The Right Way to Start Your Audiology Clinic in the UK

Starting up Audiology clinics again after lockdown is tricky, things just aren’t the same and likely never will be again. We have written this article to help you understand the most recent guidance given by related professional bodies and how this will apply to your clinics. We also give our experience of doing this and what we have found. In this article, where possible we direct you to evidence base, research and resources to help you on your way.

COVID-19 guidance on Audiology services is rapidly evolving as we learn more. There has been a number of guidance documents released by Audiology professional bodies and ENT UK. In this article we will be looking at the most recent guidance to help Audiologists run clinics and include our experience from running clinics during this pandemic.

The main documents we will be referring to are Audiology & Otology guidance during Covid-19 released 1 June 2020 (UK A.P.B., 2020) released jointly by Audiology Professional bodies and Graduated Return to Elective ENT Within the COVID-19 Pandemic released 25^th May by ENT UK (ENT UK, 2020). These updated documents replace previous guidance given by these organisations and try to give a united front on guidance to Audiology professionals.

Audiology in the UK is recognised as an essential service in the UK, and as such can continue through the COVID-19 pandemic (A.P.B. et al, 2020) according to appropriate safety measures and practices being in place which will be outlined in this article.

Digital first Approach

This is a nice term for referring to everything but face to face appointments. This could be using telephone, video streaming, email and other forms of digital mediums for contacting patients. Even instruction videos come under this and can be very useful to email patients.

Remote fitting and testing is now available through a lot of the manufacturers mostly with RITE aids but with limitations. We are currently writing an article on this approach. Register for our news letter and be the first to read this.

Our Experience: After triaging repairs by phone we have been getting patients to post their repairs direct to the manufacturers who return the repaired aids directly to the patient. Initial consultations have also worked well for us over Skype.

Face to face appointments

Should only be made when there is clinical need that cannot be met by the digital first approach and when you are clinically and operationally ready to operate safely in this new COVID environment.

These patients need to be screened for COVID at the point of booking with the following questions:

Do you or anyone in your household:

1. have coronavirus?
2. have a new, continuous cough?
3. have a high temperature (37.8oC or over)?
4. have a loss or change to your sense of smell or taste?

Our Experience: We have found it effective to screen using this criteria at point of booking and at the point of collecting the patient for their appointment. With reminders being sent out with email and text appointment reminders.

Our Experience: Initially we had been calling all our patients up the day before their appointments as well but this proved to be infective for 2 reasons, first we generally only got hold of about ¾ of the patients, secondly as clinics started getting busier it became too much to do.

In these appointments social distancing should be maintained (2 metres distance from your patient). This distance guards you form speech generate airborne droplets. Waiting rooms and clinic room seating need organised accordingly.

When within 2 metres of the patient appropriate PPE needs to be worn (see section below for details on this)

It’s interesting to note that ENT UK (2020) recognise that the external ear canal is not virus bearing, thus there is no evidence to say COVID can be transmitted via wax in a normal ear but could in someone with a perforated tympanic membrane (TM) especially if wet. However, in general you don’t know until you look. 

Time for appointments

We have found that appointment lengths have needed to be increased in general but only by 5-7 minutes to accommodate donning & doffing PPE during appointments and wiping down all the surfaces with alcohol based wipes, including computer keyboard and equipment used (which was done before anyway).

What is appropriate PPE for Audiology

This depends on the procedure being performed with Microsuction having the highest associated risks.

In general, it is recommended that all patients wear face masks to/during their appointments, ENT UK made reference to suitable face coverings being acceptable also.

Our Experience: In practical terms not everyone has masks and some forget, what we have done is when collecting the patient for their appointment from outside the clinic we have taken spare masks for the patient to put on and use.

Otoscopy

The Audiologist must wear IIR fluid resistant face mask or higher specification (FFP2/FFP3 or equivalent) and the patient needs to wear a face mask where possible. UK A.P.B. (2020) state that disposable gloves, apron and eye protection are optional but I would suggest it would be best practice to wear eye protection as it isn’t intrusive for the audiologist and is effective at protecting against COVID infection via this path.

It also makes sense to use video otoscopy where possible as an alternative to the usually otoscope. This creates extra distance between you and the patient.

PTA, Tymp, REMs, impression taking, fitting hearing aids and other similar procedures

For these procedures use the same PPE as for Otoscopy.

Microsuction for wax removal

The Audiologist needs to wear full PPE which in this case means face mask, disposable gloves, apron and eye protection. This could also include an appropriate face shield designed for wearing over medical loupes.

Our Experience: Naturally the people we see have difficulty hearing, so when you put a face mask on for some patients it makes it impossible for them to hear you. In these instances we have used a face shield instead if needing to be within 2 metres of the patient.

There are some points to make on this:

• Don’t use fenestrated suction tips (the ones with a hole in the handle to give pressure control) as these can generate aerosols. 
• Eye protection depends on what you are using in the way of vision, Loupes are generally attached on to safety glasses anyway so fit close to the face to give a certain degree of protection against aerosols. Surgical microscope, you need to wear eye protection but this may prove a bit tricky if you wear the large classic safety googles like you used at school in science so you will need a low profile set of safety glasses that fit close to the head.
• Other methods of vision mentioned in ENT UK (2020) are an endoscope with a remote screen. I’m not aware of a suitable endoscope with a remote screen that actually works for this procedure. I was trained in a system but personally found it unsuitable for this procedure.
• Cleaning loupes between patient can be tricky and timely. Using a face shield while performing the procedure will circumvent this issue. You can easily dispose of the shield after each patient or if it is reusable just wipe it. You can get loupes with face shields incorporated into them which work very well.
• Suction pumps exhausts must be filtered (air coming out of pump is filtered) and filters need to be changed regularly.

