Prevention of COVID-19 transmission in the healthcare setting

See COVID-19 for main article

Background

COVID-19 PPE Summary Table

Example summary flow chart for determining PPE use














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

Template:COVID epidemiology

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

Hand Hygiene.png
  • 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!

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

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

External Links

Video

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References