COVID –19College of General Practitioners of Sri Lanka

Prior to the COVID-19 pandemic, General Practitioners (GPs) were the �rst contact points for most infec-tious diseases which they treated willingly and without any spread of the disease to themselves, the clinic sta� or other patients. But the situation has changed with the emerging COVID-19 infection, due to high possibility of the virus infecting the doctor, the clinic sta� and the other patients in their clinics unless proper precautions are taken. Therefore maximum precautionary measures should be taken to avoid the spread of COVID-19 by isolating such patients from your regular clientele thus protecting your patients, yourself and your sta�.

Let us look at the basic steps and action you need to take for your clinic, to ensure a safe environment.

Note :

This document is based on the “Provisional Clinical Practice Guidelines on COVID-19 suspected and con�rmed patients in collaboration with the Ceylon College of Physicians Coordinated by Epidemiology Unit of the Ministry of Health-Sri Lanka”, taking into consideration relevant points for our practice situation.

This is an interim document; suggestions and innovative points in line with proven scienti�c knowledge on COVID-19 are welcome and these will be considered by the task force of College of General Practitioners of Sri Lanka (CGPSL) in future versions of this document and also the amendments made by the Ministry of Health.

This document is divided into three sections for convenience as follows:

A. Basic principles to be followed for a safe clinic operation

B. Identi�cation of the legal position in connection with the Health Ministry directives regarding general practice. (Annex-1)

C. Questionnaire to assist in a Telephone consultation (Annex -2)

A practical plan of action to assist a General Practitioner

to run the clinic

under the present context

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A. Basic principles to follow for a safe clinic operation

1. What to wear at the clinic

• Clothes should be cotton and washable. Ties to be avoided and half sleeve will be better • Not to insist on uniforms for sta� if they cannot wash it daily. Cotton, loose casuals are preferable which can be dumped into soapy water before they enter their homes after work and kept immersed completely for about �fteen minutes. They should be washed separately from the clothes of their household members. • When the sta� travel from home to work and, once they reach the workplace it may be a good practice for them to change into their uniform or change into another set of dress. • Use the hand hygiene practice before the sta� wear their disposable mask and their pair of disposable gloves . This should be used for that session only and then disposed of, into a pedal bin with a lid for proper disposal after adding 0.1% hypochlorite solution or burning. • When the session is over, they can change into their original dress, use the hand hygiene procedure before traveling back home. • Once they reach home, hand hygiene procedure must be followed �rst, both set of dresses submerged into soapy water and they should have a bath before they mingle with the family members.

Disposable masks must be well �tting, covering both nose and mouth. They should not be allowed to dangle around the neck of the wearer and should not be touched once they are on. They should be removed if they are moist or damaged and need to be discarded.

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STEPS OF HAND WASHING WITH SOAP AND WATER

2. My Entrance

There should be a hand washing facility outside the entrance to the building. The clinic assistant should insist that patient should use it before entering the triage area. (Soap and water hand-washing station need to be readily available). There should be disposable tissue and a waste bin with a foot operated lid at this point.

There should be a prominent Board at least 3 feet x 2 feet which says in big letters in all three languages the following

The triage nurse should wear an apron, pair of disposable gloves and disposable mask which are mandatory. These should be discarded at the end of each session.

Note: A triage facility at the entry point is ideal if room space is available at the entrance to screen patients with COVID-19 symptoms and send them to the isolation room. Such patients should be provided with a disposable face mask, if they are not already wearing one. If such room space is not available, you must depend on remote consultations at the �rst instance in such patients for which the above board would be useful.

A questionnaire is prepared to aid in the telephone consultation (please see Annex-2)

During telephone consultations, if the patient falls into any of the categories listed below, they should be directed to a designated government hospital for treatment. They can call hotline number 1390 where the government will arrange transport to the hospital. This information should be communicated and docu-mented by the GP himself. • Patients with medical emergencies. Patients presenting with symptoms of fever, upper respiratory tract infections, body pain, headache, vomiting, rhinorrhoea, or any other symptoms suggestive of COVID-19 infection.• Patients with any contact history with a COVID-19 patient or a contact.• Patient with any history of foreign travel in the recent past.• Patients who have been quarantined by the government. (Home quarantined patients)• Patient presenting within 14 days of return from a quarantine centre or locked down areas

Please refer Provisional Guidelines for Clinical Management of COVID-19 of MOH - Annexure 4 for further guidance

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IF YOU HAVE COUGH, COLD, SORE THROAT OR FEVER

