With the uncertainty of COVID-19, Ophthalmology practices need to take extra precautions. Ophthalmology and Optometry offices are at high risk because of the close and confined contact with the human eye, along with the equipment needed to work up a patient. Taking the time to strategize with your team to set up additional safety measures will help to alleviate some of the anxiety and stress that the pandemic carries. Being prepared is especially important for patients and staff with family members who are at highest risk due to age and comorbidities. Remote work, conserving PPE, rearranging the office for social distancing, and a little bit of DIY will all go a long way towards helping protect your staff, providers, and patients.
A sense of respect and dignity will also be evident as offices begin to rebuild from the impact of the virus. If infection control guidelines are followed, for the care and safety of the people being seen as patients and working in office, better outcomes will follow. When moving from urgent patients only to routine again, patients will expect clinics to have proper plans in place for the new normal to begin. This starts by having a clean and efficient setup for practicing safe habits and protocols.
I’m sure I speak for many when I say we are looking forward to getting back to our customary “normal.” While we work towards that, it is paramount that we take special care with our safety and that of our team, families, and patients. In healthcare, we expect the unexpected: with proper precautions and protection, it’s our duty to step into the line of fire to care for our patients. We’re all learning a great deal right now about how to ensure that our patients receive the best care possible while keeping ourselves, and our families, safe.
Remember this time and how you were treated, how you reacted, what you did to take note of any opportunities, what was done to gather plans quickly, and what it will take to start from the “old” normal all over again. Will we go back to where we left off in our jobs and lives, or will we see our world forever changed, at least until a vaccine for COVID-19 has been released?
Keeping patients and staff safe during a pandemic step 1: Remote options
During the COVID-19 pandemic we have reduced the number of staff onsite. In order to do this we have allowed staff to work from home when appropriate (triaging office phone calls, for example), and also gone to lengths to scrub patient schedules to limit the amount of patients coming into the office. We have reduced the outpatient clinic visits and restricted appointments to onlyemergent or urgent care. All elective visits have been postponed and we evaluate our “back to normal” date every two weeks.
For surgery cases, we are also looking week by week, considering the two weeks out only doing urgent surgeries when absolutely necessary. Only non-elective outpatient visits and surgeries are currently happening, in order to make sure PPE is conserved and used appropriately.
During this time, the use of technology is supreme. For example, working from home (WFH) setups have allowed staff to answer phone calls from their living room, rather than exposing them at work. Leadership works with their teams to assign rotating schedules, skeleton crews, snow day operational crews, A & B teams to rotate and to ensure adequate safety for all.
Telehealth initiatives are taking place, which is really fantastic. When COVID-19 comes to a close, we may even recognize that telehealth is here to stay. We’re in communication with departments and facilities in order to share which software we are using that functions as an approved telehealth program. The software that has been used includes:
- Zoom
- StarLeaf
- SnapMD / Virtual Visit
- Facebook Messenger
Please note that TikTok—a quarantine social media favorite—has made it to the “do not use” list of inappropriate platforms. No tiger king videos allowed!
Humor aside, telehealth is crucial to be able to triage patients and provide care to them remotely, while we limit their contact with a telephone and video option. While we are delivering care this way, it's important to remember how telehealth will be used in the future. It may not always be ideal for Ophthalmology, and certainly more challenging for Optometry; however, what about on a snow day for clinics in the northeast? If there was a state emergency, and public transportation was shut down, telehealth would come in handy and be a relief for many patients in need.
Other activities to support remote teamwork include:
- Set up weekly, rather than monthly, provider meetings for MDs and ODs to connect virtually during COVID-19 operations
- Set up staff huddles every day, with the option for the MDs and ODs to join, including both on-site and remote teams
- Send out a written huddle to all (staff and providers), outlining all plans and assignments to follow each day
- Send out a “weekly wins” emails, written by the manager or Chief of the Division, highlighting the win of the week to congratulate staff
- Recognize staff as much as possible by setting up a virtual team engagement board, sending cards and doing shout outs through email
- Remember to celebrate birthdays, graduations and special occasions, by using eCards instead of an in-person lunchroom cake
Keeping patients and staff safe during a pandemic step 2: Conserving PPE
Even with remote or work-from-home options in place, have a plan in place to re-deploy MDS and ODs to other facilities when necessary. Conserving PPE so that each doctor and staff member is protected is crucial in this moment, so here are tips for efficient use of resources as instituted by our own practice leadership and staff.
