Charles is Section Chief at a psychiatric hospital and a lover of all things adventure. He is glad to be alive and can't wait for tomorrow!
Coronavirus vs. Hospital
As a team member in a 400-bed hospital, recent news of the outbreak has caused concern for our leadership and our staff/patient population.
I will try to summarize the impact of one positive case of COVID 19 in a hospital setting and provide a step-by-step preparedness plan for a hospital that may not fully understand what is needed to provide a safe environment.
What is COVID-19?
According to the CDC, COVID-19 is a respiratory illness that can spread from person to person. The virus that causes COVID-19 is a novel coronavirus that was first identified during an investigation into an outbreak in Wuhan, China.
Healthcare Preparedness: Personal Protective Equipment
The initial consideration for a Healthcare provider should be Personal Protective Equipment, (PPE). To provide effective care, staff and patients must protect themselves from potential exposure.
To meet this critical requirement, the following PPE is required for healthcare staff: NIOSH-approved N95 respirators, gowns, gloves, face shield/eye protection, etc. This includes, but is not limited to, surgical N95 respirators.
The following PPE is recommended for patients with confirmed or suspected COVID 19 infection: facemask when being evaluated medically.
For healthcare activities with low, medium, or high risk of contamination, surgical gowns can be used. These gowns are intended to be worn by healthcare personnel during surgical procedures.
If the risk of bodily fluid exposure is low or minimal, gowns that claim minimal or low levels of barrier protection can be used.
These gowns should not be worn during surgical or invasive procedures, or for medium to high-risk contamination patient care activities.
Face Shield/Eye Protection
Appropriately fitted, indirectly vented goggles* with a manufacturer’s anti-fog coating provide the most reliable practical eye protection from splashes, sprays, and respiratory droplets.
Newer styles of goggles may provide better indirect airflow properties to reduce fogging, as well as better peripheral vision and more size options for fitting goggles to different workers. Many styles of goggles fit adequately over prescription glasses with minimal gaps. However, to be efficacious, goggles must fit snugly, particularly from the corners of the eye across the brow.
While highly effective as eye protection, goggles do not provide splash or spray protection to other parts of the face. Face shields are commonly used as an infection control alternative to goggles. As opposed to goggles, a face shield can also provide protection to other facial areas.
To provide better face and eye protection from splashes and sprays, a face shield should have crown and chin protection and wrap around the face to the point of the ear, which reduces the likelihood that a splash could go around the edge of the shield and reach the eyes.
Disposable face shields for medical personnel made of lightweight films that are attached to a surgical mask or fit loosely around the face should not be relied upon as optimal protection
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* Directly vented goggles may allow penetration by splashes or sprays; therefore, indirectly vented or non-vented goggles are preferred for infection control.
Nonsterile disposable patient examination gloves, which are used for routine patient care in healthcare settings, are appropriate for the care of patients with suspected or confirmed COVID-19.
- The American Society for Testing and Materials (ASTM) external icon has developed standards for patient examination gloves.
- The ASTM has developed standards for patient examination gloves.
- Length requirements for patient exam gloves must be a minimum of 220mm-230mm depending on glove size and material type.
A respirator is a personal protective device that is worn on the face or head and covers at least the nose and mouth. A respirator is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including infectious agents), gases, or vapors.
- Respirators, including those intended for use in healthcare settings, are certified by the CDC/NIOSH. N95 respirators reduce the wearer’s exposure to airborne particles, from small particle aerosols to large droplets. N95 respirators are tight-fitting respirators that filter out at least 95% of particles in the air, including large and small particles.
- Not everyone is able to wear a respirator due to medical conditions that may be made worse when breathing through a respirator. Before using a respirator or getting fit-tested, workers must have a medical evaluation to make sure that they are able to wear a respirator safely.
- Achieving an adequate seal to the face is essential. United States regulations require that workers undergo an annual fit test and conduct a user seal check each time the respirator is used. Workers must pass a fit test to confirm a proper seal before using a respirator in the workplace.
- When properly fitted and worn, minimal leakage occurs around the edges of the respirator when the user inhales. This means almost all the air is directed through the filter media.
Unlike NIOSH-approved N95s, face masks are loose-fitting and provide only barrier protection against droplets, including large respiratory particles.
- No fit testing or seal check is necessary with face masks.
- Most face masks do not effectively filter small particles from the air and do not prevent leakage around the edge of the mask when the user inhales.
- The role of face masks is for patient source control, to prevent contamination of the surrounding area when a person coughs or sneezes. Patients with confirmed or suspected COVID-19 should wear a face mask until they are isolated in a hospital or at home. The patient does not need to wear a face mask while isolated.
Minimize Chances for Exposures
As a healthcare professional, one of the most important things you can do to help others is to help yourself. PPE is tantamount to your ability to stay in the fight. Without PPE your risk for exposure puts you in the position of being exposed and therefore subject to quarantine and unable to help the people that need it most.
When Is Someone Infectious?
The onset and duration of viral shedding and period of infectiousness for COVID-19 are not yet known. It is possible that SARS-CoV-2 RNA may be detectable in the upper or lower respiratory tract for weeks after illness onset, similar to infection with MERS-CoV and SARS-CoV. However, detection of viral RNA does not necessarily mean that an infectious virus is present.
Asymptomatic infection with SARS-CoV-2 has been reported, but it is not yet known what role asymptomatic infection plays in transmission. Similarly, the role of pre-symptomatic transmission (infection detection during the incubation period prior to illness onset) is unknown. Existing literature regarding SARS-CoV-2 and other coronaviruses (e.g. MERS-CoV, SARS-CoV) suggests that the incubation period may range from 2–14 days at the time of this writing.
Which Body Fluids Can Spread Infection?