FOR THE SAFETY OF FELLOW PATIENTS,

YOUR DOCTOR AND THEIR FAMILY AND STAFF

PLEASE MEET YOUR TRIAGE NURSE OR

CALL THIS NUMBER ( )

FOR A TELEPHONE CONSULTATION INITIALLY. ”

“

3. Waiting Area

• Chairs will be placed at least one meter distance apart.• There should be a hand sanitizer in the waiting area. The clinic assistant should insist the patient to use it before entering the waiting area. There should be disposable tissue and a waste bin with a foot operated lid.• The isolation room should have a separate entrance and exit for the patient to leave after being seen by the doctor and issuing of the drugs, preferably by the doctor himself)• Patients should be encouraged to come with prior appointments whenever possible, to prevent overcrowding. Walk-in patients to be discouraged.• Patients can also be discouraged to wait in the waiting area and go home and come back if they reside close by, at a predetermined time.• Remove all magazines and toys from the waiting area.

4. Consultation Room

• Wash hands well with soap and water and use a tissue to dry hands• We should wear our disposable mask after washing our hands well with soap and water before the clinic starts. After each consultation hand hygiene needs to be strictly adhered to.• If you have an isolation room where a patient needs to be seen, it is mandatory that you wear an apron, pair of disposable gloves and disposable mask. The disposable gloves and apron should be removed after seeing the patient should not be reused. (Thus reasonably priced polythene aprons would be ideal. College is planning to design one shortly)• Consultation room not being air conditioned is ideal. If the room is air-conditioned, switch o� and allow the windows to be opened.• It would be a good idea to have a pedestal/table fan behind the GP so that the blow of air would be from the doctor to the patient• Using a non contact digital thermometer (If a�ordable) at this point of time makes the patient feel more comfortable. If not the normal thermometer can be used and cleaned with 70% isopropyl alcohol/or use the axilla as an alternative and clean it up as usually what we do• Always sit a meter away from the patient.• Only one person to accompany the patient if necessary. Eg: elderly patient or a child).• The doctor should examine the chest from behind as well as avoid examining the throat.• Keep the consultation brief and relevant.• Where ever possible follow up consultation should be minimized and Whatsapp can be used to review reports via a professional telephone consultations• Discourage the whole family coming to show one person. If they come as a family, the rest of them have to stand out and not occupy the sitting area. • Wash hands well with soap and water and use a tissue to dry hands after the session is over

All your masks and gloves and that of the clinic sta� of the clinic to be put in a yellow bag and mouth of bag tied and can be burnt if you have facilities to do so. If not, follow the procedure you usually follow.

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5. Dispensary

• Avoid / minimize delay in dispensing the medicines.• When dispensing, common principles like pre packing of fast moving items and keeping them ready, keeping fast moving items at arm’s length etc. which will help in faster dispensing would be helpful.

6. Cleaning the clinic

• Before beginning and at the end of session the clinic should be cleaned. Floor and the �at surfaces like frequently touched dispensary working areas need to be cleaned with 0.1 % sodium hypochlorite and sitting room chairs, door knobs etc. need to be cleaned with 70 % isopropyl alcohol taking turns by the sta� before they remove their gloves. Spraying and wiping may reduce the amount of material used.• Use of a closed dust bin in areas of clinic and availability of disposable tissues in di�erent areas in the clinic is important and this must be emptied after each session into the same yellow bag used for gloves and masks for proper disposal. Disposing of sharps need to be attended to, as during the usual practice.

7. After Clinic

• All members of the clinic once they reach home (the doctor and clinic assistants) should immerse their dress including under garments in soapy water for at least 15 minutes.• They should have a bath and then wash their dress separately from the clothes of other household members

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It is of satisfactory understanding that there has been no circular issued to close down private practice of Medical Practitioners during this pandemic or such circular has been later removed as it is not to be found among the circulars issued so far.

Yet again, any practice that has been sealed by the police taking into consideration section 262 of the penal code {Quoted below}, for the o�ence of helping to spread a disease.

“262. Whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with impris-onment of either description for a term which may extend to six months, or with �ne, or with both.”

-Penal Code Section 262-

As such it can be safely concluded, that so far as the safety measures and precautions to spread the virus have been adhered to, there will not be legal repercussions on General Practitioners.

Acknowledgement: Miss Dilani Jayathilake- Attorney at law

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Annex 1

Identification of the legal position in connection with the Ministry of Health directives regarding the general practice.