- Change into scrubs in the morning. If you don’t have scrubs, bring an extra set of clothes in the office
- Wear a surgical cap and mask during the day
- Place proper disposal bins around clinic for face masks and gloves removal. Seperate from the regular trash
- Use only one room for patient care, shut down the others and shut the door with a sign
- Minimize IOP checks as much as possible
- Remove all patient magazines, pamphlets and patient information out of the waiting rooms
- Remember to gown up if possible and wear surgical face masks if available, with a plastic attached shield
- Keep a can of disinfectant wipes in each room
- Clean keyboard, mouse, 20D lens, door knobs, slit lamp and chair between all patients.
- Wash/Purell hands before and after each patient contact – “pump in and pump out”
Many institutions are making their own hand sanitizer right now.
Keeping patients and staff safe during a pandemic step 3: Use the space you have
Make social distancing tape floor signage/tape markings. This practice used unicorn tape for a positive mood lifter during uncharted waters and difficult times!
Spread out the seating in the office. Move chairs in a checkered pattern to keep patients waiting even more separated than usual. Remember, if you have flooring like the below example, each square measures close to a foot! You can count 6 squares to keep the distance.
Remember, when normal operations come back, be mindful that social distancing will last and may be the new exception. Try to minimize capacity issues with too many patients scheduled or in the waiting room at any given time. Utilize your space well, and continue as you normally would under “normal” conditions to leave extra space for those who are bound by wheelchair or coming in by stretcher.
Lock all PPE in one centralized area to keep from theft. Yes, during these hard times theft has been identified. Keep PPE in the manager’s office and each morning grab the mask you need for the work day. Make sure the supply of PPE is available to patients as they will need it too. If your medical center or large facility is screening at the front door, great: less PPE for you to have to give away.
Keeping patients and staff safe during a pandemic step 4: DIY when necessary
While many facilities and hospitals have their own guidelines to follow around COVID-19 operations, ophthalmology practices are encouraged to think of creative ideas in addition to the set guidelines and available resources. Unless our superstar employees and providers think outside the box, ophthalmology clinics might find themselves missing certain resources.
In the last months, I’ve been in touch with several other facilities—both Ophthalmology and Optometry—and all have shared invaluable tips for improving operations. Earlier this year, I wrote about improving practice efficiency, and the teamwork and generosity shown by other practices in my research is more important than ever, now. During this time of crisis, I’ve worked with my colleagues across the Greater Boston area to help each other share advice and provide guidance. We all learn and improve from each other.
This how-to for making your own hard acrylic slit lamp face shield was shared with me by an Ophthalmology team member from Boston University. We need to support each other during times like this—because there will be more hardships and change like it. We all have information and helpful ideas and whether they’re part of your practice or not, can benefit from.
How to make your own slit lamp shield in 5 steps
Thank you again to the eyecare team from BU University & BMC for sharing!
Tools and Materials:
- Drill (may be handheld or corded)
- Dremel tool – do not need to be an expert to use. Very helpful because of its cutter tip!
- 18”x24”x0.093” clear acrylic sheet (yields two slit lamp shields): Using thicker acrylic should provide a robust shield that is easier to clean and sanitize
- Plastic sheet cutting tool
- 2” wood hole saw with arbor
- Dremel 5/16” oval-shaped high speed cutter tip
- Ruler and pencil/pen
- Scrap wood
- Eye protection
Step 1: Cut acrylic sheet in half
The large sheet needs to be cut into two 12”x18” sheets. Note the plastic has a plastic film that comes off at the end. Keep it on while working on it to help protect the plastic.
