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Care for the Perioperative Patient for COVID-19 or PUI Patients

TRANSPORT OF PATIENTS 

  • Staff should follow droplet precautions donning PPE including: 
    – Isolation gown
    – Mask with face shield or goggles
    – Gloves 
  • The patient should wear a mask during transport if not intubated. 
  • There should be a separate individual who clears the transport path and opens all doors. 
  • The transport team will transport the intubated patient directly to the operating room (OR) that has been designated for COVID-19 patients. Do not bring the patient to the holding or PACU areas.  

The designated OR for each facility is: 

Kettering: OR 6 

Grandview: OR 7 or Bronch Lab as backup location 

Soin: OR 5 

Fort Hamilton: OR 2 

Southview: Main OR 5 

Patients originating in the ICU 
Should have their airway secured in ICU prior to transport to OR, then remain intubated and taken back to ICU for extubation and recovery post-OR. For those already on a ventilator – these would originate and return to ICU. 

Patients originating elsewhere (floor/COVID unit)  
Intubation should take place in a designated negative pressure room (OR – if negative pressure available – but will often be outside of OR) prior to transport to OR.  

Designated locations for each facility: 

Kettering: OR 6 – negative pressure room 

Grandview: OR 7 – negative pressure room 

Soin: Negative pressure endo room 

Fort Hamilton: OR 2 for intubation – Unit 4 West for extubation 

Southview: Labor and Delivery room 1308 

Post-OR patient should be taken to negative pressure room in PACU for extubation and recovery. 

For patients recovering in the OR (if above options not possible): 
Patients should be extubated onto an anesthesia circuit facemask to reduce aerosolization. Then a simple oxygen mask should be placed to continue to minimize aerosolization from coughing.  Avoid HFNO (high flow nasal oxygen). 

OPERATING ROOM 

The American Society of Anesthesiologists (ASA) and other groups are recommending airborne precautions for anesthesia providers who are manipulating the airway. Powered Air-purifying Respirators (PAPRs) are limited in the OR areas and are being used on the designated units and Emergency Departments (EDs). 

Due to the closure of some operating rooms and the decreasing surgical volume, the projected numbers of N95 masks and goggles needed for anesthesia providers is lower compared to other areas. Based on current surgical case volume, the estimated needs are as follows. These numbers are intentionally slightly higher than likely needed in case of an unexpected increase in volume: 

Kettering 

(35)  N95 masks/day 

Soin 

(15)  N95 masks/day 

Grandview 

(20)  N95 masks/day 

Fort Hamilton 

(15)  N95 masks/day 

Southview  

Several Go bags for potential emergent OB cases requiring intubation 

One N95 mask would be distributed to each anesthesia provider for the entire day. An adequate supply of goggles will be sent to each Surgery department, 2 per open operating room. Paper bags also will need to be distributed for mask storage during breaks.   

Intra-op Care of the Patient 

Anesthesia: 

The anesthesia machine HEPA filter must be changed. Prior to case start, place a new HEPA filter between the Y-piece of the breathing circuit and the patient’s mask, endotracheal tube, or laryngeal mask airway. The gas sampling tubing should also be protected by a HEPA filter and gases exiting the gas analyzer should be scavenged and not allowed to return to the room air. 

PPE for anesthesia during intubation and extubation will include: 

  • Either an N95 mask or PAPR if the anesthesia is unable to wear the N95
  • A face shield or goggles
  • A gown
  • Gloves

The designated process for anesthesia to obtain N95 masks or PAPR for each facility is: 

Kettering 

Anesthesia Controls Distribution 

Grandview 

Contact Materials Distribution (937) 723-3243 

Soin 

Kept on OR Covid-19 cart 

Fort Hamilton 

In director’s office – Contact Joe Hooper, Donna Barker, or Dr. Churchwell for access. 

Southview 

Kept in Anesthesia Block Cart 

  • Double gloves will enable one to shed the outer gloves after intubation and minimize subsequent environmental contamination. 
  • Designate the most experienced anesthesia professional available to perform intubation, if possible. 
  • Avoid awake fiberoptic intubation unless specifically indicated. Droplets containing viral pathogens may become aerosolized during this procedure. Aerosolization generates smaller liquid particles that may become suspended in air currents, traverse filtration barriers, and inspired. 
  • Consider a rapid sequence induction (RSI) to avoid manual ventilation of the patient’s lungs and potential aerosolization. If manual ventilation is required, apply small tidal volumes. 
  • After removing protective equipment, avoid touching your hair or face and perform hand hygiene. 

If devices such as point-of-care ultrasound are used: 

  • A long sheath cover of the ultrasound unit and cable should be used to minimize contamination of the equipment. 
  • Non-essential parts of the ultrasound cart may best be covered with drapes to minimize droplet exposure. 
  • After the case, clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area with an EPA-approved hospital disinfectant. 

Non-Anesthesia Staff: 

  • The circulators and other OR staff should not assist in the intubation. 
  • Standard precaution PPE must be worn by all support staff in the operating room. 
    • All surgical staff and surgeons will use regular surgical masks.   
  • Essential personnel only in the OR during intubation and extubation. 
  • The circulator should utilize a “runner” outside of the OR suite to retrieve additional supplies as needed. 
  • Keep the case cart and additional “hold” supplies out of the room to reduce the risk of cross-contamination.    

POSTOPERATIVE CARE OF THE PATIENT

Post-procedure: 

After the patient has left the OR, leave as much time as possible before subsequent patient care for the removal of airborne infectious contamination. The length of time depends on the number of air exchanges per hour in the specific room or space.  

ACH § ¶  (Air Changes/Hour)  Time (mins.) required for removal 
99% efficiency 
Time (mins.) required for removal 
99.9% efficiency 
138  207 
69  104 
6+  46  69 
35  52 
10+  28  41 
12+  23  35 
15+  18  28 
20  14  21 
50 

https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

After discharge, terminal cleaning must be performed. Staff should delay entry into the room until a sufficient time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, staff may enter the room and should wear a gown and gloves when performing terminal cleaning. A face mask and eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated or otherwise required based on the selected cleaning products. (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/infection-prevention-control-faq.html

Any specimen should be double bagged and transported to the lab. Gloves should be worn to transport the specimen.   

Call to inform the lab prior to transporting the specimen.  

Suggested COVID-19 Cart Supplies 

Needed from CS: 

____ Clorox wipes 

____ (1 box) Small exam gloves 

____ (1 box) Medium exam gloves 

____ (1 box) Large exam gloves 

____ (1 box) Isolation gowns 

____ Supply of N95 masks (some locations) 

____ (10) Face shields 

____ (1) Box lock (placed inside of cart) 

March 26, 2020