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| ''See [[COVID-19]] for main article''
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| ==Background==
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| {{COVID PPE summary table}} | | {{COVID PPE summary table}} |
| {{COVID virology}}
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| {{COVID epidemiology}}
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|
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| === Transmission ===
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| * Simply walking into a room is NOT a recognized risk of transmission. Must make contact with respiratory droplet (directly or indirectly)
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| * Masks: MOST IMPORTANT utility is to put on the coughing individual
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| ** Research clearly demonstrates it decreases shedding of infectious material in the environment
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| ** This is more effective than HCWs wearing masks prophylactically to prevent catching the infection when not actually performing close contact patient care
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| * How long to shut a patient room down after a COVID patient is in there?
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| ** 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
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| ** 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)
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| *** Most modern rooms designed to have 12 air exchanges per hour
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| *** Ventilation symptoms vary. So, older / fewer exchanges per hour => more time.
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| ===Isolation===
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| * 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.
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| * CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
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| ==General Measures==
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| [[File:Hand Hygiene.png|thumb|]]
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| * Exercise general infection precautions
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| *Person-to-person transmission occurs with close contact (6 feet)
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| *'''Direct Transmission:''' contact with mucous membranes or respiratory droplets
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| *'''Indirect Transmission:''' cough —> secretions left on surface —> 2nd person touches surface secretions and touches face & mucous membranes
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| *'''Hygiene General Recommendations'''
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| ** Avoid touching your face
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| ** Frequent Handwashing
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| **Alcohol based hand sanitizer
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| **Diligent hand wasing
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| **20 seconds minimum
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| **Image shows commonly forgotten areas: thumb (ulnar aspect), fingertips, WRIST (Borrowed from WHO Hand Hygiene for Healthcare)
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| ** Wear a mask if you develop respiratory symptoms (fever, cough, rhinorrhea, congestion) to prevent spread
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| **Avoid unnecessary travel
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| **Stay home if symptomatic
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| ** Home care does not mean being out in the parks with other groups of people
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| ** Contact your supervisor: due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
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| ==Contact with Patients at Risk/Persons Under Investigation==
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| ===Recommended PPE===
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| ''Contact and droplet precautions including eye protection''
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| *Face mask
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| *Gloves and gown
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| *Negative pressure room preferred, but not required
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|
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| ;See video below indicates the proper order for donning and doffing PPE for clinical evaluation of a patient
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| ===Patients and Procedures Included in this Category===
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| *General care of PUI patients
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| *Collection of nasopharyngeal swab specimens
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| === PPE Guidelines ===
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| * EVERY PATIENT CONTACT: Respiratory droplet precautions. Contact precautions also recommended but if gowns in short supply consider reserving for aerosol-generating procedures
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| ** Droplet = surgical mask, eye protection
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| ** Contact = gown and gloves
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| * For AEROSOL GENERATING procedures: airborne precautions (N95/PAPR)
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| ** Due to higher risk of aerosolizing droplets-- infection itself doesn’t seem to be spread via airborne route)
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| ** Aerosol generating procedures (avoid when possible)
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| *** Bag-valve mask (BMV)
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| *** CPAP/BiPAP
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| *** Intubation
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| *** Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
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| *** Bronchoscopy
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| *** Chest PT
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| ** Technique:
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| *** Mask donning (often incorrectly done):
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| **** Wash hands BEFORE touching mask
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| **** Grip mask by loops/bands/ties only
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| **** Coloured portion typically faces outward
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| **** Mold / pinch the stiff edge to the shape of your nose
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| **** Pull the bottom of the mask over your mouth AND chin
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| **** Make sure you are up to date with fit testing
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| *** Mask removal:
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| **** Wash hands BEFORE touching mask
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| **** Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF!
