Skip to main content

Table 1 Procedural changes: Uniting Medically Supervised Injecting Centre (MSIC) and North Richmond Community Health Medically Supervised Injecting Room (MSIR)

From: Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia

MSIC MSIR
Screening—clients and staff
Screening (including travel history, symptoms and temperature) of all clients entering the service. Symptomatic clients were assessed and referred for testing. All MSIC staff similarly screened Screening (including travel history, symptoms and temperature) of all clients entering the service. Symptomatic clients tested onsite (asymptomatic clients tested periodically as per state directives). Installation of a mass fever screening system. All MSIR staff similarly screened
Exclusion from the service—clients and staff
Exclusion criteria: Returned from international travel in preceding 14 days (MSIC and MSIR); considered a close contact because visited specified COVID-19 hotspots in preceding 14 days (MSIC only); any known exposure to the virus in the preceding 14 days (MSIC and MSIR); MSIR clients with unexplained fever, or fever and COVID-19 symptoms. From 22 July, MSIR clients not agreeing to wear a mask not permitted entry (masks provided onsite)
Physical distancing and other changes within the services—clients and staff
Overall—MSIC staff to remain 1.5 m distance from clients while they are using the service except in case of emergency. All client-facing staff to wear personal protective equipment (PPE) in clinical areas (as below). Hourly cleaning of clinical areas. Encouraging client time spent in the service to be less than one hour, unless they require monitoring due to decreased level of consciousness or post-overdose Overall—MSIR staff to remain 1.5 m distance from clients while they are using the service except in case of emergency. All client-facing staff to wear PPE in clinical areas (as below). Hourly cleaning of clinical areas. Air conditioning settings changed and air purifiers with HEPA filters in all client areas. Implementation of a support role to guide clients through service and procedural changes. Encouraging clients to reduce time spent in the service and exit as soon as safe to do so
Registration area—Controlling entry through the door, reducing number of clients in this area to a maximum of three, and two staff to comply with capacity per square metre and physical distancing, barriers placed at the registration desk. MSIC staff to wear surgical masks and protective eyewear in this area Registration area—Controlling entry through the door, reducing number of clients in this area to a maximum of six (four MSIR and two NSP/clinic clients) to comply with capacity per square metre and physical distancing. MSIR staff to wear N95 masks, face shields, gloves and gowns in this area
Injecting area—Making each booth single person only, with the option for two double booths and a maximum of 12 clients from 7 July. All MSIC staff to wear N95 masks and protective eyewear in this area Injecting area—Closing every 2nd booth (reducing injecting positions from 20 to 13). Limiting vein care to less than 15 min. All MSIR staff to wear N95 masks, faces shields, gloves and gowns in this area
Aftercare area—Reduced seating available in this area. Refreshments removed. Promotion of opioid agonist treatment (OAT) referral options and take-home naloxone (THN) with training encouraged for all clients. Limiting time clients spend in aftercare area. Collection of feedback from clients on changes in service provision during COVID-19. All MSIC staff to wear surgical masks and protective eyewear in this area Aftercare area—Reduced seating available in this area. Refreshments removed. Offering clients OAT, overdose/THN training and nicotine replacement therapy (NRT). Limiting time clients spend in aftercare area. All MSIR staff to wear N95 masks, face shields, gloves and gowns in this area
Overdose response
All MSIC staff to wear full PPE—gown, face shield, N95 mask and gloves when responding to an overdose that may require bag valve mask (BVM) resuscitation. All MSIC staff responding to an overdose with oxygen only are required to wear N95 masks and protective eyewear—no gown or gloves are required for these responses All MSIR staff to wear full PPE (gown, full face shield, N95 mask and gloves) when responding to an overdose. Implementation of a scribe at MSIR to record observations and support staff with communication
MSIC changed first response to overdose: ceased BVM resuscitation for clients who are apnoeic (not breathing) due to aerosolization risk. Replaced by immediate naloxone administration (below) MSIR changed first response to overdose: oxygen flow limited to 6 l/min, use of non-rebreather masks if 6 l/min with a Hudson mask is not sufficient. No nebulising medication administered. Severe overdoses moved to (enclosed) medical monitoring room using evacuation slide sheet and crash mat for response, which may include ventilatory support
Naloxone (800 mcg IMI) administered immediately for apnoeic clients, in place of BVM—repeat in 2 to 3 min as necessary Naloxone (1200 mcg IMI) administered immediately for apnoeic clients (800 mcg IMI if some breathing but less than 5 breaths per minute)
Commence BVM only if client not responsive to naloxone Commence BVM in enclosed medical monitoring room using two-handed vice grip on the mask to reduce aerosolization risk
Reduction in oxygen flow to 6 l/min when administering oxygen through Hudson mask, due to aerosolization risk. Staff encouraged to turn oxygen off before removing Hudson mask to reduce any slight risk of aerosolization Reduction in oxygen flow to 6 l/min using non-rebreather mask if required
Tracking and testing—clients and staff
Facilitated access to COVID-19 swab testing COVID-19 swab testing onsite
Tracking register implemented for staff onsite—record of risk exposure (e.g. responded to overdose) absences, COVID tests and results
“Stage Log” for all MSIC staff, documenting time in and time out of each stage during working shift. Also in staff kitchen area where staff have breaks
MSIC management team seating changed so that alternative teams placed in different ‘air space’ to reduce contact and transmission risk. Shift patterns of front-line staff unable to be altered due to smaller staff numbers
MSIR staff movements recorded through the service to assist with contact tracing, if necessary. Activation of the COVIDsafe app on two service phones to facilitate contract tracing
MSIR has onsite CCTV (since inception) (not available at MSIC)
MSIR staff divided into teams to further reduce contact between staff and limit number of contacts in the event of a confirmed case. Shift patterns altered to reduce staff crossover
  MSIR recommissioned a consulting room in the Registration area as a ‘single occupant/single use’ alternative injecting and aftercare area for clients who meet COVID-19 testing criteria and who agree to an onsite test. This is an additional mechanism to support COVID-19 testing, self-isolation and isolation planning, and reduce risks of transmission due to non-disclosure/masking of COVID-19 symptoms
Education about virus transmission risks—clients and staff
At least weekly briefings with clinical staff about implementation of and changes to procedures in relation to COVID-19 and transmission risks. Informal audits done on donning and doffing of PPE and reminders about mask hygiene. Weekly teleconferences between the MSIC and MSIR to discuss ongoing response and procedural changes. Specific COVID-19 pandemic training undertaken by MSIR staff
Educational material about the virus, including local harm reduction messages, about the importance of hand hygiene, cough etiquette, physical distancing and testing placed throughout all service and office areas. Conversations with clients occurring daily as part of service provision. Ongoing monitoring of adherence to COVID-19 government directives
Ancillary services support—clients
Facilitating access to temporary accommodation Facilitating access to short-term accommodation through co-located onsite housing officer. Facilitating access to telehealth, including drug treatment services, income support and legal services
Promotion of referral options for OAT Providing onsite OAT (i.e. long-acting injectable buprenorphine), and as part of a COVID-19 outreach service for clients in short-term accommodation
Mental health support provided by specialist onsite mental health clinicians
Advocacy in relation to legal issues arising (e.g. policing of COVID-19 restrictions) through lockdown periods
  1. The MSIC and MSIR differ in terms of service location, and overall service structure. The MSIR is a programme of North Richmond Community Health (NRCH), a community health provider. NRCH and partner organisations provide co-located health and social support services in addition to the supervised injecting facility. In contrast, MSIC is a standalone supervised injecting facility