Dear Dr
The COVID-19 Pandemic has been declared a national disaster. General Practitioners have an important role to play in containing the spread of SARS-CoV-2 (the cause of COVID-19) through the early identification and appropriate referral of potential cases for investigation. We further need to provide the correct guidance re isolation and quarantine while educating our patients about prevention and managing their multiple fears. To provide this service and continue caring for our usual patients, we need to protect ourselves, our frontline staff and unaffected patients visiting our rooms from potential exposure. This guide does not attempt to be comprehensive nor to replace the official guidance from the WHO, NICD, DOH, WCDOH and the provincial and private testing sites but merely to highlight important practical points about the provision of primary care during this rapidly evolving global and now national health crisis.
Correctly Identifying potential COVID-19 cases for further investigation
The most important public health principle is to contain the spread of the virus. It is therefore neither safe nor appropriate to have patients walking into our waiting rooms without being screened for potential COVID-19 infection first. This screening can be done telephonically by frontline staff with the appropriate questions or through a visible notice on the practice door informing patients with acute onset of a respiratory illness to not enter but rather go home and contact the doctor telephonically to establish risk prior to consultation. If there is a travel or contact history in a patient with acute respiratory symptoms the patient should contact the COVID-19 General Public Hotline number on 0800 029 999 directly. While this may seem cumbersome it is our duty to take the proper steps to protect our staff and avert the disaster of our waiting rooms becoming COVID-19 Transmission sites.
The WCDOH COVID-19 Advice for Health Workers gives a step-by-step guide to when to suspect the infection, what to do, where to call, how to manage, refer and notify and how to clean and disinfect and has been forwarded to all members previously. It should be printed out for easy reference.
Practitioners should suspect COVID-19 in any patient with recent acute onset of cough, fever, shortness of breath or sore throat and who was in close contact with someone who has contracted the disease or is suspected to be infected or was present in a building where COVID-19 affected patients were being treated. Establish whether the patient travelled or came into contact with anyone who travelled to any of the countries with established community transmission of the SARS-Corona Virus-2. This list of countries updates on a daily basis and can be accessed at http://www.nicd.ac.za/diseases-a-z-index/covid-19/daily-updates-of-countries/ Patients with severe Pneumonia of unknown aetiology should also be investigated for COVID-19. The criteria for a “Person Under Investigation” or PUI will change with time and when community spread becomes established. These criteria are updated regularly by the NICD. Please check their website: http://www.nicd.ac.za/diseases-a-z-index/covid-19/
Important Phone Numbers for Practitioners:
If COVID-19 is suspected or specialist guidance regarding risk is needed any of the following numbers may be tried: – NICD Hotline 082 883 9920 or text name and query to 066 562 4021.
- WCDOH COVID-19 Advice for Healthcare Workers: 021 9284102
- Latest NICD 24hr Clinician Hotline 0800 11 1131
- Tygerberg: 0834191452 or 021 9384911 or 021 938 9645
- Groote Schuur: 021 4049111 (ask for ID Registrar on call)
It is essential that suspected COVID-19 cases presenting to your rooms are identified as early as possible. Patients should be triaged at presentation with a simple screening questionnaire for COVID-19. A notice or poster should be placed prominently at the practice entrance alerting patients who identify as at risk of COVID-19 not to enter the general waiting area and to rather call the NICD Public Hotline or “Call Ahead” to the doctor. If you are alerted that a patient at reception or in the waiting area is a suspected COVID-19 case please take the following measures immediately: – Give the patient a surgical mask (N95 respirator mask not needed for patients)
- Move the patient to a separate area/room if available (or at least 2m away from other patients)
- Provide tissues and instruction to cover the nose and mouth during coughing or sneezing while shielding the face with a flexed elbow
- An alcohol based hand sanitizer should be made available at reception and hand hygiene performed immediately after coughing or sneezing
- The patient should be triaged quickly to establish clinical severity and receive appropriate care
- Contact the relevant clinical centres for further advice and fill out the required forms for the patient to undergo screening. The information required can be obtained from the patient telephonically.
We do not recommend that General Practitioners perform the naso- and oro-pharyngeal swabs required for investigation of a COVID-19 suspect unless they have the correct Personal Protective Equipment (PPE) and know and regularly practice the principles of “donning and doffing” (putting on and taking off) PPE. Double gloving is recommended. The step by step instructions developed by the Anaesthetics Department of the University of Toronto provides excellent guidance in this regard and can be accessed on https://www.anesthesia.utoronto.ca/news/coronavirus-and-safety-precautions or watch a short reference video on https://vimeo.com/397604374 (as recommended by Prof. Bruce Biccard UCT Department of Anaesthesia and Perioperative Medicine)
NB: A practitioner who swabs a patient who then tests positive for COVID-19 can continue to work while monitoring himself for symptoms BUT only if he was fully protected by the correct PPE during the procedure.
If you had occupational exposure (to a confirmed COVID-19 patient) without wearing full PPE you will need to stop working and self-quarantine for 14 days. You should be tested as soon as you develop any symptoms.
The current recommendation is to please NOT SWAB any completely asymptomatic persons who are concerned about potential exposure while travelling or moving through airports or during general interaction with international visitors. There is a fair amount of pressure from patients and employers to “find out” the COVID-19 status of such a person. Swabs performed while asymptomatic can falsely reassure, lead to non-adherence of the recommended self-quarantine periods and should not be done.
Recommendations will change and be adapted as the pandemic and our local situation evolves. This is a rapidly changing space and we urge practitioners to stay up to date with the current guidelines on www.nicd.ac.za
Let us do our best to educate our patients to contain the spread of COVID-19 in our communities, manage their fears with the correct information, identify infections early, manage self-quarantine, self-isolation and appropriate referral according to the latest guidelines and let us achieve this by staying informed, staying safe and protecting ourselves always.
It is also critical to put out your own public awareness notices of do and don’t for patients and to encourage social distancing in your waiting rooms. To note that many practices have already moved to an appointment basis only and asking for patients to wait in cars.
As a doctor, you are in an extremely vulnerable situation and shall be feeling overwhelmed, confused, and frustrated. This is the time to work together effectively to fight this pandemic and limit both its duration and impact on our very vulnerable society. The office shall be calling on practice needs including whether your practice needs training for staff to screen and triage patients via the telephone. We have submitted to the NDOH and WCDOH clear feedback not to encourage high risk patients to come to the doctors rooms but to call before hand.
Please ensure that you visit the regularly updated page https://www.emcmobi.co.za/corona101/ and watch for ongoing information via SMS and to the web portal
President Ramaphosa said that this is the most definitive Thuma Mina (Send Me) moment for our country. As Primary Healthcare Workers we have been “sent” perhaps more than our fellow citizens to fight this at grassroot level. Let us step up and deliver together.
Regards
Network Management