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| ==Aerosol-Generating Procedures== | | ==Aerosol-Generating Procedures== |
| ''Contact and aerosol precautions including eye protection'' | | ''Due to higher risk of aerosolizing droplets; infection itself doesn’t seem to be spread via airborne route'' |
| ===Recommended PPE===
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| *N95 or PAPR
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| *Surgical Mask over N95
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| *Goggles that surround eyes with facial contact, face shield, or full joint-replacement-hood with visor
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| *Bunny suit, preferably with hood or disposable fluid-proof gown
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| **If no hooded suit available, sterile disposable cap
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| *2 pairs gloves, 1 under sleeves of bunny suit or gown and 1 over, under-layer gloves would ideally be long cuffed
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| *Negative pressure room required
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| ===Procedures Generating Aerosol=== | | ===Recommended Provider PPE=== |
| *[[Intubation]]
| | ''Contact (including eye protection) and airborne precautions'' |
| *[[BiPAP]]
| | *N95 mask or higher-level respirator (e.g. PAPR), plus eye protection, gloves, and gown<ref>https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html#take_precautions</ref> |
| *Nebulized medications (e.g. albuterol nebs) | | **Consider head coverage: sterile disposable cap with gown or bunny suit |
| *[[BVM]] | | **Consider two pairs gloves, one under sleeves of gown and one over |
| | **Consider shoe covers |
| | **Consider buddy system for donning/doffing |
| | ***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 |
| | *Negative pressure room required, if at all possible |
| | *Limit personnel in room to only those essential for patient care |
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| ===Specific Considerations During Intubation=== | | ====Mask Use Technique==== |
| * High risk procedure for aeresolization | | * Mask donning (often incorrectly done): |
| ** Patient ideally in negative pressure room. Limit individuals in room to essential staff only. | | ** Wash hands BEFORE touching mask |
| ** PPE for all in room: N95, gown, gloves, eye shield | | ** Grip mask by loops/bands/ties only |
| ** Minimum PPE for provider intubating: same as above (N95, gown, gloves, eye shield) | | ** Coloured portion typically faces outward |
| ** Optional PPE for provider intubating: PAPR, double glove, double gown, shoe covers, buddy system for donning/doffing | | ** Mold / pinch the stiff edge to the shape of your nose |
| * Use BVM with viral filter | | ** Pull the bottom of the mask over your mouth AND chin |
| * Use sufficient paralytics to prevent coughing gagging | | ** Make sure you are up to date with fit testing |
| * Most experienced provider should perform intubation. | | * Mask removal: |
| * Ventilate using [[EBQ:ARDSnet_Trial |ARDSnet protocol]] | | ** Wash hands BEFORE touching mask |
| | ** Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF! |
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| | | ===Aerosol-generating procedures list=== |
| | | ''Avoid these procedures when possible'' |
| *Intubate early, use VL so you’re face is further away. Clean VL with grey wipes, observe 3 min wet time
| | * [[Bag-valve-mask]] (BVM) |
| *Avoid BiPAP, high flow nasal cannula (HFNC), nebulizers
| | * CPAP/[[BiPAP]] |
| **Use MDI/spacer instead of nebs
| | * [[Intubation]] |
| **If needed HFNC with surgical mask over patient is preferred over BiPAP
| | * Nebulizer administration (if possible, use MDI instead) |
| *Use viral filter on BVM/ETT, vent or BiPAP. RT is stocking then with our BVMs. Have already been on our vents and BiPAP.
| | * Bronchoscopy |
| *When intubating patients, for any unclear cases, wear N95, face shield, gown and gloves
| | * Chest PT |
| **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
| | *[[Oxygen therapy|High-Flow Nasal Cannula]] |
| **Pre-oxygenate with NRB and use apneic nasal cannula during intubation. | |
| **Avoid using bag-valve-mask if possible
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| ***Only bag patient after cuff on ETT is inflated
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| **RSI to ensure paralysis. Consider higher range of dosing of paralytic to avoid patient coughing.
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| ==PPE Shortage/Limiting Usage Guidelines==
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| In case of PPE shortage or in an attempt to save on PPE supplies, the following guidelines were approved by CDC 3/13/20
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| * 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:
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| * 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.
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| ** Based on non peer reviewed reports from Washington State
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| ==See Also== | | ==See Also== |
| {{COVID see also}} | | {{Special:Prefixindex/COVID-19 |hideredirects=1}} |
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| ==External Links== | | ==External Links== |
| | *[https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html Main CDC Guidance for Infection Prevention and Control in Healthcare Setting] |
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| ==Video== | | ==Video== |
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| ==References== | | ==References== |
| <references/> | | <references/> |
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| | [[Category:ID]] |
| | [[Category:COVID-19]] |