Prevention of COVID-19 transmission in the healthcare setting
Revision as of 12:49, 21 March 2020 by Rossdonaldson1 (talk | contribs) (→COVID-19 PPE Summary Table)
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
- Face mask
- Gloves and gown
- Negative pressure room preferred, 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
PPE Guidelines
- EVERY PATIENT CONTACT: Respiratory droplet precautions. Contact precautions also recommended but if gowns in short supply consider reserving for aerosol-generating procedures
- Droplet = surgical mask, eye protection
- Contact = gown and gloves
- 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):
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
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/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
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