The safety of all members of our health care team is a top priority for Kettering Health Network as we navigate the rapidly evolving clinical situation around COVID-19. As we gain experience and learn more about this infection, we recognize that using airborne precautions in all clinical situations is not necessary. As a result, Kettering Health Network is now recommending standard/droplet/contact precautions for all ambulatory, acute care, and emergency department patients with known or suspected COVID-19 disease across all of our entities. Patients who are known or suspected to have COVID-19 who require aerosol generating procedures like intubation or nebulizer therapy will be performed in airborne/contact precautions with eye protection with a PAPR or N95 mask plus a face shield or goggles (similar to prior guidance). This change is in line with the World Health Organization (WHO) rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) recommendations. Based on available evidence and expert opinion, the COVID-19 virus, similar to other coronaviruses and influenza, is primarily transmitted through close contact and large droplets. The CDC currently recommends enhanced measures including airborne isolations precautions for patients undergoing aerosol generating procedures such as intubation, bronchoscopy, and nebulized therapies, and we will continue to support this. With expanded laboratory testing capabilities, we will also make testing available to a broader group of patients with fever or respiratory symptoms who do not meet current CDC criteria.
Why are we changing to contact and droplet isolations precautions?
- Droplet/contact precautions is clinically appropriate for COVID-19 patient care and is consistent with guidelines from WHO and other countries.
- Ensure that we are able to maintain appropriate PPE for the highest risk patients.
- Simplify PPE use in most settings. The current process is more complicated and may lead to increased risk while removing PPE.
- Streamline care for these patients.
- Allows all sites to get patients into precautions more consistently.
- Note: PPE use for suspected or positive COVID cases will continue to require a trained PPE observer to assist with donning and doffing. Since some patient room doors do not have a window, observation of doffing may not always be possible.
What about patients who test positive?
- COVID-19 patients will remain in droplet/contact precautions with eye protection with a trained observer to ensure proper PPE donning and doffing (see above). As above, patients requiring aerosol generating procedures will remain in airborne/contact isolation and in a negative pressure room if available. This approach will facilitate testing among patients entering our system while keeping our workforce safe and ensuring the most rational use of PPE for the highest risk scenarios.
Which patients should remain in airborne precautions?
- Patients requiring (or anticipated to require) aerosol generating procedures including endotracheal intubation, non-invasive positive pressure ventilation, bronchoscopy, cardiopulmonary resuscitation, suctioning, non-invasive positive pressure ventilation, and nebulizer therapy. Preferentially using metered dose inhalers instead of nebulizers for any person being tested for or diagnosed with COVID-19 is strongly recommended.
- Negative pressure airborne isolation rooms will be used if available. If negative pressure rooms are unavailable, patients will be placed in a standard room with staff using PAPR or N95 with eye protection, gowns and gloves.
How should suspected and confirmed COVID-19 patients be transported?
- Patients with suspected or confirmed COVID-19 should be placed in a mask for transport. The patients should be transported by nurses or NAs if at all possible, not by transporters.
- The health care providers transporting the patient should use droplet with contact precautions: gloves, gown, mask, and eye protection.
- An employee who is not wearing PPE should proceed the transporters to press elevator buttons, door openers etc.
- Receiving teams such as in radiology should use droplet with contact precautions: gloves, gown, mask, and eye protection.
What precautions are required for specimen collection?
- Nasopharyngeal swabs often generate a strong cough reflex. Standard/Contact/Droplet precautions with eye protection are recommended.
Should health care workers wear facemasks outside of direct patient care?
- Facemasks should not be used outside of direct patient care or housekeeping.
- Facemasks are useful when worn by sick patients to prevent contamination of the surrounding area when they cough or sneeze.
- Facemasks (along with hand hygiene, eye protection, gown and gloves) are useful for health care workers during discrete episodes of direct patient care that may result in close contact and should be doffed appropriately after each interaction.
- All PPE must be conserved during this time of great need and therefore must not be worn outside of these episodes.
*Adapted from University of Washington Medicine 2020
Please click here to see a flowchart of this recommendation.