Prevention of COVID-19 transmission in the healthcare setting
Revisión del 13:01 21 mar 2020 de Rossdonaldson1 (discusión | contribs.) (→Contact with Patients at Risk/Persons Under Investigation)
See COVID-19 for main article
Background
COVID-19 PPE Summary Table
| Contact Category | Precations | Room Type |
| General (all persons) | Social distancing; meticulous hygiene; basic mask | NA |
| Undifferentiated patients at risk (e.g. prior to evaluation or testing) | Contact and droplet precautions, including eye protection | Negative-pressure NOT required |
| Persons Under Investigation | Contact and droplet precautions, including eye protection | Negative-pressure NOT required |
| Aerosol-Generating Procedures | Contact and airborne precautions, including eye protection | Negative-pressure required |
See prevention of COVID-19 transmission in the healthcare setting for full PPE recommendations
Transmission
- Simply walking into a room is NOT a recognized risk of transmission. Must make contact with respiratory droplet (directly or indirectly)
- Masks: MOST IMPORTANT utility is to put on the coughing individual
- Research clearly demonstrates it decreases shedding of infectious material in the environment
- This is more effective than HCWs wearing masks prophylactically to prevent catching the infection when not actually performing close contact patient care
- How long to shut a patient room down after a COVID patient is in there?
- It’s not about the risk of contracting the infection but about the ability to clean room safely without respiratory protection precautions by the cleaner
- 30-40 minutes usually sufficient (for most modern facilities) as long as no aerosol-generating procedure performed (longer, time not clearly stated at this time)
- Most modern rooms designed to have 12 air exchanges per hour
- Ventilation symptoms vary. So, older / fewer exchanges per hour => more time.
Isolation
- Persons diagnosed with COVID-19 are considered cleared after 14 days from symptom onset or 3 days after resolution of fever and improvement of other symptoms, whichever is longer.
- CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
General Measures
- Exercise general infection precautions
- Person-to-person transmission occurs with close contact (6 feet)
- Direct Transmission: contact with mucous membranes or respiratory droplets
- Indirect Transmission: cough —> secretions left on surface —> 2nd person touches surface secretions and touches face & mucous membranes
- Hygiene General Recommendations
- Avoid touching your face
- Frequent Handwashing
- Alcohol based hand sanitizer
- Diligent hand wasing
- 20 seconds minimum
- Image shows commonly forgotten areas: thumb (ulnar aspect), fingertips, WRIST (Borrowed from WHO Hand Hygiene for Healthcare)
- Wear a mask if you develop respiratory symptoms (fever, cough, rhinorrhea, congestion) to prevent spread
- Avoid unnecessary travel
- Stay home if symptomatic
- Home care does not mean being out in the parks with other groups of people
- Contact your supervisor: due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
Contact with Patients at Risk/Persons Under Investigation
Recommended PPE
Contact and droplet precautions including eye protection
- Droplet = surgical mask, eye protection
- Contact = gown and gloves
- If gowns in short supply, consider reserving for PUIs and/or aerosol-generating procedures
- Negative pressure room preferred may be prefered for PUIs, but not required
- See video below indicates the proper order for donning and doffing PPE for clinical evaluation of a patient
Patients and Procedures Included in this Category
- General care of PUI patients
- Collection of nasopharyngeal swab specimens
Aerosol-Generating Procedures
Contact and aerosol precautions including eye protection
Recommended PPE
- N95 or PAPR
- Surgical Mask over N95
- Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor
- Bunny suit, preferably with hood or disposable fluid-proof gown
- If no hooded suit available, sterile disposable cap
- 2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
- Negative pressure room required
- For AEROSOL GENERATING procedures: airborne precautions (N95/PAPR)
- Due to higher risk of aerosolizing droplets-- infection itself doesn’t seem to be spread via airborne route)
- Aerosol generating procedures (avoid when possible)
- Bag-valve mask (BMV)
- CPAP/BiPAP
- Intubation
- Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
- Bronchoscopy
- Chest PT
- Technique:
- Mask donning (often incorrectly done):
- Wash hands BEFORE touching mask
- Grip mask by loops/bands/ties only
- Coloured portion typically faces outward
- Mold / pinch the stiff edge to the shape of your nose
- Pull the bottom of the mask over your mouth AND chin
- Make sure you are up to date with fit testing
- Mask removal:
- Wash hands BEFORE touching mask
- Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF!
- Mask donning (often incorrectly done):
Procedures Generating Aerosol
- Intubation
- BiPAP
- Nebulized medications (e.g. albuterol nebs)
- BVM
Specific Considerations During Intubation
- High risk procedure for aeresolization
- Patient ideally in negative pressure room. Limit individuals in room to essential staff only.
- PPE for all in room: N95, gown, gloves, eye shield
- Minimum PPE for provider intubating: same as above (N95, gown, gloves, eye shield)
- Optional PPE for provider intubating: PAPR, double glove, double gown, shoe covers, buddy system for donning/doffing
- Use BVM with viral filter
- Use sufficient paralytics to prevent coughing gagging
- Most experienced provider should perform intubation.
- Ventilate using ARDSnet protocol
- Intubate early, use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
- Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
- Use MDI/spacer instead of nebs
- If needed HFNC with surgical mask over patient is preferred over BiPAP
- Use viral filter on BVM/ETT, vent or BiPAP. RT is stocking then with our BVMs. Have already been on our vents and BiPAP.
- When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
- If using PAPR, then need pre-assigned RN outside the room to help decontaminate it by wiping it down with purple wipes before you take it off
- Pre-oxygenate with NRB and use apneic nasal cannula during intubation.
- Avoid using bag-valve-mask if possible
- Only bag patient after cuff on ETT is inflated
- RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
PPE Shortage and Limiting Usage Guidelines
In case of PPE shortage or in an attempt to save on PPE supplies, the following guidelines were approved by CDC 3/13/20
- Same respirator can be worn for multiple serial patient contacts (e.g. in between successive COVID/PUI (patients under investigation) without exchanging respirator. Therefore, in between each patient:
- No need to change mask or eye protection
- BUT need to change gown and gloves
- Respirator reuse possible? Higher risk because of having to touch the mask and either self-inoculate or transmit to another patient (e.g. wear it for a patient, then you remove, and then you put it back on)
- If you must do this because of limited supplies, don and doff properly and perform proper hand hygiene in between
- CDC / NIOSH will allow certain N95s to be used beyond manufacture-designated shelf life
- See list of appropriate models here (manufactured between 2003-2013)
- N95 Reuse? Probably okay to re-use same N95 during an 8 hour shift as long as no tears or visible contamination. Store facedown in labeled re-sealable bag/container.
- Based on non peer reviewed reports from Washington State
See Also
COVID-19 Pages
- COVID-19 (main)
External Links
Video
{{#widget:YouTube|id=exV5hEG62CY}}