  • Procure all the necessary PPE
  • Train yourself and your staff how to don and doff PPE
  • Put in place appropriate processes and methods to dispose of PPE
  • Develop and document a PPE protocol that includes all the processes and procedures for safe and appropriate management of PPE
  • If you are working in a domiciliary and or care home setting
  • Know how you will transport PPE supplies
  • Know ‘sessional use’ of PPE in domiciliary settings and care homes
  • Know how you will dispose of PPE
  • Have a process in place for hand decontamination

At 5 STAR CLINIC LTD all the above points regarding PPE are stated and explained in the infection prevention and control on Covid-19 document.

 

Factor 5: Virtual first approaches

A ‘virtual first’ approach with remote consultations must remain standard practice during this period.

 

  • Maximise all opportunities for a remote virtual consultation
  • Justify and document why a remote consultation is not possible
  • Check for Covid-19 High Risk Red Flags of
    • Age > 70
    • BMI >40
    • Weakened immune system
    • Comorbidities that cause immunosuppression
      • Diabetes
      • HIV/AIDS
      • RA
      • Pre-existing infection
      • Alcohol abuse
      • Smoking
      • Long term steroid use
      • People with known cancer diagnosis and currently having active Rx
    • Screen for clinical red flags relevant to the body areas in question
    • Consider whether you need to send this patient directly to an appropriate urgent/emergency NHS pathway
    • Know how to manage the condition using diagnostic safety-netting initially
    • Check the relevant timescales for the symptom development of potential differential diagnoses in order to provide timely virtual follow-up
    • Organise a timely virtual follow-up to monitor symptom progression where necessary
    • Provide clear warning of red-flag warning symptoms that are relevant to the bodily area in question
    • Provide clear signposting information to urgent and emergency NHS services
    • Provide clear direction about when and how to contact the clinic by phone if symptoms do not improve within the expected timeframe
    • Document advice and assessment findings in the patient’s clinical record

 

At 5 STAR CLINIC all the staff has all the necessary knowledge in line with CSP and HCPC requirement and therefore is able to address the above points.

 

 

Factor 6: Patient risk assessment and clinical reasoning

You must undertake a risk assessment and make a clinically reasoned decision for offering either a face-to-face or remote consultation for each patient and for each of their planned contacts. You must document your rationale for these decisions.

 

  • Undertake a Covid-19 symptom screening check at virtual triage assessment
  • Check during virtual assessment for Covid-19 high-risk red flags:
    • Age > 70
    • BMI >40
    • BAME ethnicity
    • Weakened immune system
    • Comorbidities that cause immunosuppression
      • Diabetes
      • HIV/AIDS
      • RA
      • Pre-existing infection
      • Alcohol abuse
      • Smoking
      • Long term steroid use
    • People with known cancer diagnosis and currently having active Rx
    • Screen for clinical red flags relevant to the bodily area in question that may direct referral for urgent clinical services or routine imaging diagnostics
    • Maximise all opportunities for a remote virtual consultation including watchful-waiting
    • Know whether the patient has a clinical condition that aligns to NHS clinical priorities of increasing urgent clinical care provision, routine diagnostics, planned surgery or rehabilitation
    • Identify if your patient is shielding or not
    • Ensure you have the appropriate PPE to wear
    • Know whether you need to ask the patient to wear a face-covering
    • Ensure the patient is able to comply with social-distancing requirements including for those patients who request a chaperone to be present
    • Ensure you have appropriate Infection Control and Prevention provisions in place

 

At 5 STAR CLINIC each practitioner is aware of this guideline and the CSP chart for virtual approach first. There is a triage document in place which also address part of this points, moreover each practitioner in line with the knowledge required from CSP and HCPC is able to recognise the other factors above. Any doubt can be reported to the line manager.

 

Factor 7: Patient consent for treatment

You must engage your patients in discussions regarding the rationale for remote or face-to-face consultations. If both parties deem it necessary to proceed with face-to-face care, the patient should be made aware of all current risks associated with this approach. They must give their consent and you must document these discussions and the outcome.

 

  • Understand your duty of care
  • Understand the frameworks that guide informed consent
  • Document why you have judged a virtual appointment is not indicated for any patients’ where this is the case
  • Explain the safety measures you have in place to address the risks of Covid-19 in attending a face to face appointment
  • Discuss why a F2F appointment is clinically justified where this is the case
  • Explain to patients the policy and procedures for attending clinic face to face
  • Explain to the patient the close contact that may be required during a F2F session
  • Discuss with patients attending face to face that they may be required to attend wearing a face-covering
  • Explain to patients the cleaning processes in place in treatment areas
  • Document any questions individual patients raise related to attending face to face related to Covid-19
  • Train all your staff in appropriate consent for treatment procedures
  • Members may become legally liable if they fail to risk-manage treatments and their clinical environment to safeguard patients for example with insufficient PPE, sanitisation, social distancing and other reasonable safety measures.

Informed consent should now include reference to Covid-19 and compliance with any legal obligations.

 

AT 5 STAR CLINIC LTD each patient must fill a triage form and sign a consent and a declaration of truth before any treatment. Also, all the above points are addressed between the first Triage over the phone and the second one if a f2f appointment is deemed necessary.

 

Also, the patient is made aware of the risk associated with Covid-19 infection as outlined below. This policy is made available before the Video consultation, as well as before and during the treatment are addressed any questions and concerns.

The analysis of data from TESSy shows that the risk of hospitalization increases rapidly with age already from the age of 30, and that the risk of death increases from the age of 50, although the majority of hospitalizations and deaths are among the very oldest age groups.

Older males are particularly affected, being more likely than females of the same age to be hospitalized, require ICU/respiratory support, or die.

All-cause excess mortality from EuroMOMO, particularly at this time when competing drivers (influenza and high/low temperatures) are largely absent, shows considerable excess mortality in multiple countries, affecting both the 15-64 and 65+ years age groups in the pooled analysis.

Once infected, no specific treatment for COVID-19 exists, however early supportive therapy, if healthcare capacity for this exists, can improve outcomes. In summary, the impact of severe disease of COVID-19, if acquired, is assessed as moderate for the general population.

The risk of severe disease in the EU/EEA and UK is currently considered moderate for populations with defined factors associated with elevated risk for COVID-19 in areas where appropriate physical distancing measures are in place and/or where community transmission has been reduced or maintained at low levels.

The risk of severe disease in the EU/EEA and UK is currently considered very high for populations with defined factors associated with elevated risk for COVID-19 in areas where appropriate physical distancing measures are not in place and/or where community transmission is still high and ongoing.

The analysis of TESSy data shows that persons over 65 years of age and/or people with underlying health conditions, when infected with SARS-CoV-2, are at increased risk of severe illness and death compared with younger individuals.

These vulnerable populations account for the majority of severe disease and fatalities to date. Older males are particularly affected, being more likely than females of the same age to be hospitalized, require ICU/respiratory support, or die.

For any further queries please contact us at  5starclinicenquiries@gmail.com