Very limited data are available about the detection of SARS-CoV-2 and infectious virus in clinical specimens. SARS-CoV-2 RNA has been detected from upper and lower respiratory tract specimens, and SARS-CoV-2 has been isolated from upper respiratory tract specimens and bronchoalveolar lavage fluid. SARS-CoV-2 RNA has been detected in blood and stool specimens, but whether the infectious virus is present in extrapulmonary specimens is currently unknown.
The duration of SARS-CoV-2 RNA detection in upper and lower respiratory tract specimens and in extrapulmonary specimens is not yet known but may be several weeks or longer, which has been observed in cases of MERS-CoV or SARS-CoV infection.
While viable, infectious SARS-CoV has been isolated from respiratory, blood, urine, and stool specimens; in contrast, viable, infectious MERS-CoV has only been isolated from respiratory tract specimens. It is not yet known whether other non-respiratory body fluids from an infected person including vomit, urine, breast milk, or semen can contain viable, infectious SARS-CoV-2.
Preventative Cleaning Measures
Supplies and equipment for environmental cleaning. Essential supplies and equipment for environmental cleaning include:
- Surface cleaning supplies: portable containers (e.g., bottles, small buckets) for storing environmental cleaning products (or solutions) and surface cleaning cloths
- Floor cleaning supplies: mops or cleaning squeegee with floor cloths, buckets, and wet floor/caution signs
In general, all the essential environmental cleaning supplies and equipment are reusable; however, facilities can also choose to use disposable supplies (e.g., cloths) for certain cleaning tasks and/or where resources allow. Cleaning equipment should be appropriate for the intended purpose, cleaned and stored dry between uses, properly used, and well maintained.
Surface Cleaning Supplies
Portable containers for environmental cleaning products (or solutions) should be clean, dry, appropriately sized, labeled, and dated. Narrow necked bottles are preferred over buckets to prevent the "double-dipping" of cleaning cloths, which can contaminate solutions. Squeeze bottles are preferred over spray bottles for applying cleaning or disinfectant solutions directly to cleaning cloths prior to application to a surface.
Surface cleaning cloths should be cotton or microfiber (disposable wipes can be used if resources allow). Have a supply of different colored cloths to allow color-coding: for example, one color for cleaning and a second color for disinfecting. Color-coding also prevents cross-contamination between areas, like from toilets to patient areas, or isolation areas to general patient areas. For example, red cloths could be used specifically for toilet areas, blue for general patient areas, and yellow for isolation areas.
Floor Cleaning Supplies
Mop heads or floor cloths should be cotton or microfiber, and generally, a cart or trolley with two or three buckets should be used for the mopping process—see the preparation of supplies and equipment section (above). It is highly recommended to display a wet floor/caution sign prior to starting mopping activities.
Modern Supplemental Cleaning and Sanitizing Measures
With the introduction of the novel coronavirus into our healthcare system, a surge in potentially infectious staff and patients have filled hospitals to capacity. There are quick turnarounds of patient beds and these must be put back into service quickly.
Alternate Care Sites
When caring for a large population, there may come a time when it is necessary to isolate large numbers of patients. I have included the measures I personally used to create and manage an alternate care site in a hospital setting below. I started by studying and implementing the guidelines provided by the CDC.
Alternate Care Site Example 1
Alternate Care Site Example 2
Initial COVID-19 Diagnosis and Subsequent Client Care
Clients presenting with COVID19 symptoms are removed from their housing units and placed into an isolation ward for testing.
- Clients remain isolated in an individual room pending COVID19 testing results.
- A negative result requires the client to be placed back into his housing unit/ positive results will require the client to be placed in the Alternate Care Site for 14-21-day quarantine and exit testing.
- Prior to arrival at the ACS, the client’s bed and the mattress are sanitized and moved to the ACS prior to the client’s arrival. (Cot’s provided after hours).
- Beds are placed 6’ apart. Partitions were made on-site with PVC pipe and canvas drop cloths.
- The client's clothing is bagged and sent to our in-house laundry facility for an initial cleaning with a high temp (160 degrees) wash and dry then delivered to the client with a hamper.
- Client laundry is picked up from the ACS 3 times a week and returned 3 times a week. Client laundry is kept and laundered in labeled mesh laundry bags.
- A soiled linen cart is provided for bedding and towels.
- A clean linen tent is provided with a HEPA air scrubber.
- Meals are provided by TPH Food Service.
- The client dining area is available in the ACS.
- Entertainment is provided via portable radio cd/players, TV, and DVD mobile carts.
- Coloring books, crayons, board games, DVD’s are available.
- Male and female showers and toilets are available at the ACS.
- Staff entering the ACS must wear full PPE. This is provided at the main entry point
- Doffing and donning of PPE is accomplished in the foyer of the ACS
- PPE consist of face shield/eye protection, KN95/N95 respirator, disposable gown, gloves, and foot coverings
- The ACS has a self-contained dedicated HVAC system. This provides 6-12 air changes per hour.
- For buildings constructed before 2001, the CDC recommends 6 air changes per hour for proper air quality and reduction in viral load
- To increase the indoor air quality, Merv13 HEPA filters were installed in the ACS HVAC system.
- Additional large volume HEPA air scrubbers were rented and installed in the ACS to improve upon the existing HVAC system
- Air changes were calculated using the dimensions of the space and this formula: ACPH = number of air changes per hour; higher values correspond to better ventilation
- Q = Volumetric flow rate of air in cubic feet per minute (cfm)
- Vol = Space volume L × W × H, in cubic feet
- UV sanitizing robotic vacuums (Roomba)
This article is accurate and true to the best of the author’s knowledge. Content is for informational or entertainment purposes only and does not substitute for personal counsel or professional advice in business, financial, legal, or technical matters.