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Annex 2

Questions to be asked in a telephone / Remote consultation with a patient having respiratory symptoms

This is a general questionnaire to be �lled during a telephone/remote consultation with a suspected patient with Respiratory Tract infection to decide on a plan of action and then advise the patient what to do next?

The questions are given to ensure important aspects are not missed. Feel free to develop it further

1. Your name please?

2. Can I have your age please?

3. Sex to be noted

4. Please give your address at the moment (if relevant)

5. Your telephone number please (if relevant)

6. What is your occupation? (Travel guide / Health care worker etc.)

7. Brie�y give a history of your symptoms (Do not interrupt till the patient has �nished his/ her story. Do not ask leading questions. Once patient has �nished talking, you can clarify doubts if any Checklist to be ticked while patient is talking Yes No Duration I. Fever II. CoughI II. Sore throat IV. Shortness of breath V. Diarrhoea VI. Loss of taste, smell etc. VII. Regular patient of yours or new patient of yours Any other extra details you need to record (if any)

8. Have you come in close contact with anyone who was positive / suspected for COVID-19 /

symptoms of fever, cough, sore throat……?

9. Have you travelled out of Sri Lanka in the last 14 days? If so give details

10. Have any of your relations/ friends who went aboard visited you in the last 14 days? If so give details

11. Have you come in close contact with any foreigner or those who travelled abroad presently living at

home/while travelling in public transport/social gathering/ religious get together to the best of

your knowledge in the last 14 days? If so give details

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12. Have you been in a locked down area since the COVID-19 epidemic started? If so give details

13. Have you returned to / arrived in Sri Lanka in the past one month?

If the answer to above is ”Yes”

i. Which countries have you visited Write down in the order of visits?

ii. Number of days stayed in each country in a chronological order

iii. Where have you travelled in Sri Lanka after your arrival?

14. Were you sent to a quarantine centre recently? If so do you have the certi�cate?

15. Tell me about your past health condition

Have you had any medical illnesses like,

Yes No

• Hypertension • Diabetes Mellitus• Cardiovascular disease• Wheezing episodes /Bronchial asthma• Any other medical illnesses of signi�cance

At this point a decision could be made whether the person has to be seen in person or sent for specialized care unit for further assessment

16. To which MOH area do you belong? (this will help us to inform the relevant MOH)

17. Please let me know about your home environment for me to suggest on adequacy as to self quarantine measures (For MOH to decide on quarantine measures and GP to coordinate same) END OF REMOTE/TELEPHONE CONSULTATION

My Notes

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Source:Provisional Clinical Practice Guide Line on COVID-19 suspected and con�rmed patients - Epidemiology Unit

Temporary isola�on

Clinical Management/No�fy

Clinical Management/No�fy

Temporary isola�on

Designated hospital

Primary care assessment of Suspected COVID-19 Patient

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Dr. K. Chandrasekher (General Practitioner)

Dr. Sanath Hettige (Specialist Family Physician)

Dr. Preethi Wijegoonewardene (General Practitioner)

Dr. Pushpa Weerasinghe(General Practitioner)

Dr. Kalpanie Wijewardana (General Practitioner)

Dr. D.K.D. Mathew(General Practitioner)

Guidelines Development and Editorial Committee

Dr. Ananda Wijewickrama(Consultant Physician)National Institute of Infectious Diseases

Dr. Jayantha Weeraman(Consultant Paediatrician)Epidemiology Unit, MoH

Dr. Kanthi Nanayakkara(Consultant Virologist & Vaccinologist)Medical Research Institute

Dr. Jananie Kottahachchi(Senior Lecturer, Consultant Microbiologist)Faculty of Medical SciencesUniversity of Sri Jayewardenapura

Dr. Jayantha Jayatissa(Specialist in Family Medicine)

Disclaimer -The information set out in this publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. The CGPSL and its employees and contributors to this publication have no liability (including for negligence) to any users of the information contained in this publication.

The CGPSL makes no warranties in regard to third party information provided in links, which remains the responsibility of the relevant publishing body.

GUIDANCE FOR GENERAL PRACTITIONERSFORMULATED BY THE COLLEGE OF GENERAL PRACTIONERS OF SRI LANKA,

APPROVED BY THE SRI LANKA MEDICAL ASSOCIATION INTER-COLLEGIATE COMMITTEE

AND REVIEWED BY THE EPIDEMIOLOGY UNIT OF MINISTRY OF HEALTH