Mark the sheet at 12 inches.
Use a straightedge to score the plastic with the plastic sheet cutting tool. Plastic is hard to work with: you have to scrape a line into the plastic and then snap the plastic. If the divot is too shallow, the plastic doesn’t break along the line. If you do it right, it makes a great, clean break. If you skimp on the depth, you can crack the plastic or have a less than straight line. Make sure you score the backside to cut the film.
Example of crooked break. (The sheet was still usable.)
Step 2: Mark sheet
Measure 7 inches from the top of the 12”x18” sheet (short length on top and bottom, long length on sides). Mark the center of the line (should be 6” from edge if you made the sheet the right size).
From this center mark, measure out 1 3/8” (one and three/eighths inches) from the mark on either side. Each one of these marks will be the center of each hole.
Step 3: Cut holes
Make sure to wear eye protection! Cutting plastic is hard. It tends to break and shatter.
Make a pilot hole in the wood to be your guide, and make it deep enough so that the teeth of the hole saw can get through the plastic.
If you have a torque setting on your drill, use it so that the drill stops if the resistance is too high. Otherwise, forcing it when the teeth get caught can break the plastic. (I set mine to 20.)
You’ll learn how to get through the plastic with practice. Try not to mess up the pilot hole, as it makes it impossible to keep the hole cutter straight. If you know someone with more experience cutting round holes in plastic, ask them!
And remember, two holes per sheet. When you’re done, you’ll have some rough looking holes.
My scrap wood with a pilot hole a little deeper to allow the blades to cut through the plastic.
In the first picture, I went too fast for the pilot hole and made a mess in the middle. The second picture is an example of a clean pilot hole, allowing me to take out the disc as shown.
It should look like this. There are many pointy plastic pieces to take care of next.
Step 4: Clean up with Dremel
The Dremel tool is cool, fast, and a whirling storm of danger. Be careful, and protect your eyes and hands!
I used the 5/16” oval-shaped high speed cutter tip to smooth out the inside edges of the holes, as well as to round off the outside corners to avoid injury in the exam room. Be sure you have a firm grip on the tool. It also makes a lot of plastic dust that goes everywhere.
Respect the blade.
Step 5: Remove film and place on slit lamp
Once you’re done, simply peel the film off each side and you should have a nice, large, clear slit lamp shield. It can be moved from one slit lamp to another. Clean as you would any plastic surface.
If you can’t DIY, what can you do?
You can also use an AVERY plastic shield to make a very basic slit lamp protector. The above harder shield is recommended as it’s more durable, but if you can’t spend the time making the harder version, CVS or Walgreens will have the plastic AVERY brand film sheets you can use instead.
However, it’s more flimsy than the DIY option, and may be harder to clean after each patient. Use the measurements of your slit lamp lens in-office to make the circle cuts for the eyes.
And best of all, these companies and organizations are distributing free breath shields:
- AAO
- ZEISS: Fill out the information required, and the estimated turnaround time to receive these items is two weeks.
- Marco.com
- TopCon
- Haag-Streit
- Heidelberg Engineering
- For indirects: BIO breath shields. They also give out shields for Heine, not just Keeler
Don’t forget to check in with your partners and affiliates - you can share best practices and even help to donate supplies in this challenging time of need. We all need each other!
Tips to think about for reopening and recovery:
- Severe restrictions: social distancing, no visitor policy, mandating masks for staff and patients, proper signage throughout the clinic space
- Watch and monitor capacity issues: limit too many providers on at one time, keeping a close eye on the waiting room areas and only allowing a max amount of patients in clinic at one time or per day
- Continue to monitor PPE to match amount of patients coming in and staff needed to run the practice every day
- Don’t over crowd or gather in lunch rooms, and continue to hold virtual meetings
- Slowly add volume back to schedules: start with urgent, semi-urgent, routine, new normal phases - start with four phases!
Remember to wash your hands, protect others and yourself!
