Tier 1 exposure sites in general practice – prevention and response

A person cleaning a general practice waiting room after it became a Tier 1 exposure site.
  2 September 2021  Dr Jeannie Knapp, GP and Primary Health Care Improvement GP Adviser, NWMPHN

Becoming a COVID-19 Tier 1 exposure site is sending shivers down the spines of most general practices in the state.

We obviously worry about the risk of COVID-19 to ourselves, our staff and our patients, but we are also concerned about our businesses and business continuity. In this article I have provided some tips for preventing and preparing for exposure, how to respond if you do become a Tier 1 exposure site, and what to do afterwards.

Prevention

The phrase ‘prevention is better than cure’ is often attributed to the Dutch philosopher Desiderius Erasmus in around 1500. We usually apply this to disease processes, but we could also apply it to reducing our risk of becoming a Tier 1 exposure site.

The Infection Prevention Helpline provides free advice on infection prevention and control. It is now available free to Victorian general practices, community pharmacists, Aboriginal Community Controlled Health Organisations and nurse practitioner owned or led primary care practices to help them continue to keep their staff and patients safe. Consider giving them a call and running through your prevention action plan with them for handy tips and advice.

Health Pathways Melbourne has a page on managing your practice during COVID-19, with many suggestions for prevention.

Some of the things to consider are included below.

Planning ahead

  • Ensure all staff and patients check into the clinic using the QR code to ensure you have a record of everyone who is present. More information on this process is available on our website.
  • Appoint a practice pandemic leader and coordinator who will monitor the situation and communicate important updates to the team.
  • Ensure the business has and follows a COVIDSafe Plan. The RACGP has a COVIDSafe Plan template available to download.
  • Plan for people needing to work from home, including having remote access to systems and forwarding of the main practice phone.
  • Consider dividing staff into pandemic and non-pandemic groups to protect those who are more vulnerable, such as immunocompromised, pregnant, and elderly staff, and those with comorbidities.
  • Consider using the Emergency Response Planning Tool, endorsed by the RACGP, to plan the practice’s response to emergencies including pandemics. You can register for free access to the tool on our website.

Personal protective equipment (PPE)

  • Make sure you have adequate levels of supplies such as PPE and disinfectant and ensure that the supplies you purchase meet standards. North Western Melbourne Primary Health Network (NWMPHN) is distributing personal protective equipment to eligible health services. You can find PPE request forms on our website.
  • Choose PPE by current alert level rating. At the time of writing we are at the highest risk level in Victoria – COVID Peak (black).
  • Follow instructions for Victorian health care workers to make sure you are properly putting on, fit checking and taking off your PPE.

Physical distancing and infection control

Tips for your waiting room

  • Space waiting room chairs 1.5 metres apart.
  • Stagger face-to-face appointments over the day.
  • Have patients wait in car parks until their doctor is ready to see them (if possible).
  • Encourage no-contact cashless transactions.

Tips for your clinical rooms

  • Set up clinical rooms to allow physical distancing.
  • Minimise exposure time to the patient where practical (aim for less than 15 minutes).

Tips for the entire practice

  • Maintain physical distancing with other staff except where required for clinical care.
  • Increase the frequency of hand washing.
  • Ensuring adequate ventilation by keeping doors or windows open
  • Increase the frequency of standard cleaning measures.
  • Disinfect all touch points (such as EFTPOS terminals, light switches, doors and stethoscopes) after each patient contact.
  • Ensure all cleaning contractors are aware of COVIDSafe protocols.
  • Require all practice staff to complete a daily attestation according to the current Victorian level of COVID-19 risk.
  • Ensure staff members are fully trained in the use of personal protective equipment (PPE) and contact and aerosol precautions.

Pre-screening patients

  • Ask patients with symptoms to wait in specified areas, (such as outside, in a car or in separate rooms) and see symptomatic patients in closed off/separate areas.
  • Use telehealth where possible for routine and non-urgent care.
  • Run separate locations or separate opening hours for patients with possible COVID-19 symptoms, and those without.
  • Triage appointment requests and patients on arrival. A suggested script is:
    • “Have you had contact with someone who is a confirmed case of COVID‑19 or coronavirus?”
    • “Have you been at a recent exposure site or are you otherwise required to isolate?”
    • “Have you had a fever?”
    • “Do you have any current respiratory symptoms like shortness of breath, a runny nose, sore throat, fever, hoarse voice, loss of taste or smell or cough?”
    • “Are you awaiting a COVID swab result?”
    • “What is your occupation?”
    • “What is your place of residence?”

Preparation

As we know, even with the best will in the world, there is always still a small risk of being exposed to COVID-19. Below are are some suggestions for practice preparedness in the event of needing to quickly switch to off-site work.

  • Have a plan prepared for what to do if you become a Tier 1 exposure site, including how your staff will work from home.
  • Make sure staff are aware of how to remotely log into systems.
  • Perform a trial run. Does each off-site staff member know how to log in? How will paperwork be handled? Email? Does everyone know how to print PDFs for email?
  • Consider cross-training staff in using critical workplace systems, and consider the impact of absences of critical staff.
  • Divide staff into teams with no face-to-face crossover to ensure business continuity in the event of an exposure in the practice team.

Responding to becoming a Tier 1 exposure site

What to do if you are notified you are Tier 1 exposure site, or a COVID-19 positive patient visits the practice:

  • If you identify a positive case, notify the Victorian Department of Health on 1300 651 160, or complete an online COVID‑19 notification form.
  • If the positive case occurs elsewhere, the Victorian Department of Health will notify you that you have become an exposure site.

When the Local Public Health Unit (LPHU) contacts your practice:

  • Practices will need to provide the LPHU with contacts who attended the practice within the specified window (inclusive of staff, patients, contractors and anyone else who may have attended the practice).
  • Check the level of PPE worn by those involved, their distance apart, the specific examinations that took place (for example: an ENT exam has higher risk) and time spent in an enclosed room.
  • Identify areas of the practice involved (for example: bathrooms, consult rooms, reception).
  • Remember to ask for a contact and contact number for the LPHU. In high case load environments, Tier 1 sites may be managed by LPHUs outside of their catchment.
  • Staff may be need to be furloughed for 14 days (the LPHU will provide information about testing and isolation requirements).
  • Practices will need to close for deep cleaning (the LPHU will provide information on cleaning requirements). Rebates covering 80 per cent of the cleaning costs up to $10,000 per site are available for eligible small to medium-sized businesses, including general practices.
  • Practices will need a certificate for deep cleaning to be sent to the LPHU.

Once the above process is complete, the LPHU will confirm when the practice can reopen.

Process for practices that become Tier 1 exposure sites

  • Ensure your practice manager is notified.
  • Pivot to your working from home plan as above.
  • Have staff in self-isolation triage and conduct telehealth consultations remotely.
  • Ensure that all areas that the positive case has been in contact with have been cleaned as per the infection control guidelines.
  • If a practice is required to close for cleaning, consider cold chain requirements for vaccination stock.
  • Report to WorkSafe Victoria within 48 hours if the positive case(s) involves an owner, staff member or contractor.

Review after the event

It is good practice after any critical event to review processes, celebrate what went well, and review and make changes to anything that didn’t go so well. This gives you an opportunity to improve policies and processes, update staff training and respond better in future.

Resources HealthPathways Melbourne logo

 Infection Prevention Helpline

 Health Pathways Melbourne

 Victorian Government