While this procedure is not classed as an Aerosol Generating Procedure (AGP), it can generate aerosols if the ear is wet which could be due to eardrops or infection. The real issue is if it is due to a moist perforation, then it could expose you to respiratory secretions. If there is a blockage obscuring the view of the TM (which there always is) then you won’t know until it is removed. The short of it is in my opinion you need to wear an FFP2 or FFP3 face mask or equivalent and face shield ideally is also part of your full PPE.

Domiciliary visits

These are tricky and as a temporary measure we have suspended our domiciliary services. But if you are just domiciliary based you don’t have many options. UK A.P.B. (2020) advise that domiciliary appointments should only be carried out if you really have to and there is no other option

• Not much point in the patient wearing a face mask in this setting.
• Wear full PPE
• PPE should be donned before entering the home. It is advisable to let the patient know this before the appointment or they may be a little shocked to see you.
• The documents states that PPE should be doffed before leaving the home, but it seems to make more sense to do this when out of the home.
• Used PPE is to be placed in a disposable waste bag, knotted, and then this bag placed inside a 2nd waste bag to also be tied securely. These bags should be left at the home but requested to be kept separate from other waste and put aside for at least 72 hours before being put in the usual household waste bin.
• All equipment needs to be cleaned before putting them in the car

Keep the patients informed

Given the heightened anxiety of many patients around COVID, we have found it very important to inform patients when we will be coming closer than 2 metres, why and letting them know when we don and doff PPE.

Problems with PPE

Problems you may notice with PPE at the moment is that everything is in short supply and due to this prices have gone up.

In addition, it is just really hard to get hold of everything you need. Supplies Hear is the only specialist supplier that understands all your requirements for PPE and has all the PPE you need in stock. What’s more all the PPE sold has already been tried and testing in Audiology clinics.

PPE’s Done and Doffing

Before using PPE you will need to go through some simple training on how to Done and Doff your PPE. You need to also remember that this should be done while at least 2 metres away from patient.

Hand Hygiene

Is the overriding principal of infection control. All audiologists must understand how to wash their hands correctly and when to use hand sanitising gel. As a simple rule to go by for this is hand sanitiser isn’t suitable to be used when hands are visibly dirty or it has been applied 5 times already, in which case your hands need to be washed. Hands must be washed/sanitised after every patient contact.

The documents state no clothes below the elbow (not to be confused with below the waist) making reference to the NHS standard of bare below the elbow policy in place in all medical settings.

Disinfecting surfaces

It is recommended to use alcohol-based disinfectant wipes (ethanol, propan-2-ol, propan1-ol) in concentrations of 70-80%, this has been proven to effectively kill viral spores such as those from COVID 19. If this is not possible, disinfection spray with paper towels can be used.

Things you should know about face masks

Fit is everything

It may sound obvious but face masks are only affective if they are put on correctly, so training needs to be given. Also, when using FFP2/3 masks fit tests should be performed where possible. The easiest way to do this is to get a specialist in to perform these for you.

Single use

Can be used continually for a whole clinic but if you touch it or take it off for any reason it must be disposed of and a new one worn. Because of this it would be good practice to dispose of masks after each patient.

Ratings and standards

There are a number of rating for Masks you may find floating around that indicate it filteration capacity, in general, the higher the number the better they are.

An FFP mask (“Filtering Face piece Particles”) is an individual respirator protection mask. Wearing this type of mask is more restrictive than a surgical mask (heat-related discomfort, breathing resistance), but it protects from inhaling infectious pathogens. These are available with and without exhaling valve however ENT UK (2020) have advised against valved masks, as the air exhaled is not filtered.

FFP1/2/3 are European standard N95 are American and KN95 is the Chinese standard.

The HSE has verified that the FFP2/N95/KN95 are all of comparable filtration standard. These are suitable for AGP procedures.

• FFP1 masks which filter at least 80% of aerosols (inward leakage < 22%);
• FFP2 masks which filter at least 94% of aerosols (inward leakage < 8%);
• FFP3 masks which filter at least 99% of aerosols (inward leakage < 2%).

A surgical mask is a medical equipment and are designed to prevent the wearer from spreading droplets in the vicinity. It also protects the wearer from droplets produced by a person directly in front of them. However, depending on the circumstances, it does not protect from inhaling the very small particles suspended in the air that potentially carry the virus.

• Type I: bacteria filtering effectiveness > 95%.
• Type II: bacteria filtering effectiveness > 98%.
• Type IIR: bacteria filtering effectiveness > 98% and splash-resistant.

Type IIR are recommend for general Audiology use (UK A.P.B., 2020)

How often can PPE to be used

• Gloves – disposable – 1 pair per clinical activity
• Face mask – disposable – 1 to be used for each clinic, but if touched or taken off must be disposed of and a new one worn
• Apron – disposable – 1 per clinical activity
• Safety Glasses – reusable – to be cleaned after each clinical activity 
• Loupes – reusable – to be cleaned after each clinical activity
• Face Shield – disposable – 1 per clinical activity some. The standard face masks don’t fit with loupes. You can purchase loupes with face shield attachments on or specially made face shields that will accommodate loupes.

Disposal of PPE 

• In clinical waste bin / in line with local policy
• Or double bagged then taken home and put aside for at least 72 hours before being put in the usual household waste bin.

Uniform

This is very often over looked but is very important. Clothes worn during clinics should be changed out of at the end of your clinic before going home, then put in the washer machine straight away when you get home. This should be washed separately from other clothes at 60°C.